Neurourology and Urodynamics 22:284^295 (2003) E¡ectiveness of Pelvic Floor Muscle Exercise Therapy Supplemented With a Health Education Program to Promote Long-Term Adherence Among Women With Urinary Incontinence Dianne Alewijnse, 1 Job F.M. Metsemakers, 2 Ilse E.P.E. Mesters, 1 * and Bart van den Borne 1 1 Department of Health Education and Health Promotion, Maastricht University, Maastricht, The Netherlands 2 Department of Family Practice, Maastricht University, Maastricht, The Netherlands Aims: A longitudinal randomized controlled trial (RCT) was conducted to evaluate the e¡ective- ness of physiotherapeutic pelvic £oor muscle exercise (PFME) therapy supplemented with a health education program to promote long-term adherence among women with stress, mixed, and urge urinary incontinence (UI). Methods: Women (n ¼ 129) were evaluated by their general practitioner (GP) and randomized in either the control group (PFME therapy alone) or one of the three experi- mental groups (PFME therapy with one of the three health education program versions). Therapy consisted of 9^18 individual 30 min sessions with a specialized physiotherapist, over 14^22 weeks. Outcome measures were weekly frequency of wet episodes and adherence behavior. Women were assessed up to 1 year after therapy. Results: The health education program had no additional impact to individual contact during PFME therapy on treatment outcome, nor on adherence. However, the individual physiotherapeutic treatment protocol was very e¡ective in reducing weekly fre- quency of wet episodes from 23 to 8 times a week immediately after therapy, and e¡ects were main- tained during the 1-year follow-up period. Adherence was very high; most women followed the behavioral advice on average 6 days/week at posttest and still 4^5 days 1 year after therapy. Results were not di¡erent between incontinence types. Women who had relatively frequent wet episodes before and 1 year after therapy had higher adherence levels compared to women who had fewer weekly losses. Conclusions: Results suggest that a standardized protocol checklist for physiothera- pists covering all treatment aspects of PFME therapy, may optimize long-term treatment outcome and adherence behavior among patients, and outshines the addition of a health education program. Neurourol. Urodynam. 22:284 ^295, 2003. ß 2003 Wiley-Liss, Inc. Key words: adherence; patient education; pelvic £oor muscle exercise therapy; urinary inconti- nence INTRODUCTION Urinary incontinence (UI) comprised of three common types stress, urge, and mixed UI [Abrams et al., 1988]. Pelvic £oor muscle exercise (PFME) therapy has proven e¡ective for all three [Hay-Smith et al., 2001] and PFME ther- apy is recommended as the ¢rst-choice treatment for women with these types of UI after remediable conditions have been excluded. In prior studies up to 70% of patients were cured or improved after therapy [Berghmans et al., 1998a], but success rates declined during follow-up as adherence to the program deteriorated [BÖ andTalseth,1996; Lagro-Janssen and VanWeel, 1998; Chen et al., 1999]. An intervention aimed at promoting long-term adherence to PFME therapy seems warranted. Various authors have pointed out that patient education in physiotherapy, and especially the part of encouraging adher- ence behavior, lacks a systematic behavioral approach [Sluijs et al., 1993]. A literature search was conducted to evaluate approaches designed to improve adherence to PFME therapy. In four studies, the PFME program included adherence- promoting strategies: audiocassette tapes to guide exercising at home, telephone calls as reminders, and follow-up visits to provide feedback and reinforcement. One study found that after 6 weeks of training at home, adherence was signi¢cantly better in the group that had used an exercise tape, compared to the group without the tape [Gallo and Staskin, 1997]. Surpris- ingly, in the other three studies adherence behavior itself was Abbreviations: PFME therapy, pelvic £oor muscle exercise therapy; PFMEs, pelvic £oor muscle exercises; UI, urinary incontinence; GP, general practi- tioner; RCT, randomized controlled trial; ICS, International Continence Society. Grant sponsor: Praeventiefonds/ZON (Netherlands Care Research); Grant number: 28-2505. *Correspondence to: Ilse E.P.E. Mesters, Maastricht University, The Research Institutes Health and Extra, The Netherlands School of Primary Care (CaRe), Department of Health Education and Health Promotion, Faculty of Health Sciences, P.O. box 616, 6200 MD Maastricht, The Nether- lands. E-mail: i.mesters@gvo.unimaas.nl Received 22 January 2002; Accepted 21 January 2003 Published online inWiley InterScience (www.interscience.wiley.com) DOI 10.1002/nau.10122 ß 2003Wiley-Liss,Inc.