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Goode PS, Burgio KL, Locher JL, et al. Effect of Behavioral Training With or Without Pelvic Floor Electrical Stimulation on Stress Incontinence in Women: A Randomized Controlled Trial. JAMA. 2003;290(3):345–352. doi:10.1001/jama.290.3.345
Author Affiliations: Department of Veterans Affairs Medical Center, Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Birmingham, Ala (Drs Goode and Burgio), and School of Medicine and Center for Aging (Drs Goode, Burgio, Locher, Roth, Richter, Varner, and Lloyd), and Schools of Nursing (Dr Umlauf) and Public Health (Dr Roth), University of Alabama at Birmingham.
Context Pelvic floor electrical stimulation (PFES) has been shown to be effective
for stress incontinence. However, its role in a multicomponent behavioral
training program has not been defined.
Objective To determine if PFES increases efficacy of behavioral training for community-dwelling
women with stress incontinence.
Design and Setting Prospective randomized controlled trial conducted from October 1, 1995,
through May 1, 2001, at a university-based outpatient continence clinic in
the United States.
Patients Volunteer sample of 200 ambulatory, nondemented, community-dwelling
women aged 40 to 78 years with stress or mixed incontinence with stress as
the predominant pattern; stratified by race, type of incontinence (stress
only vs mixed), and severity (frequency of episodes).
Interventions Patients were randomly assigned to 8 weeks (4 visits) of behavioral
training, 8 weeks (4 visits) of the behavioral training plus home PFES, or
8 weeks of self-administered behavioral treatment using a self-help booklet
Main Outcome Measures Primary outcome was percentage reduction in the number of incontinent
episodes as documented in bladder diaries. Secondary outcomes were patient
satisfaction and changes in quality of life.
Results Intention-to-treat analysis showed that incontinence was reduced a mean
of 68.6% with behavioral training, 71.9% with behavioral training plus PFES,
and 52.5% with the self-help booklet (P = .005).
In comparison with the self-help booklet, behavioral training (P = .02) and behavioral training plus PFES (P =
.002) were significantly more effective, but they were not significantly different
from each other (P = .60). The PFES group had significantly
better patient self-perception of outcome (P<.001)
and satisfaction with progress (P = .02). Significant
improvements were seen across all 3 groups on the Incontinence Impact Questionnaire
but with no between-group differences.
Conclusions Treatment with PFES did not increase effectiveness of a comprehensive
behavioral program for women with stress incontinence. A self-help booklet
reduced incontinence and improved quality of life but not as much as the clinic-based
Pelvic floor electrical stimulation (PFES) has been used for the treatment
of urinary incontinence since 1952.1 In the
original study, PFES was added to pelvic floor muscle exercises and cured
7 of 17 women who had failed previous attempts to treat their stress urinary
incontinence with exercise alone. The treatment of PFES using a vaginal probe
was not reported in the literature until 1967 when interest in this therapy
resurfaced.2 Since then, PFES has become widely
used and is now approved for reimbursement by Medicare and many other insurance
Pelvic floor electrical stimulation activates pudendal nerve afferents,
which in turn results in activation of pudendal and hypogastric nerve efferents,
causing contraction of smooth and striated periurethral muscles and striated
pelvic floor muscles.3 This provides a form
of passive exercise with the goal of improving the urethral closure mechanism.
In addition, PFES can be useful in teaching pelvic floor muscle contraction
to women who cannot identify or contract these muscles voluntarily because
of extreme weakness.
Previous research has demonstrated the efficacy of PFES compared with
sham PFES.4,5 There is also some
evidence that PFES yields results similar to those of pelvic floor muscle
training,6 although some investigators have
found pelvic floor muscle exercise training to be superior.7 Several
studies have combined PFES with various methods of pelvic floor muscle training
and exercise and reported successful outcomes.8-11
Only 2 studies have examined the issue of whether electrical stimulation
improves the outcomes of pelvic floor muscle training. A single, small study
(N = 14) compared pelvic floor muscle exercise and exercise augmented with
PFES and found that the addition of PFES improved outcome as measured with
bladder diaries and muscle strength.12 In the
other study, pelvic floor muscle exercises augmented with both PFES and biofeedback
produced greater improvements in symptoms and muscle strength compared with
pelvic floor muscle exercises alone.13 However,
because PFES and biofeedback were used together, it is not possible to isolate
the effect of adding PFES. Thus, while PFES shows promise in the treatment
of stress incontinence, the role of electrical stimulation in behavioral treatment
with pelvic floor muscle training and exercise has not been clearly defined.
The present study was designed to determine whether PFES enhances the
outcome of behavioral training in the treatment of stress incontinence. A
multicomponent behavioral treatment protocol with and without home PFES was
compared with a control condition consisting of self-administered behavioral
Community-dwelling older women with stress incontinence were recruited
through local advertisements, community outreach, and professional referrals,
and then screened by telephone to determine eligibility. To be scheduled for
an evaluation, women had to be 40 years or older, ambulatory, and describe
a pattern of predominantly stress incontinence occurring at least twice per
week and persisting for at least 3 months. Informed consent procedures were
approved by the university's institutional review board for human use, and
all patients provided informed consent. The study was conducted from October
1, 1995, through May 1, 2001.
The evaluation consisted of a continence and medical history, physical
examination, postvoid catheterization for residual urine, urodynamic evaluation,
level of hemoglobin A1C measured for patients with diabetes, and
urinalysis (urine dipstick on clean-catch specimen with microscopic evaluation
if indicated). A Q-tip test was performed to identify patients with bladder
neck hypermobility, defined as greater than or equal to 30° of rotation.14 In addition, the Mini-Mental State Examination was
used to screen for dementia.15 If patients
had a urinary tract infection (urine colony count >10 000), fecal impaction,
severe atrophic vaginitis, or uncontrolled diabetes, they were offered or
referred for treatment and reconsidered for study participation when the symptoms
of these underlying conditions were resolved.
Urodynamic testing was performed according to International Continence
Society guidelines16 in the Continence Research
Clinic by specially trained nurse practitioners to document stress leakage
(for inclusion) and to classify the type of incontinence for stratification
(stress only vs mixed stress and urge). Two-channel supine water cystometry
was performed using a No. 12 Fr double lumen urodynamic catheter, a rectal
balloon, and room temperature sterile water at a continuous filling rate of
50 mL/min up to a maximum of 500 mL. Presence of detrusor instability was
noted as well as the bladder capacity. The catheter was removed and several
maneuvers were performed to provoke stress incontinence: changes in position
(lying to sitting, sitting to standing), coughing (4 times while lying, 4
times while standing), and heel bouncing (4 times).
To measure pretreatment frequency of incontinence, patients were given
2 weeks of bladder diary booklets.17 Patients
documented the time of every void and incontinent episode, the volume of each
episode of urine loss, and the circumstances of each episode. Volume of an
incontinence episode was estimated as small if the urine would wet only their
underwear and as large if the volume was sufficient to dampen their outer
clothing if a pad were not in place. The Hopkins Symptom Checklist 90-R (psychological
distress),18 Incontinence Impact Questionnaire,19 and Short Form 36 Health Survey20 were
completed by patients at home and returned with baseline diaries at the second
To be included, patients had to average at least 2 incontinence episodes
per week on the 2-week baseline bladder diary, and stress incontinence had
to be the predominant pattern (ie, the number of stress episodes had to exceed
the number of urge and other episodes). Also, stress incontinence had to be
objectively demonstrated during urodynamic testing. Patients were excluded
if they had continual leakage, postvoid residual urine volume greater than
150 mL, severe uterine prolapse (past the vaginal introitus), decompensated
congestive heart failure, hemoglobin A1C ≥9, or impaired mental
status (Mini-Mental State Examination score <24).
The study was a randomized controlled trial. Patients were randomized
to behavioral training (biofeedback-assisted pelvic floor muscle training,
home exercises, bladder control strategies, and self-monitoring with bladder
diaries), or the same program with the addition of home PFES treatments, or
a control condition consisting of self-administered behavioral training administered
with a self-help booklet. Stratification procedures were used at randomization
to ensure that groups had similar types and severity of incontinence and race
distribution (black or white). Race was self-indentified by the patient. Baseline
bladder diaries and urodynamic test results were used to classify incontinence
as stress only or mixed stress and urge. The baseline bladder diaries were
also used to stratify patients as having mild (<5 episodes/wk), moderate
(5-10 episodes/wk), or severe incontinence (>10 episodes/wk). Within each
stratum, patients were randomized using a block size of 6 to ensure equity
in group size. The randomization schedule was computer-generated by the biostatistician
and implemented by the nurse practitioners. A sample size of 200 was selected
to allow detection of 15% differences in reduction of episodes on bladder
diary between treatment groups with 85% power and a significance level of
.05, assuming a 2-sided hypothesis test and a pooled within-group SD of 20%.
For all patients, treatment was implemented over an 8-week period. Patients
completed a daily bladder diary throughout treatment.
Behavioral Training. Treatment consisted of 4 clinic visits at 2-week intervals. Interventions
were implemented by female nurse practitioners who were specially trained
by the behavioral psychologist (K.L.B.) and physician principal investigator
(P.S.G.) in behavioral treatment of incontinence. At each visit, clinic staff
reviewed bladder diaries to ensure that entries were clear and interpretable.
During visit 1, anorectal biofeedback was used to help patients identify
pelvic floor muscles and teach them how to contract and relax these muscles
selectively while keeping abdominal muscles relaxed.21,22 A
3-balloon probe provided manometric feedback of anal sphincter pressure (representing
pelvic floor muscles) and rectal pressure (reflecting intra-abdominal pressure).23 Using biofeedback, the nurse practitioner taught
the patient to isolate the pelvic floor muscles. The patient practiced pelvic
floor muscle contraction and relaxation until she and the nurse practitioner
felt the patient was ready to do the exercises at home without biofeedback.
The biofeedback session typically lasted 20 minutes.
Patients were given verbal and written instructions for 3 sessions of
pelvic floor muscle exercises daily. Each session consisted of 15 repetitions
of 2- to 4-second contractions with equal periods of relaxation. The initial
duration of each individual contraction was determined based on the ability
demonstrated by the patient in the training session. Patients were advised
to do 1 session lying, sitting, and standing, and whenever possible to integrate
the exercises into other daily activities. Once daily they were to practice
interruption or slowing of the urinary stream during voiding.
During visit 2, the bladder diary was reviewed. Patients were then taught
to use "stress strategies" to prevent urine leakage.21,22,24 Specifically,
they were instructed to contract their pelvic floor muscles during any activity
that usually resulted in leakage (eg, coughing, sneezing, lifting, standing
up from a chair). If they forgot to use the stress strategy and experienced
urine leakage during an activity, they were to tighten their pelvic floor
muscles immediately, with the expectation that this would strengthen the habit
of using their muscles in the future. They were also taught to manage the
sensation of urgency using the "urge strategy."21,22,24 Instead
of rushing to the toilet, which increases pressure on the bladder and exposes
patients to visual cues that can trigger incontinence, patients were encouraged
to stand or sit still, relax the entire body, and contract pelvic floor muscles
repeatedly to diminish urgency, inhibit detrusor contractions, and prevent
urine loss. When urgency subsided, they were instructed to proceed to the
toilet without rushing.
During visits 2, 3, and 4, the home exercise regimen was adjusted by
gradually increasing the duration of each contraction to a maximum of 10 seconds,
with an equal period of relaxation between contractions. Progress was reviewed
and persistence with exercises and bladder control strategies reinforced.
Also during visit 3, patients who had not achieved at least 50% improvement
were offered a repeat biofeedback session.
Pelvic Floor Electrical Stimulation. This treatment included all of the components of behavioral training
with the addition of home PFES. During treatment visit 1, a home unit (Hollister
InCare, Libertyville, Ill) was programmed to deliver stimulation via vaginal
probe with the following parameters: biphasic pulses (frequency of 20 Hz),
pulse width of 1 milliseconds, and pulse train to rest period of 1:1 (to keep
the exercise and relaxation phases the same among treatment groups). Frequency
settings between 20 and 50 Hz have been reported as optimal for sphincter
closure and pelvic floor muscle contraction, and 5 to 20 Hz for reflex detrusor
20 Hz was selected since many of the patients were expected to have mixed
stress and urge incontinence. The current intensity was adjusted by the patient
to the maximum level she could tolerate comfortably, up to 100 mA. Simultaneous
with each muscle contraction induced by PFES, patients performed a voluntary
pelvic floor muscle contraction.
All patients felt comfortable enough with the PFES unit to take it home
after session 1. Patients were instructed to use the PFES unit for 15 minutes
every other day. On alternate days, to keep the exercise time consistent between
groups, patients were instructed to perform 3 sessions of pelvic floor muscle
exercises (as in the behavioral training group).
Self-administered Behavioral Training: Control Condition. The self-help booklet provided written instructions for an 8-week self-help
behavioral program that was based on the behavioral training program described
above but was completely self-administered, without benefit of professional
expertise or equipment. The booklet included the entire program in simple
lay language: isolating the pelvic floor muscles, progressive home exercise,
self-monitoring, and bladder control strategies. The text was adapted from
the self-help book Staying Dry: A Practical Guide to Bladder
Control.24 Patients were given the booklet
and an appointment for a return visit in 8 weeks. They were also given a supply
of bladder diaries and stamped envelopes for returning completed diaries each
Following treatment visit 4, patients completed 2 weeks of posttreatment
bladder diaries and a patient satisfaction questionnaire, and repeated the
Hopkins Symptom Checklist 90-R, the Incontinence Impact Questionnaire, and
the Short Form 36 Health Survey. These materials were collected when they
returned for their posttreatment visit. During this visit patients were encouraged
to repeat urodynamic testing.
To determine any baseline differences on key variables, the treatment
groups were compared using χ2 analysis and analysis of variance
(ANOVA). The primary outcome measure was reduction in the frequency of incontinent
episodes as recorded in the bladder diaries. The pretreatment and posttreatment
frequency of incontinence were used to calculate a percentage reduction for
each patient ([pretreatment frequency − posttreatment frequency] ÷
[pretreatment frequency] × 100%)21,22,30 Thus,
100% represented total continence, 0% signified no improvement, and a negative
percentage indicated an increase in incontinent episodes. One-way ANOVA was
used to test for differences between the 3 groups on treatment outcome. This
study was based on intention-to-treat analysis, using the last value carried
forward, along with careful attrition analysis. Thus, when patients did not
complete treatment, the most recent bladder diaries were used to calculate
outcome. Post-hoc analyses were conducted to make pairwise comparisons of
the treatment groups.
Differences between the groups on patient satisfaction and subjective
assessment of treatment outcome were tested using the χ2 statistic
for categorical variables or the Kruskal-Wallis test for ordinal variables.
Other outcome measures, including the Incontinence Impact Questionnaire, the
Hopkins Symptom Checklist 90-R, the Short Form 36 Health Survey, and urodynamic
measures were examined using 3 (for number of treatment groups) by 2 (for
pretreatment vs posttreatment) repeated measures ANOVA, using a more conservative
value of P<.01 as significant to provide additional
protection against committing type 1 errors due to multiple comparisons.
Of 508 women who were evaluated clinically, 308 were ineligible or did
not participate, and 200 were randomized (Figure 1). The attrition rate was 18.2% in the behavioral group,
11.9% in the PFES group, and 37.3% in the self-help booklet group (P = .001). Figure 1 details
reasons for attrition. No one withdrew because of adverse effects. The PFES
group reported 4 (6%) occurrences of vaginal irritation, 3 due to slippage
of the PFES probe resulting in a pinching sensation, and 1 due to the conduction
gel, which resolved after changing brands.
Characteristics of the participants are presented in Table 1. Before treatment, there were no significant differences
among the 3 treatment groups on any of the key parameters (P>.10 for all comparisons).
Before treatment, the weekly frequency of incontinence was similar across
the 3 groups (P = .94) (Table 2). Behavioral training resulted in a mean 68.6% reduction
in frequency of episodes; behavioral training plus PFES, a mean 71.9% reduction;
and treatment with the self-help booklet, a mean 52.5% reduction (P = .005). In comparison with the self-help booklet, post-hoc tests
revealed behavioral training with PFES (P = .002)
and without PFES (P = .02) were significantly more
effective. However, the addition of PFES did not seem to improve the results
of behavioral training (P = .60). Similarly, a larger
proportion of patients in the behavioral training and the PFES groups achieved
at least 50% improvement of incontinence (P<.001)
although there was no difference in the number of cures (100% improvement)
in each group (P = .95) (Figure 2).
We investigated whether baseline characteristics were associated with
treatment outcome. Percentage reduction of episodes was not related to severity
of incontinence as measured by number of episodes on bladder diary (P = .99) or to type of incontinence (P = .23). Subgroup analysis revealed that only the PFES group exhibited
a difference in outcome by type of incontinence with patients with stress
incontinence having a mean 85.1% reduction of episodes and patients with mixed
incontinence having a mean 65.0% reduction in episodes (P = .02). Whether treatment outcome differed for the subgroup of patients
with detrusor overactivity on urodynamic testing could not be determined because
of small sample size in this subgroup.
Posttreatment reduction of incontinence was examined in the subgroup
of patients who completed treatment. The mean percentage reduction for the
54 participants in the behavioral training subgroup was 80.2%; for the 59
in the behavioral training plus PFES subgroup, 78.3%; and for the 42 in the
self-help booklet subgroup (n = 42) 75.3%. Outcomes did not differ by treatment
group (P = .64).
Thirty (45.5%) of 66 participants in the behavioral training group,
36 of 67 (53.7%) in the PFES group, and 16 (23.9%) of 67 in the self-help
booklet group agreed to complete posttreatment urodynamic testing. These individuals
were compared on all baseline characteristics in Table 1 and they did not differ significantly. On posttreatment
stress testing, 27.6% of the behavioral training group, 47.2% of the PFES
group, and 37.5% of the self-help booklet group no longer had leakage (P = .27). On cystometry, mean (SD) bladder capacity decreased
from 329.2 (130.0) mL to 326.4 (146.2) mL in the behavioral training group
(P = .88); increased from 327.9 (128.4) mL to 370.4
(143.4) mL in the PFES group (P = .03); and increased
from 326.2 (138.4) mL to 355.4 (115.3) mL in the self-help booklet group (P = .31). The main effect for treatment group was not significant
(P = .24).
The patient perceptions of progress and satisfaction with treatment
are presented in Table 3. Post-hoc
pairwise testing revealed that significantly more women in the PFES group
thought that they were much better than in the behavioral training (P = .048) or self-help booklet groups (P<.001), and that more women in the behavioral training group thought
they were much better than in the booklet group (P =
.01). Furthermore, PFES resulted in more patients who were completely satisfied
than did the self-help booklet (P = .002), but other
pairwise comparisons were not significant. Thus, from the viewpoint of the
patients, all 3 treatments yielded positive results, with behavioral training
plus PFES yielding better overall outcomes and satisfaction with progress.
Repeated measures ANOVA revealed significant improvement on total incontinence-related
quality-of-life scores as well as all 4 subscales of the Incontinence Impact
Questionnaire (P<.001 for all). Total Incontinence
Impact Questionnaire score improved from a mean score of 93.1 to 57.6 following
treatment. Changes in mean subscale scores were 24.2 to 15.5 for physical
activity; 22.1 to 13.7 for travel; 19.1 to 11.2 for social; and 28.5 to 18.4
for emotion. However, there were no significant group effects or group by
time interactions on the total score or the subscales (P = .23 to P = .90). Thus, Incontinence Impact
Questionnaire scores improved substantially across all 3 treatment groups,
but no differences among treatment groups were found.
Repeated measures ANOVA revealed no statistically significant changes
in psychological distress as measured by the Global Severity Index of the
Hopkins Symptom Checklist 90-R or any of its 9 subscales. Likewise, the Short
Form 36 Health Survey did not demonstrate any statistically significant changes
in quality of life.
The results of this study show that PFES did not enhance the outcomes
of biofeedback-assisted behavioral training for stress incontinence in women.
This finding differs from the results of a previous study, which has reported
that adding PFES improved outcomes of pelvic floor muscle training.12 However, that study was small (N = 14) and the women
did not receive biofeedback. It is possible that PFES enhances outcomes by
helping women to identify their pelvic floor muscles. When women are already
receiving biofeedback training to help them identify pelvic floor muscles,
then adding PFES may not make a significant difference. This would be consistent
with another previous study, which showed that adding both biofeedback and
PFES together to pelvic floor muscle exercise produced better outcomes.13 Thus, the current evidence suggests that the 2 technologies
may overlap in function. Either may improve the results of pelvic floor muscle
exercise training, but both technologies apparently are not needed in the
same protocol for most women with stress incontinence.
It is possible that neither technology is needed as part of initial
therapy for urinary incontinence but should be reserved for patients who do
not improve with a less invasive behavioral program. We recently reported
a clinical trial of women with urge incontinence who did equally well if taught
pelvic muscle exercises by a nurse practitioner using biofeedback or using
manual palpation as a part of a comprehensive behavioral program.30 A stepped approach in which biofeedback or PFES technologies
can be added if a less invasive program fails is consistent with current reimbursement
policies of the Centers for Medicare and Medicaid Services, which allow reimbursement
for PFES or biofeedback only after a patient has failed a course of pelvic
floor muscle training without these technologies.31,32
Although PFES did not improve results on the primary outcome measure
(reduction of incontinent episodes), patient self-reports indicated that women
in the PFES group perceived significantly better outcomes. Thus, apparently
some subjective treatment outcomes were affected by the addition of electrical
stimulation but were not reflected in the measure of incontinent episodes.
Alternatively, patients' knowledge that they were receiving the electrical
stimulation may have led to some degree of placebo effect reflected in their
subjective assessment of improvement.
The other component of behavioral therapy that was examined in this
study was the contact with clinical staff to manage the training. The self-help
group received the complete behavioral program, but it was administered via
a self-help booklet and without clinic visits. Although the intention-to-treat
analysis showed that both the behavioral training with biofeedback and the
training enhanced with PFES were superior to the self-administered behavioral
training, it is important to note that the dropout rate in the self-help group
(37.3%) was higher than that of the other 2 groups (18.2% in behavioral training
and 11.9% in PFES). In the efficacy analysis, including only treatment completers,
there were no significant differences among the groups on reduction of incontinent
episodes. Thus, the self-help condition was less effective mainly because
of its higher rate of attrition.
In a trial of a similar self-help booklet for urge incontinence,30 the dropout rate in the booklet group was no greater
than that for women enrolled in a comprehensive behavioral program with clinic
visits every 2 weeks. Therefore, unlike the present study of stress incontinence,
the self-administered behavioral therapy was equally effective in reducing
episodes as was the behavioral therapy administered in the clinic. It is quite
possible that patients with stress incontinence discontinued the self-help
treatment due to lack of efficacy. Perhaps pelvic muscle strength is more
important to prevent stress episodes than to prevent urge episodes. Women
with urge incontinence may experience early success in suppressing urgency,
but women with stress incontinence may become discouraged before developing
sufficient strength to contract their pelvic muscles sufficiently to prevent
stress episodes without the reinforcement of the nurse practitioner. The results
suggest that behavioral training for stress incontinence is optimally implemented
in the clinic in which clinicians can ensure that patients are exercising
the correct muscles and can encourage patients to persist with their efforts
long enough for the training to yield results.
In both the intention-to-treat analysis and the analysis of completers,
the self-administered behavioral treatment program was effective for both
stress and urge incontinence. These findings are promising for the dissemination
of behavioral training because a booklet can be given to women with incontinence
in a number of clinical settings including primary care. However, the results
of the self-help intervention in these clinical trials could differ from the
results of implementing this intervention in a clinical practice for several
reasons. The booklet in these clinical trials was administered to patients
in a specialty continence clinic after a complete evaluation of their incontinence.
In addition, because one of the specific aims of these clinical trials sponsored
by the National Institutes of Health was to investigate the mechanisms by
which behavioral treatment improves incontinence, we assessed pelvic floor
muscle strength. Although it was imbedded in the urodynamic procedures and
used the same instrumentation, measurement of the strength of muscle contraction
necessitated assisting the patient to identify and contract the muscles. Thus,
we may have inadvertently given patients extra pelvic floor muscle instruction
that they would otherwise have not received by simply receiving a booklet.
The self-help intervention may be sensitive to patient motivation, and
the highly motivated participants in clinical trials may not be representative
of the general clinic population. Furthermore, the self-help program included
keeping continuous bladder diaries that were mailed in weekly. All of these
factors may have produced results better than what would be achieved in a
clinic population by simply handing out a booklet. The logical next step is
a trial of this self-help program in a clinic population of women with stress
and urge incontinence. Also, studies with longer follow-up are needed to ascertain
the durability of behavioral treatments.
In conclusion, a biofeedback-assisted multicomponent behavioral training
program in healthy, nondemented, community-dwelling women was as effective
in improving stress incontinence as the program with the addition of PFES.
A self-help booklet reduced incontinence but not as much as the clinic-based
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