The Effect of Pelvic Floor Muscle Exercise on Female Sexual Function During Pregnancy and Postpartum A Systematic Review

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REVIEW
The Effect of Pelvic Floor Muscle Exercise on Female Sexual Function
During Pregnancy and Postpartum: A Systematic Review
Sahar Sadat Sobhgol, PhD candidate,1 Holly Priddis, PhD,1 Caroline A. Smith, PhD,2 and
Hannah Grace Dahlen, PhD1,3,4
ABSTRACT
Received Ju
1School of
NSW, Aust
2National In
Western S
3Ingham Ins
4National In
Copyright ª
Elsevier Inc
https://doi.o
Sex Med R
Introduction: Pelvic floor muscle exercise (PFME) is recommended as a first-line treatment for urinary
incontinence. However, a review of the literature suggests the effect of PFME on sexual function (SF), partic-
ularly during pregnancy and the postpartum period, is understudied.
Aim: To assess the effect of PFME on SF during pregnancy and the postpartum period.
Methods: The following databases were searched: CINAHL (EBSCOhost), Health Collection (Informit),
PubMed (National Center for Biotechnology Information), Embase (Ovid), MEDLINE, Cochrane, Health
Source, Scopus, Wiley, Health & Medical Complete (ProQuest), Joanna Briggs Institute, and Google Scholar.
Results from published randomized controlled trials (RCTs) and non-RCTs from 2004 to January 2018 on
pregnant and postnatal women were included. PEDro and Critical Appraisal Skills Programme scores were used
to assess the quality of studies. Data were analysed using a qualitative approach.
Main Outcome Measure: The primary outcome was the impact of antenatal or postnatal PFME on at least 1
SF variable, including desire, arousal, orgasm, pain, lubrication, and satisfaction. The secondary outcome was the
impact of PFME on PFM strength.
Results: We identified 10 studies with a total of 3607 participants. These included 4 RCTs, 1 quasi-
experimental study, 3 interventional cohort studies, and 2 long-term follow up cohort studies. No studies
examined the effect of PFME on SF during pregnancy. 7 studies reported that PFME alone improved sexual
desire, arousal, orgasm, and satisfaction in the postpartum period.
Conclusion: The current data needs to be interpreted in the context of the studies’ risk of bias, small sample
sizes, and varying outcome assessment tools. The majority of the included studies reported that postnatal PFME
was effective in improving SF. However, there is a lack of studies describing the effect of PFME on SF during
pregnancy, and only minimal data are available on the postpartum period. More RCTs are needed in this area.
Sobhgol SS, Priddis H, Smith CA, et al. The Effect of Pelvic Floor Muscle Exercise on Female Sexual
Function During Pregnancy and Postpartum: A Systematic Review. Sex Med Rev 2018;XX:XXeXX.
Copyright � 2018, International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.
Key Words: Sexual Function; Dyspareunia; Pregnancy; Postpartum; Pelvic Floor Muscle Exercise; Pelvic Floor
Muscle Strength
Sexuality and intimacy are natural parts of human life.1
Women experience physical and psychological changes as they
go through the cycles of life,1,2 and the transition to parenthood
is one of the cycles that can affect women’s sexuality.1,3
ne 7, 2018. Accepted August 16, 2018.
Nursing and Midwifery, Western Sydney University, Penrith,
ralia;
stitute of Complementary Medicine Health Research Institute,
ydney University, Penrith, NSW, Australia;
titute, Liverpool, NSW, Australia;
stitute of Complementary Medicine, Campbelltown, NSW, Australia
2018, International Society for Sexual Medicine. Published by
. All rights reserved.
rg/10.1016/j.sxmr.2018.08.002
ev 2018;-:1e16
The prevalence of sexual dysfunction is largely unknown and
likely underreported.4 Sexual dysfunction is defined as a distur-
bance in sexual desire and psychophysiological changes that
characterize the sexual response and cause interpersonal diffi-
culties and marked distress.5 Sexual dysfunction affects an esti-
mated 43% of women in general2 and in 63e93% of pregnant
women.6 In 2012, Acele et al7 reported that 91.3% of women
experience at least 1 sexual problem in the postpartum period. In
2015, Khajehie et al8 claimed that >64% of Australian women
report sexual dysfunction and >70% report sexual dissatisfaction
during the first year after birth.
The etiology of female sexual dysfunction is multifactorial,
with both physical and psychological causes.4,9 Impaired pelvic
floor muscle strength (PFMS) after birth is a major factor
1
https://doi.org/10.1016/j.sxmr.2018.08.002
Table 1. Inclusion and exclusion criteria
Inclusion criteria
Design
� Systematic reviews; randomized controlled trials; and quasi-
experimental, cohort, and observational studies. Both short-
term and long-term follow-up studies in the postnatal period
were included.
Participants
� Pregnant and/or postnatal primiparous or multiparous women
with or without pelvic floor dysfunction at baseline
Intervention
� All types of antenatal or postnatal PFME alone or combined with
other exercises or lifestyle interventions or adjunctive therapy
(eg, vaginal cones, electrotherapy, biofeedback therapy)
Comparator(s)/control
� Control group with no treatment
� Comparison group receiving only education on SF or PFME
without supervision and follow-up, or a less intensive protocol
Main outcomes
� Primary: the impact of antenatal or postnatal PFME on at least 1
SF variable, including but not limited to desire, arousal, orgasm,
pain, lubrication, and satisfaction
� Secondary: the effect of PFME on pelvic floor muscle strength
Exclusion criteria
� Studies that used other interventions with no PFME
� Studies including children and adolescents and non-pregnant or
non-postnatal women (short term or long term)
� Published guidelines, opinion pieces, and poster presentations
PFME ¼ pelvic floor muscle exercise; SF ¼ sexual function.
2 Sobhgol et al
affecting female sexual function (SF) in the postpartum period.9
Vaginal birth, instrumental vaginal birth, perineal trauma, and
episiotomy often lead to pelvic floor muscle (PFM) damage,
often negatively influencing PFMS and SF.10
It seems that pelvic floor muscle exercise (PFME) may play a
role in treatment or prevention of female SF.5,9,11 PFMs permit
intercourse and parturition and play a role in sexual response11
by improving genital arousal and attainment of orgasm.12 In
contrast, weak muscles may provide inadequate stimulation and
arousal, hindering orgasmic potential.12 Several studies have
shown that PFME may improve sexual desire and orgasmic ca-
pacity in the general population13,14 and in non-orgasmic
women with poor pelvic muscle tone.4 In contrast, others
found no relationship between SF and PFMS.10,15
There is a small number of published reviews on the effect of
PFME on female SF in the general population5,16; however,
there have been no reviews of the literature to assess specifically
the effect of antenatal or postnatal PFME on female SF during
pregnancy and the postpartum period. Therefore, the aim of this
review was to assess the effect of PFME on SF during pregnancy
and the postpartum period by exploring the following: (i)
whether there is any evidence that antenatal PFME improves SF
during pregnancy and in the immediate postpartum period, (ii)
whether there is any evidence that postnatal PFME improves SF
in the postpartum period, and (iii) the most effective PFME
program to recommend to women antenatally or postnatally.
METHODS
Search Strategy
Inclusion and exclusion criteria for our study are shown in
Table 1. CINAHL (EBSCOhost), Health Collection (Informit),
PubMed (National Center for Biotechnology Information),
Embase (Ovid), MEDLINE, Cochrane, Health Source, Scopus,
Wiley, Health & Medical Complete (ProQuest), Joanna Briggs
Institute, and Google Scholar were searched. English language
was not a search criterion. Articles published between January
2004 and January 2018 were included. Key words used in
combination were as follows: “pelvic floor muscle exercise” [all
fields], “pregnancy,” “postpartum,” “postnatal,” “childbirth,”
“sexual function,” and “dyspareunia.” Scopus and Google
Scholar yielded thehttp://refhub.elsevier.com/S2050-0521(18)30087-8/sref44
http://refhub.elsevier.com/S2050-0521(18)30087-8/sref44
http://refhub.elsevier.com/S2050-0521(18)30087-8/sref45
http://refhub.elsevier.com/S2050-0521(18)30087-8/sref45
http://refhub.elsevier.com/S2050-0521(18)30087-8/sref45
	The Effect of Pelvic Floor Muscle Exercise on Female Sexual Function During Pregnancy and Postpartum: A Systematic Review
	Methods
	Search Strategy
	Selection Process
	Quality Appraisal of Studies
	Summary Measure
	Results
	Quality Appraisal of Included Studies
	Effect of PFME on SF During Pregnancy
	Effect of PFME on SF in the Postpartum Period
	Characteristics of the Included Studies
	Training Programs
	Outcome Measurement Tools
	Outcomes
	Effect of PFME on PFMS
	Discussion
	Do Antenatal PFMEs Improve SF During Pregnancy or in the Immediate Postpartum Period?
	Does Postnatal PFME Improve SF in the Postpartum Period?
	What Is the Most Effective Antenatal or Postnatal PFME Program to Recommend to Women?
	Summary
	Limitations and Strength
	Conclusion
	Statement of authorship
	Statement of authorship
	Referencesmost results using the preceding key words.
Selection Process
Our selection process is outlined in Figure 1. Titles and ab-
stracts were screened. The full texts of related papers were read in
full, and the most relevant articles were included in this review.
The reference lists from selected studies were checked to identify
other studies that could have been overlooked by the electronic
key word search. The search was conducted by 1 reviewer (S.S.)
and was confirmed by the institutional librarian. Decisions
regarding the inclusion of articles were made by agreement
among all authors. When necessary, the authors of the selected
articles were contacted to obtain more information.
The following details for each study were extracted: author(s),
journal, year of publication, country, study objectives, popula-
tion, study design, sampling size, mean age, descriptions of the
control group and intervention groups, characteristics of the
PFME program, and outcomes.
Quality Appraisal of Studies
The quality of the methodology of included randomized
controlled trials (RCTs) and quasi-experimental study were
scored using the PEDro rating scale.17,18 assigning 1 point to
each of the following items: random allocation, concealed allo-
cation, similarity at baseline, subject blinding, therapist blinding,
assessor blinding, 85% follow-up for at least 1 key outcome,
intention-to-treat analysis, between-group comparisons, report of
point estimates, and variability. The total score is reported on a
scale of 1e10. A PEDro score of �6 indicates good quality, a
score of 4e5 indicates fair quality, and a score �3 indicates poor
quality.17,18
The quality of the non-RCTs, including the cohort studies
and the cross-sectional study, was assessed using the Critical
Appraisal Skills Programme (CASP) cohort checklist. The CASP
questions focus on the validity and generalizability of the
methods and findings.19 All the authors were in agreement as to
the quality assessment of studies and the scoring given.
Sex Med Rev 2018;-:1e16
Titles and abstracts screened 
(n = 4,033) 
 
Sc
re
en
in
g 
 
 
In
cl
ud
ed
 
 
 
 E
lig
ib
ili
ty
 
Id
en
tifi
ca
tio
n Addi onal records iden fied 
through other sources 
(n = 0) 
3,913 records removed for duplicates, and 
general topics in sexual func on 
Records screened 
(n =120) 
Records excluded 
(n = 87) 
Full-text ar cles assessed 
for eligibility 
(n = 33 )
Full-text ar cles excluded, 
with reasons 
(n = 23) 
Studies included in 
qualita ve synthesis 
(n =10)
Studies included in 
quan ta ve synthesis 
(meta-analysis) 
(n = 0 )
Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-analyses flow diagram of the study selection process.
Pelvic Floor Exercises and Female Sexual Function 3
Summary Measure
It was not possible to perform a meta-analysis owing to the
variations in measurement tools used in the included studies, as
well as the variations in how outcomes were reported. A narrative
analysis was undertaken.
RESULTS
The study selection process is outlined in Figure 1. The
database search yielded a total of 4,033 articles initially. Once
duplicates and articles on general topics in the general population
were excluded, 120 articles remained for screening. Of these, 87
were removed because they discussed topics such as urinary or
fecal incontinence and general topics related to SF during preg-
nancy or postpartum. Of the 33 articles remaining for review, 23
were removed for not being available in the full text, not
examining PFME, or being related to childbirth outcomes,
leaving 10 articles for inclusion in this review. These included 4
RCTs,9,20e22 1 quasi-experimental study,23 3 interventional
cohort studies,24e26 and 2 long-term cohort studies.4,27 1 sys-
tematic review28 examining the effect of postpartum pelvic floor
rehabilitation and perineal stretching and massage during the
Sex Med Rev 2018;-:1e16
third trimester of pregnancy and second stage of labor on post-
partum dyspareunia was considered for inclusion. Because the
full text of this systematic review was not available in English, it
is included as literature in the Discussion section of this review.
The full text of 1 article that reported results of an RCT20 was in
Persian and was included in this review because the first author is
fluent in Persian.
Quality Appraisal of Included Studies
PEDro scores in the reported RCTs ranged from 520 to 7,22
indicating fair- to good-quality RCTs. The median PEDro
score was 6.9,21 The quasi-experimental study23 had a PEDro
score of 5 (Table 2).
The quality of the cohort studies24e26 and the cross-sectional
study4 was assessed using the CASP cohort checklist, which
varied widely across the studies. Because of the limited number
of RCTs, the relevant cohort studies were included. These cohort
studies ranged from long-term follow-up studies in larger pop-
ulations4,27 to interventional studies with smaller sample
sizes.24e26 The limitations of the included studies were small
sample size,24e26 lack of a control group for comparison,24e26
4 Sobhgol et al
not using a comprehensive validated SF scale,4,22,27 and not
monitoring PFME performance of participants.4,27
Effect of PFME on SF During Pregnancy
No study analyzed the effect of antenatal PFME on SF during
pregnancy or the immediate postpartum period.
Effect of PFME on SF in the Postpartum Period
Characteristics of the Included Studies
All 10 studies included in this review assessed the effect of
postnatal PEME on SF in the postpartum period.4,9,20e27
Table 3 summarizes the characteristics of the included studies.
4 RCTs were included, with sample sizes ranging from 7521 to
17522 participants. The study population in all RCTs consisted
of primiparous women who had given birth to a singleton baby
via a normal vaginal birth.9,20e22 The effect of PFME on SF was
assessed as a primary outcome in the RCTs by Citak et al,21
Golmakani et al,9 and Modarres et al,20 and the participants
included women with no previous pelvic floor dysfunction.
Tennjford et al22 assessed the effect of PFME on SF as a sec-
ondary outcome and included women with and without a history
of major levator ani defect. The quasi-experimental study (n ¼
100) by Bekhatroh et al23 included primiparous women with no
history of pelvic floor dysfunction who experienced different
modes of birth.
The interventional cohort studies included in this review had
relatively smaller sample sizes, ranging from 3024 to 50,26 without
a control group for comparison. El-Begway et al24 included
multiparous women after vaginal birth. Dionisi et al25 andGagnon
et al26 included participants with different modes of birth and
parities. The effect of PFME on SF was assessed as a secondary
outcome in the study reported by Gagnon et al.26 The cohort
study of Dionisi et al25 was the only study in this review that used
several interventions including PFME as an adjunctive therapy in
combination with transcutaneous electrical nerve stimulation
(TENS) and myofascial stretching to treat postpartum dyspar-
eunia from 3 to 36 months after birth.
The cross-sectional study by Dean et al4 was a long-term
follow-up study (n ¼ 2765) at 6 years after birth that assessed
the association between PFME and SF as a secondary outcome.
Participants were heterogeneous in terms of mode of birth,
parity, and previous history of urinary or fecal incontinence. The
cohort study of Morkved et al,27 another long-term follow-up
study, assessed the long-term effect of antenatal and postnatal
PFME on urinary incontinence and sexual satisfaction at 6 years
after birth. The initial RCT29 was designed to assess the effect of
antenatal PFME on urinary incontinence during pregnancy and
the first 3 months after birth.
Training Programs
The characteristics of the control and intervention groups are
outlined in Table 4. 9 of the 10 included studies4,9,20e27
reported PFME alone without any adjunctive therapy as an
intervention. Only the study by Dionisi et al25used a combi-
nation of several treatments to treat dyspareunia. Control groups
in the RCTs ranged from no intervention,21 education on the
benefits of PFME,9 education on SF,20 and individual assessment
of performance of PFM contraction without further follow-up or
supervision.22
The RCTs used various PFME programs in terms of the char-
acteristics of PFM contractions and relaxation, commencement in
the postpartum period, and durations of the program and follow-
up. PFME started as early as 6 and 8 weeks postpartum in the
RCTs reported by Tennjford22 and Golmakani et al,9 respectively,
and as early as 4 and 6 months postpartum, respectively, in the
RCTs reported by Citak et al21 and Modarres et al.20 The first
training session also differed among the RCTs. Golmakani et al,9
Citak et al,21 and Tennjford et al22 used vaginal palpation as
direct feedback in the first individual training session. The follow-
up ranged from a weekly telephone call,20 2 weekly follow-up
telephone calls with PFM assessment every 4 weeks,9 twice-
monthly follow-up telephone calls,21 and weekly group
training.22 All RCTs provided the women a diary to complete at
home.9,20e22 The highest reported rate of compliance was for the
RCT of Tennjford et al22 with weekly group training. The highest
dropout was reported byCitak et al,21 with once- or twice-monthly
telephone follow-up. Modarres et al20 did not report any dropouts
with weekly telephone follow-up.
Bekhatroh et al,23 in a quasi-experimental study, implemented
2 types of PFME (Table 4). The authors reported no dropout
with twice-monthly telephone follow-up and 4 weekly PFMS
assessments. The control group did not receive any instruction
on PFME.
The cohort studies also used a variety of PFME programs. El-
Begway et al24 conducted individual PFME training sessions
using vaginal palpation as direct feedback. The duration of
training was 3 months, but commencement time and follow-up
were not reported. Gagnon et al26 provided participants (n ¼ 50)
with initial group PFME training, followed by individual
training using vaginal palpation for validation at 2, 5, and 12
weeks after the first appointment. No dropouts were reported
during individual training sessions. Women who participated in
this cohort study were at least at 3 months postpartum. The
characteristics of PFME were not described. Dionisi et al25 used
a combination of interventions (TENS, PFME, and myofascial
stretching) to treat women with postpartum dyspareunia from 3
to 36 months after birth. There was no report on PFME char-
acteristics. Participants were followed up weekly to receive TENS
for 10 weeks, and no dropouts were reported.
The cross-sectional study byDean et al4 was a long-term follow-
up study undertaken in the postpartum period. The characteristics
of PFMEwere not described owing to study design. The long-term
follow-up cohort study by Morkved et al27 was conducted 6 years
after an initial RCT29 that included an intensive antenatal PFME
program (using vaginal palpation as direct feedback at first training
Sex Med Rev 2018;-:1e16
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Sex Med Rev 2018;-:1e16
Pelvic Floor Exercises and Female Sexual Function 5
session), commencing from 20 weeks’ gestation up to 36 weeks of
pregnancy, for a duration of 12 weeks, with weekly group training
follow-up and daily home PFME. A 20% dropout rate was re-
ported in the women allocated to the PFME program. Women in
both the control and intervention groups were then encouraged to
continue PFME in the postpartum period and were assessed for
urinary symptoms and SF in a cohort study at 6 years after birth.
However, the quality of postnatal PFME performed by partici-
pants was not assessed owing to the study design.
Outcome Measurement Tools
The specific measurement tools used by the included studies
to assess SF and PFMS are outlined in Table 5. The studies
variously used the Bailes Sexual Self-Efficacy Scale,9,23 the Fe-
male Sexual Function Index (FSFI),21,24 the Lindburg ques-
tionnaire,20 the Norwegian version of the International
Consultation on Incontinence Modular Questionnaire and
Sexual Matters Module,22 the Pelvic Organ Prolapse/Urinary
Incontinence and Sexual Questionnaire-12,26 and a self-designed
questionnaire based on the Golmobok Rust Inventory of Sexual
Satisfaction4 to assess SF. 1 study25 used the Marinoff Dyspar-
eunia Scale, a cotton swab test, and a visual analog scale to assess
dyspareunia, perineal pain, and vulvar pain.
The methods used in the studies to assess PFM function
included the Brink scale,9,23 a modified Oxford Grading
system using an inflatable intravaginal device attached to
manometer,21,26 a high-precision pressure transducer con-
nected to a vaginal balloon catheter,22 and a Peritron perine-
ometer.24 In the study by Dionisi et al,25 digital examination,
anovulvar distance, and computer surface electromyography
assessment were used to assess pelvic floor function and peri-
neal integrity.
OUTCOMES
The findings of the included studies are summarized in Table 5.
3 of the 4 RCTs9,20,21 reported that postnatal PFME improved SF.
Golmakani et al9 reported significant differences between their
control and intervention groups in terms of sexual desire, arousal,
orgasm, and body acceptance after 8 weeks of PFME that was
started at 8 weeks after birth (P ¼ .001). The level of desire that
women experienced also showed improvement in the control
group at 8 weeks postpartum compared with baseline (P¼ .001).
Consistent with this finding, Modarres et al20 reported a signifi-
cant difference in the sexual satisfaction score between the inter-
vention and control groups (54.22± 0.01 vs 36.8± 2.8; P140 but after
dropout was 75 (IG: 37, CG: 38)
primiparous women who had vaginal
birth
IG: 23.0 ± 3.2
CG: 22.2 ± 3.1
El-Begway et al,24
2010, Egypt
To evaluate the effect of PFME on female SF in
the postpartum period
Interventional
cohort
CASP 30 multiparous women who had vaginal
birth
31.09 ± 4.29
Tennfjord et al,22
2015, Norway
To evaluate the effect of PFME on vaginal
symptoms and sexual matters,* dyspareunia,
and coital incontinence in the postpartum
period (a secondary outcome)
RCT PEDro
7/10
175 (IG: 87, CG: 88) primiparous women
(with and without major levator ani
muscle defect) with a singleton vaginal
birth
IG: 29.5 ± 4.3
CG: 30.1 ± 4.3
Dean et al,4
2008, Australia
To investigate the relationships of SF with
delivery mode history, PFME, and
incontinence
Cohort CASP 4,214 primiparous and multiparous
women (mean parity of 2.4)
35
Bekhatroh et al,23
2017, Egypt
To identify the effect of PFME on women’s
sexual self-efficacy after delivery
Quasi-experimental PEDro
5/10
100 (IG: 50, CG: 50) primiparous women ,
6 weeks after birth, with a healthy
baby, no complications (psychological
disorder, pelvic organ prolapse grades
3 and 4)
IG: 22.16 ± 3.70
CG: 22.16 ± 3.70
Gagnon et al,26
2016, Canada
To evaluate changes in pelvic floor function
(pelvic organ prolapse/urinary incontinence
and SF) in women who attended a
standardized 1-on-1 PFME training after a
group workshop
Interventional
cohort
CASP 50 primiparous and multiparous women 31.4 ± 3.7
Dionisi et al,25
2011, Italy
To evaluate the efficacy of TENS in combination
with PFME for the treatment of vulvar pain
and dyspareunia in postpartum women
Interventional
cohort
CASP 45 women (primiparous and multiparous)
in the postpartum period after vaginal
birth with a complaint of dyspareunia
32.6 ± 4.4
Morkved et al,27
2007, Norway
To assess the long-term effects of the PFME
program during the first pregnancy on
urinary/anal incontinence and sexual
satisfaction
Cohort — 188 (of 301) primiparous women who
previously participated in an RCT and
assessed at 6 years after birth
—
CASP ¼ Critical Appraisal Skills Programme; CG ¼ control group; IG ¼ intervention group; PFM ¼ pelvic floor muscle; PFME ¼ pelvic floor muscle exercise; RCT ¼ randomized controlled trial; SF ¼ sexual
function; TENS ¼ transcutaneous electrical nerve stimulation.
*Sexual matters included the following questions: Do worries about your vagina interfere with your sex life? Do you feel that your relationship with your partner is affected by vaginal symptoms? How much
do you feel that your sex life has been spoiled by vaginal symptoms?
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Pelvic Floor Exercises and Female Sexual Function 7
differ significantly between the 2 groups (P¼ .359).21 In contrast
to these findings, the RCT by Tennjford et al22 showed no dif-
ference in vaginal and sexual dysfunction symptoms between their
treatment and control groups after 4 months of PFME started at 6
weeks postpartum (P ¼ .59).
In the quasi-experimental study by Bekhatroh et al,23 post-
natal PFME alone improved all aspects of sexual efficacy,
including desire, sensuality, arousal, orgasm, emotion, commu-
nication, and body acceptance at 4 and 8 weeks after
commencement of PFME in the treatment group (P .05).
Urinary incontinence symptoms were significantly associated
with sexual dysfunction (P 1 year.25 Postpartum sexual
dysfunction should be managed properly to promote resumption
of normal SF and prevent long-term physical and psychosocial
problems.35
In this review, 7 of the 10 included studies, including 3
RCTs,9,20,21 the quasi-experimental study,23 and 3 cohort
studies,4,24,27 reported that PFME alone improved most domains
of SF, including sexual self-efficacy,9,23 arousal,9,21,23,24 body
acceptance,9,23 desire,9,21,23,24 sexual satisfaction,20 orgasm,9,23,24
and pain,9,21,23,24 in the postpartum period. Modarres et al20 and
Golmakani et al9 found that PFME improved sexual satisfaction
and sexual self-efficacy in postnatal women,whereas Citak et al21
found that PFME improved SF but not sexual satisfaction. 3
studies reported improvement in pain and sexual desire following
birth in the control groups in the postpartum period.9,21,22 A
possible explanation for this finding is that birth trauma, fatigue,
and altered family dynamics are associated with low desire and pain
after birth and improved during the first few months after
birth.9,21,22 Only 1 study25 used PFME as an adjunctive therapy
and showed that 10weeks of TENS therapy,myofascial stretching,
and PFME almost completely resolved symptoms of dyspareunia
Table 4. Description of control and intervention protocols in the included RCTs
Author, year, country Control
Active intervention group
Intervention Intensity Frequency and duration Supervision and follow-up Length of program
Golmakani et al,9
2015, Iran
No PFME education
(brief education on the
benefit of Kegel exercise)
PFME NA 3 sets of 15e20 contractions
lasting 5e10 seconds and
relaxing for 5e10 seconds.
Initial individual training
session using vaginal
palpation for validation
with 2 weekly follow-ups
and 4 weekly PFMS
assessments and a home
checklist.
From 8 to 16 weeks after
birth.
Modarres et al,20
2012, Iran
No PFME education (brief
education about SF)
PFME NA 10 contractions lasting 1e3
seconds with 3 seconds
resting, and to increase to
90e100 contractions 3
times a day.
Weekly phone calls and
home diary to be checked
weekly.
From 6 to 12 months after
birth for 16 weeks.
Citak et al,21
2010, Turkey
No PFME instruction PFME Moderate Moderate contractions with
relaxation periods from 3
seconds to a maximum of
10 seconds followed by
faster contraction and
relaxation 10e15 times a
day.
Individual PFME training
using vaginal palpation for
validation with telephone
follow-up twice in the first
month and once in the
second and third months
and a home diary.
From 4 to 7 months
postpartum.
El-Begway et al,24
2010, Egypt
No control groups PFME Maximum 5e6 sets (each set 10
contractions), 3 sessions
per week, and each
session for 20 minutes.
First individual PFME
training using vaginal
palpation for validation.
No statement on follow-
up.
For 3 months postpartum;
not stated for how long
postpartum.
Tennfjord et al,22
2015, Norway
Written information and
assessment of PFM
contractions without
follow-up
PFME
Bo et al25
protocol
Maximum 3 sets of 8e12 maximum
PFM contractions daily.
First individual PFME
training by a
physiotherapist followed
by weekly group training
and a home diary.
From 6 weeks to 4 months
postpartum.
Dionisi et al,25
2011, Italy
No control group TENS and PFME
and myofascial
stretching
NA PFME: Daily contraction and
relaxation exercises at
home for 15 minutes in
the morning and 10
minutes in the evening
with an outpatient
information session on
biofeedback PFME. TENS:
30 minutes weekly for 10
sessions using standard
protocol of 30 minutes of
biphasic pulses.
Weekly TENS. Daily PFME
and myofascial stretching
at home.
Not stated about follow-up
for PFME.
10 sessions for a total of 10
weeks in the postpartum
period (7e37 months).
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Table 4. Continued
Author, year, country Control
Active intervention group
Intervention Intensity Frequency and duration Supervision and follow-up Length of program
Gagnon et al,26
2016, Canada
No control group PFME NA No statement on the
frequency and
characteristics of PFME.
Women were examined
and performed PFME with
direct feedback. A
physiotherapist helped
women incorporate PFME
into their daily life.
Initial group workshop
followed by 4 sessions of
individual physiotherapy
session at weeks 2, 5, and
12 after first appointment.
At least 3 months after birth.
Bekhatroh et al,23
2017, Egypt
No PFME training PFME Maximum Type A Kegel exercise: 30
times per day (3 sets of 10
or 2 sets of 15) of slow
contractions.
Type B Kegel exercise: 20
e50 times a day of fast
PFME.
Not stated if first session
was group or individual.
Follow up: 2 weekly
telephone phone calls to
follow up and 4 weekly
assessments of PFM
strength using the Brink
scale.
8 weeks, started from 6
weeks after birth.
Morkved et al,27
2007, Norway
Routine antenatal care
by midwives or
general practitioner
PFME and
general
exercise
Maximal 8e12 maximal PFM
contractions lasting 6e 8
seconds followed by 6
seconds of rest.
First training session by a
physiotherapist was
individual using vaginal
palpation as direct
feedback. Follow-up
included weekly group
training in different
positions in combination
with back, abdominal, and
tight muscle exercises
taught by a
physiotherapist and daily
PFME at home.
For 12 weeks started from
20 weeks’ gestation up to
36 weeks’ gestation.
Women in both the
training and control
groups were contacted
and encouraged to
continue PFME at 3
months after birth.
NA ¼ not stated; PFM ¼ pelvic floor muscle; PFME ¼ pelvic floor muscle exercise; SF ¼ sexual function; TENS ¼ transcutaneous electrical nerve stimulation.
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Table 5. Description of SF and PFM outcome measures and results
Author, year, country SF outcome measure PFMS outcome measure SF results PFMS results
Golmakani et al,9
2015, Iran
Bailes sexual self-efficacy
questionnaire (desire, sexuality,
arousal, orgasm, emotion,
communication, body acceptance,
and rejection).
PFMS was measured using
the Brink scale.
After 8 weeks of PFME: sexual desire
(P ¼ .001), arousal (P ¼ .001),
orgasm (Pet al,24
2010, Egypt
FSFI: Q1, desire; Q2, arousal; Q3,
lubrication; Q4, orgasm; Q5,
satisfaction; Q6, pain.
A perineometer was used
to assess PFMS.
Before vs after treatment: Q1, 3.5 ±
1.0 vs 5.8 ± 1.0; Q2, 3.6 ± 1.2 vs
6.9 ± 0.9; Q3, 4.2 ± 1.3 vs 6.9 ±
1.5; Q4, 4.2 ± 1.4 vs 6.5 ± 1.6; Q5,
4.6 ± 1.2 vs 6.1 ± 1.3; Q6, 4.1 ± 1.7
vs 1.5 ± 1.0 (P 
.05), scores were significantly
higher in all items (Q1eQ8) in the
study group 4 weeks after
intervention (P .05). Urinary
incontinence symptoms were
significantly related to sexual
dysfunction (P .05).
PFMS was not measured.
Morkved et al,27
2007, Norway
Not a validated
questionnaire.
— Fewer women reported urinary
incontinence symptoms at 36
weeks of pregnancy and 3 months
after birth, but this effect did not
persist at 6 years after birth
(P ¼ 1.00).
Women in the training group reported
better sexual satisfaction than
the CG at 6 years after birth
(P ¼ .006).
Not assessed at 6 years after birth.
CG ¼ control group; CRADI-8 ¼ Colorectal-Anal Distress Inventory 8; CRAIQ-7 ¼ Colorectal-Anal Impact Questionnaire 7; GRISS ¼ Golombok Rust Inventory of Sexual Satisfaction; ICIQ-FLUTsex ¼
International Consultation on Incontinence Modular Questionnaire and Sexual Matters Module; ICIQ-VS ¼ International Consultation on Incontinence Modular QuestionnaireeVaginal Symptoms; ICIQ ¼
International Consultation on Incontinence Modular Questionnaire; IG ¼ intervention group; PFDI-20 ¼ Pelvic Floor Disability Index 20; PFIQ-7 ¼ Pelvic Floor Impact Questionnaire 7; PFM ¼ pelvic floor
muscle; PFMS ¼ pelvic floor muscle strength; PISQ-12 ¼ Pelvic Organ Prolapse/Urinary Incontinence and Sexual Questionnaire 12; Q ¼ question; POPDI-6 ¼ Pelvic Organ Prolapse Distress Inventory 6;
RR ¼ risk ratio; SF ¼ sexual function; UDI-6 ¼ Urinary Distress Inventory 6; UIQ-7 ¼ Urinary Impact Questionnaire 7; VRP ¼ vaginal resting pressure.
*Sexual matters included the following questions: Do worries about your vagina interfere with your sex life? Do you feel that your relationship with your partner is affected by vaginal symptoms? How much
do you feel that your sex life has been spoiled by vaginal symptoms?
†The PFDI-20 included the pelvic organ prolapse distress inventory-6 (POPDI-6), Colorectal-Anal Distress Inventory 8 (CRADI-8) and Urinary Distress Inventory-6 (UDI-6).
‡The PFIQ-7 included the Urinary Impact Questionnaire (UIQ-7), Colorectal-Anal Impact Questionnaire (CRAIQ-7).
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Pelvic Floor Exercises and Female Sexual Function 13
caused by perineal lacerations in the postpartum period. In the
long-term follow-up study of Morkved et al,27 postnatal PFME in
women who performed antenatal PFME was associated with
improved sexual satisfaction at 6 years after birth.
These data need to be interpreted with caution, however,
owing to the methodological limitations of the included studies.
The RCT reported by Citak et al21 had a high withdrawal rate,
with no intention-to-treat analysis specified. The interventional
cohort studies also had smaller sample sizes and no control
groups.24e26 The cohort study by Dionisi et al25 used several
treatments for postnatal dyspareunia. In addition, the cohort
study by Gagnon et al26 did not report on the effect of PFME on
SF owing to missing data. The 2 long-term follow-up studies4,27
did not include PFME monitoring and follow-up programs in
the postpartum period up to 6 years after birth owing to the
study design, and 1 long-term cohort study27 did not use a
validated SF scale to measure SF. The RCT by Tennjford et al22
did not find any effect of PFME on SF in the postpartum period;
however, the authors did not measure the domains of female SF
such as desire, arousal, orgasm, and satisfaction. The RCT by
Modarres et al20 also did not compare the domains of sexual
satisfaction between 2 groups. Apart from the preceding limita-
tions, some of the included studies did not report the details of
their PFME program, such as the first training session (eg, in-
dividual or/group training, with or without vaginal palpa-
tion),20,23,25 time of initiation the postpartum period,20,24 and
duration of treatment.24
The physiological mechanism by which PFME contributes to
sexual responses was described, but not measured, in the
included studies. Sexual expression requires cognitive and
emotional capability, as well as basic physical capability,
including sensory and motor function and the ability to move
with ease.38 Consequently, healthy and functional PFMs and
genital organs are essential.9 It has been suggested that PFME
strengthens the levator ani muscles through muscular hypertro-
phy, which leads to revascularization of damaged cells and tis-
sues. This increases vaginal sensation and lubrication, as well as
the duration, intensity, and number of orgasms.5,9 Potential
psychosocial effects of PFME, such as improved self-acceptance,
body awareness, and satisfaction, also have been suggested.22,39
Rather than seeing physical therapy as only physical, a success-
ful treatment also facilitates greater self-awareness and
self-confidence, improved body image, decreased anxiety, and
feelings of empowerment,all of which encourage and affirm
optimal sexual health.38,39 In a literature review on the physical
therapy in the treatment of central pain mechanisms for female
sexual pain, Vandyken et al40 suggested that physical therapists
use evidence-based biopsychological strategies, such as cognitive-
behavioral therapy, pain biology education, mindfulness-based
stress reduction, yoga, and imaginary-based exercises, to
address the biopsychosocial components of female sexual pain.
The effects of confounding variables were not investigated in
any of the included studies. Confounding variables, including the
Sex Med Rev 2018;-:1e16
parental relationship, the psychological, biological, interpersonal,
personal, and partner factors, and the gynecologic pathology,
may adversely affect SF and diminish the benefits of PFME.5,6,21
Despite the possible associations among urinary incontinence,
SF, and PFME in postnatal women, most studies did not assess
this association. Some women with such disorders as pelvic organ
prolapse and urinary incontinence might benefit more than
others from PFME.5,22 Dean et al4 reported that urinary in-
continence symptoms were significantly associated with sexual
dysfunction at 6 years after birth. Gagnon et al26 also reported
that PFME alone in the postpartum period improved urinary
incontinence and colorectal and pelvic organ prolapse symptoms.
Various outcome measures were used to assess SF in the
included studies. Instruments such as the FSFI,21,24 Bailes Sexual
Self-Efficacy Scale,9 and Lindburg questionnaire20 comprehen-
sively measure relevant domains of SF; however, these
instruments require further validation for assessing psychophys-
iological changes during pregnancy and the postpartum period.
The use of such a wide variety of outcome assessment tools calls
into question the optimal way to assess this outcome in child-
bearing women.
What Is the Most Effective Antenatal or Postnatal
PFME Program to Recommend to Women?
PFME has been recommended as a first-line treatment for
pelvic floor dysfunction, including urinary incontinence39;
however, to date there is no consensus regarding the most
effective PFME regimen to recommend to women.16 In this
review, the included studies used a variety of PFME programs
with differences in training methods and follow-up and various
times of initiation and durations in the postpartum period. Most
studies9,21,22,24,26 used vaginal palpation to provide direct feed-
back at the first training session. The first training session was
mostly done individually,9,21,22,24 except in the study by Gagnon
et al,26 in which it was a group training session. Interestingly, all
PFME programs, regardless of the training method and
compliance rate, reported effectiveness in improving
PFMS.9,21e26 Whether biofeedback is more effective than
PFME alone has been debated in the literature. Fitz et al41
reported that PFME with biofeedback was not more effective
than PFME alone; however, Finnbogadottir et al42 reported that
women with impaired PFM contraction ability had better PFMS
after training using biofeedback methods compared with those
receiving PFME alone.
Compliance with PFME remains a challenge in interventional
studies.43,44 Various strategies have been suggested to increase
compliance rates, including intensive PFME programs, appro-
priate follow-up, and more feasible programs.44 In this review,
the reasons cited for dropout in 2 RCTs9,21 included shifts in
residency, illness of babies, inability to leave the house, becoming
pregnant again, not carrying out the PFME properly, dis-
continuing PFME, missing status, unwillingness to continue in
the study, failure to perform the exercise program according to
14 Sobhgol et al
the study, immigration, and severe postpartum bleeding.
Morkved et al29 reported an 81% adherence to the PFME
program in their RCT, meaning that nearly 20% of their par-
ticipants dropped out of the study despite intensive PFME
training and follow-up. Gagnon et al26 achieved a 93%
compliance rate by using a self-select program in which women
who were interested in group training participated in follow-up
individual training. Tennjford et al22 reported almost complete
adherence with weekly group training follow-up. To increase the
effectiveness of PFME, the quality of both the training program
and follow-up is important to increase the compliance rate and
efficacy of treatment. More research is needed in this area to
specify the factors contributing to the effectiveness of and
adherence to PFME.
SUMMARY
The available data on the effects of antenatal or postnatal
PFME on SF is limited. An RCT reported by Wilson et al45
found no significant difference in sexual satisfaction between
control and intervention groups at 1 year postpartum when
PFME was started at 3 months after birth with regular follow-up
with a physiotherapist at 3, 4, 6, and 9 months postpartum. In a
systematic review, Battut et al28 concluded that perineal massage
at the third trimester of pregnancy and second stage of labor,
application of warm packs during the second stage of labor, and
pelvic floor rehabilitation in the postpartum period were not
associated with decreased dyspareunia at 3 months and 1 year
after birth. However, the authors recommended more studies in
this area. In contrast, a recent literature review by Willans et al16
concluded that it is quite probable that desire, arousal, lubrica-
tion, and orgasm are improved by PFME in postpartum women
with urinary incontinence. However, that review was based
mainly on non-randomized studies and included only 1 study
undertaken in the postpartum period.16 Another recent system-
atic review by Ferreira et al5 concluded that PFME seems to
improve at least 1 aspect of SF. However, the authors could not
confirm strong evidence for improvements in desire, arousal,
lubrication, and orgasm owing to the heterogeneity of their study
population. Nevertheless, these 2 studies5,16 were drawn mainly
from the general female population, not from pregnant and
postnatal women. Therefore, this review will add to the knowl-
edge of the effects of antenatal and postnatal PFME on SF.
LIMITATIONS AND STRENGTH
Few studies were found on the effect of PFME (alone or in
combination with an adjunctive therapy) on SF in the postpartum
period. In addition, the included studies carried various degrees of
methodological limitations, such as small sample sizes, lack of
control group, not measuring the main domains of SF, and no
monitoring of PFME. In some of the included studies, it was not
possible to determine whether the participants were the repre-
sentative of a broader population to demonstrate generalizability.
Despite the methodological limitations, the included studies had
strengths in other areas such as examining various PFME training
methods in different populations and various follow-up programs
in the postpartum period. The strength of this review is that it has
highlighted current gaps in the literature on the effect of PFME on
SF, particularly during pregnancy and the postpartum period.
CONCLUSION
There remains a lack of evidence regarding the effect of PFME
on SF during pregnancy, and available data on the effect of
PFME on SF during the postpartum period are limited. Most
included studies reported that PFME alone improved PFMS and
some domains of SF, such as sexual satisfaction, desire, arousal,
and orgasm, in the postpartum period in both the short term and
long term. However, strong recommendations about the effec-
tiveness of antenatal or postnatal PFME on SF require more
high-quality studies, preferably RCTs.
PFME is currently part of antenatal and postnatal care;
however, there is a need to develop an antenatal and postnatal
PFME program that is feasible and effective. More research is
recommended in this area.
ACKNOWLEDGMENTS
The support provided by Western Sydney University is
gratefully acknowledged.
Corresponding Author: Sahar Sadat Sobhgol, PhD Candidate,
Western Sydney University School of Nursing andMidwifery,
Locked Bag 1797, Penrith South DC, NSW 2751, Australia.
Tel: (61) 0296859592; Fax: (61) 02968599599; E-mail: Sahar.
sobhgol@y7mail.com
Conflict of Interest: The authors report no conflicts of interest.
Funding: The funding for the original research project was pro-
vided by Western Sydney University. The current systematic
review was written as part of above research project.
STATEMENT OF AUTHORSHIP
Category 1
(a) Conception and Design
Hannah Grace Dahlen; Sahar Sadat Sobhgol
(b) Acquisition of Data
Sahar Sadat Sobhgol
(c) Analysis and Interpretation of Data
Sahar Sadat Sobhgol; Holly Priddis; Caroline A. Smith
Category 2
(a) Drafting the Article
Sahar Sadat Sobhgol
(b) Revising It for Intellectual Content
Hannah Grace Dahlen; Holly Priddis; Caroline A. Smith;
Sahar Sadat Sobhgol
Sex Med Rev 2018;-:1e16
mailto:Sahar.sobhgol@y7mail.com
mailto:Sahar.sobhgol@y7mail.com
Pelvic Floor Exercises and Female Sexual Function 15
Category 3
(a) Final Approval of the Completed Article
Sex
Sahar Sadat Sobhgol; Hannah Grace Dahlen; Holly Priddis;
Caroline A. Smith
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