Comment: The quality of evidence is downgraded by study limitations (unclear allocation concealment, unclear blinding, and incomplete outcome data in most of the trials) and by inconsistency (unexplained variability in results).
The recommendation is strong because pelvic floor muscle training is an effective, cheap and harmless treatment for urinary incontinence. The recommendation attaches a low value for potential poor availability of the intervention.
A Cochrane review «Pelvic floor muscle training with feedback or biofeedback for urinary incontinence in women»1 «Fernandes ACN, Jorge CH, Weatherall M, et al. Pelvic floor muscle training with feedback or biofeedback for urinary incontinence in women. Cochrane Database Syst Rev 2025;3(3):CD009252. »1 included 41 studies with a total of 3483 subjects. Women who received biofeedback (BF) reported little to no difference in cure or improvement compared to those who received pelvic floor muscle training (PFMT) alone (OR 1.26, 95% CI 1.00 to 1.58; 14 studies, n=1383; moderate-certainty evidence) . However, women in the biofeedback arms had more contact with the health professional than those in the non-biofeedback arms. There were 0.29 fewer leakage episodes in 24 hours ((MD 0.29 lower, 95% CI 0.42 lower to 0.16 lower; 12 studies, 932 women; moderate-certainty evidence). For quality of life, the effect estimates in separate did not show a statistically significant difference, although the possibility of a summary statistic favouring BF or no BF could not be excluded.
A meta-analysis «Wu X, Zheng X, Yi X et al. Electromyographic Biofeedback for Stress Urinary Incontinence or Pelvic Floor Dysfunction in Women: A Systematic Review and Meta-Analysis. Adv Ther 2021;38(8):4163-4177. »3 comparing PFMT with and without electromyographic biofeedback (EMG-BF) for stress urinary incontinence (SUI) included 21 trials with the total of 3865 participants. Compared with PFMT, EMG-BF + PFMT had better rates for cure and improvement in SUI (OR 4.82, 95% CI 2.21 to 10.51, I² = 85.3%), and better quality of life and quality of sexual life.
A multicentre randomised controlled trial «Hagen S, Elders A, Stratton S et al. Effectiveness of pelvic floor muscle training with and without electromyographic biofeedback for urinary incontinence in women: multicentre randomised controlled t»2 assessed the effectiveness of PFMT plus EMG-BF or PFMT alone for newly presenting stress or mixed urinary incontinence in women (n=600). Self-reported severity of urinary incontinence (International Consultation on Incontinence Questionnaire-urinary incontinence short form = ICIQ-UI SF, range 0 to 21) did not differ between the groups (ICIQ-UI SF score 8.2 in biofeedback PFMT vs 8.5 in PFMT). Comment: Women unable to contract their muscles were excluded, as biofeedback is recommended especially for these women.