Kari Bø

• Haakstad, Lene Annette Hagen; Bø, Kari; Kalhovde, John Magne; Tangen, Elene Mauseth; Clemm, Hege Synnøve Havstad & Gjestvang, Christina (2026). Varying In-Person Coaching: Effects on Weight and Urinary Incontinence in Women with Obesity in a 20-Week Randomized Controlled Trial. International Urogynecology Journal. ISSN 0937-3462. doi: 10.1007/s00192-026-06862-7. Full text in Research Archive
• Theodorsen, Nina-Margrethe Tennebekk; Donnelly, Gráinne & Bø, Kari (2026). Diastasis Rectus Abdominis: Time to Reconsider Our Approach. A Scoping Review. Journal of Women's & Pelvic Health Physical Therapy (JWPHPT). doi: 10.1097/jwh.0000000000000383. Full text in Research Archive Show summary

  Background: Pregnancy-related diastasis rectus abdominis (DRA) is common and characterized by widening of the interrecti distance (IRD). Despite increasing research interest, uncertainty remains regarding diagnostic criteria, clinical relevance, and optimal management. This lack of consensus may contribute to inconsistent practice and over-pathologization of normal pregnancy-related adaptations. This review aimed to summarize evidence on assessment, diagnosis, clinical significance, prevention, and conservative management of DRA while highlighting biopsychosocial considerations and the influence of health messaging on women’s experiences. Methods: An exploratory scoping review was conducted using MEDLINE, Embase, PubMed, and PEDro databases. Peer-reviewed observational studies, randomized controlled trials, and review articles published in English were included. Evidence was synthesized descriptively within a biopsychosocial framework. Results: Evidence suggests that IRD widening during pregnancy represents a normal physiological adaptation, with substantial spontaneous recovery occurring postpartum. However, no consensus exists regarding diagnostic cutoff values, measurement methods, or anatomical locations for defining DRA. The clinical relevance of increased IRD remains debated, particularly for small to moderate separations. Evidence supporting exercise-based interventions to reduce IRD is inconsistent, although abdominal and pelvic floor exercise appears safe and may improve function and patient-reported outcomes. Emerging research highlights the importance of biopsychosocial factors, including body image, fear of movement, and the influence of social media and clinical messaging. Conclusions: Reframing DRA as a physiological adaptation during pregnancy may reduce unnecessary concern and support confident engagement in movement and exercise. Future research should prioritize consensus on diagnostic criteria, development and use of clinically meaningful outcomes, and understanding of persistent DRA to guide evidence-based, person-centered care.

• Siafarikas, Franziska; Benth, Jurate Saltyte; Stær-Jensen, Jette; Reimers, C.; Bø, Kari & Engh, Anna Marie Ellström (2026). Levator hiatus area from 21 weeks' gestation to 8 years after first delivery according to vaginal parity: prospective cohort study with an 8‐year recall extension. Ultrasound in Obstetrics and Gynecology. ISSN 0960-7692. 68(2), p. 273–283. doi: 10.1002/uog.70278. Full text in Research Archive Show summary

  Objectives The first aim was to describe longitudinal changes in levator hiatus area from 21 weeks' gestation in the first pregnancy to 1 and 8 years after first delivery, according to subsequent vaginal parity in women with vaginal delivery or Cesarean section (CS) at first delivery. The second aim was to assess the effect of subsequent vaginal delivery on levator hiatus area after first vaginal delivery. Methods In this prospective cohort study with an 8‐year recall extension, 183 initially nulliparous women underwent three‐ and four‐dimensional transperineal ultrasound examination at 21 weeks' gestation and 1 and 8 years after first delivery. The levator hiatus area at rest, during maximum pelvic floor muscle contraction and during maximum Valsalva maneuver was assessed at each timepoint. Participants with multiple vaginal deliveries (vaginal multiparae), only one vaginal delivery (vaginal primiparae), CS for all deliveries and vaginal birth after CS were compared. The differences between study groups in levator hiatus area over time were assessed using a linear mixed model. Results Overall, vaginal multiparae showed a statistically significant non‐linear increase in levator hiatus area from 21 weeks' gestation to 8 years after first delivery ( P  < 0.001). In contrast, participants who delivered exclusively by CS showed a decrease in levator hiatus area from 21 weeks' gestation to the 8‐year follow‐up. Subsequent vaginal delivery after an initial vaginal delivery did not affect the levator hiatus area during Valsalva maneuver. At the 1‐year and 8‐year follow‐up after the first vaginal delivery, levator hiatus area at rest remained unchanged in vaginal multiparae but decreased in vaginal primiparae. At the 8‐year follow‐up, vaginal multiparae had a larger hiatus area during pelvic floor muscle contraction than did vaginal primiparae. Conclusions In this study, the levator hiatus area was influenced by the mode of the first delivery and by subsequent vaginal deliveries. Overall, the levator hiatus area increased from 21 weeks' gestation to 8 years in participants with at least one vaginal delivery and decreased in those who delivered exclusively by CS. Subsequent vaginal delivery after a first did not seem to affect the levator hiatus area measured during Valsalva maneuver. © 2026 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

• Gabrielsen, Rakel; Tellum, Tina; Bø, Kari; Engh, Anna Marie Ellström & Tennfjord, Merete Kolberg (2026). Effect of pain management, supervised exercise, and pelvic floor muscle training on sexual function in women with endometriosis: A randomized controlled trial. Acta Obstetricia et Gynecologica Scandinavica. ISSN 0001-6349. doi: 10.1111/aogs.70318. Full text in Research Archive Show summary

  Abstract Introduction Pelvic and genital pain is a common symptom among women with endometriosis and may negatively affect sexual functioning. Pelvic floor muscle training (PFMT) may improve sexual functioning, but whether this applies to women with endometriosis remains to be explored. This study is a planned secondary analysis in which we aimed to examine how general exercise and PFMT, when added to pain management, affect sexual functioning among women with endometriosis. Material and Methods Planned secondary analysis of a two‐armed, parallel‐group randomized controlled trial with intention‐to‐treat analysis. Women aged 18–45 years with laparoscopically confirmed endometriosis and experiencing pelvic/genital pain were eligible. All participants attended a pain management course. In addition to weekly home training, the exercise group ( n  = 41) participated in weekly supervised general exercise training, including PFMT, for 4 months. The control group ( n  = 40) received no further intervention. Between‐group differences in sexual function were assessed using the total score of the Female Sexual Function Index (FSFI) at the end of the 4‐month intervention and at the 12‐month follow‐up. We also examined differences in the subdomains—desire, arousal, lubrication, orgasm, satisfaction, and pain—at these time points. Clinical Trial registration: NCT05091268. Results Four months post‐intervention, the exercise group showed significantly higher total FSFI scores compared to the control group (mean difference = 3.52, 95% CI 0.49–6.54, p  = 0.023). Significant between‐group differences were also observed for the subdomains lubrication (mean difference = 0.90, 95% CI 0.17–1.63, p  = 0.016) and orgasm (mean difference = 0.81, 95% CI 0.07–1.55, p  = 0.033). No significant between‐group differences were found for desire, arousal, or pain at the end of the 4‐month intervention, or at 12 months follow‐up for any domain. Conclusions The findings suggest that the combined intervention of supervised exercise and PFMT, when added to pain management, may lead to short‐term improvements in sexual function at the end of the 4‐month intervention. Whether this effect is attributable to general exercise, PFMT, or their combination cannot be determined from the present study. However, the findings should be interpreted cautiously due to differences in sexual activity status between groups.

• Robsahm, Trude Eid; Støer, Nathalie Charlotte; Bø, Kari & Hofvind, Solveig Sand-Hanssen (2026). Exercise trajectories and current exercise and risk of breast cancer: a cohort study of 325,953 women who participated in BreastScreen Norway. Cancer Causes and Control. ISSN 0957-5243. 37(8). doi: 10.1007/s10552-026-02184-7. Full text in Research Archive Show summary

  Purpose The purpose of the study was to elucidate life-course and current exercise levels among women aged 50–69 who participated in BreastScreen Norway during the period from 2006 to 2015, and to estimate the risk of breast cancer based on exercise trajectory classes and current exercise level. Methods Self-reported data from 325,953 women were utilized for descriptive and exploratory analyses. Retrospective information about exercise levels at ages 15–19, 20–29, 30–39, and 40–49 was used to establish exercise trajectory classes, while reported exercise at ages 50–69 was considered as current activity. Hazard Ratios (HR) with 95% confidence intervals (CIs) were estimated using Cox proportional hazards models adjusting for age, educational level and body mass index (BMI). Results Adjusted HR of breast cancer was 0.92 (95% CI: 0.87–0.98) for women in the stable high class and 0.94 (95% CI: 0.89–0.99) for those in the increasing trajectory class compared to the stable low class. The HRs was 0.89 (95% CI: 0.82–0.97) for 4.5 h current exercise per week and 0.72 (95% CI: 0.62–0.84) for ≥ 6 h, compared to those reporting no cur rent exercise. Statistically significant results were observed for asymptomatic (screen-detected) and symptomatic cancers. Stratification by BMI and smoking status did not reveal substantial differences in the risk estimates. Conclusion Engaging in high-level exercise throughout one's lifetime significantly reduces the risk of breast cancer. This study highlights the importance of maintaining or increasing physical activity levels throughout life to mitigate breast cancer risk.

• Risløkken, Jeanette; Macedo, Marthe Dalevoll; Bø, Kari; Engh, Anna Marie Ellström & Siafarikas, Franziska (2026). Occurrence of wound infections after perineal tears and perineal assessment in postpartum care: A prospective cohort study. Acta Obstetricia et Gynecologica Scandinavica. ISSN 0001-6349. doi: 10.1111/aogs.70262. Full text in Research Archive Show summary

  Abstract Introduction There is considerable variation in reported perineal wound infection occurrences and limited knowledge of postpartum follow‐up for perineal injuries. The primary aim of this study was to assess the occurrence of symptoms of perineal wound infections and infections requiring medical intervention within the first 30 days postpartum. The secondary aim was to investigate perineal assessment by healthcare providers in postpartum care. Material and Methods This single‐center cohort study was conducted between October 2020 and October 2022. In this analysis, participants with perineal tears and episiotomies following vaginal deliveries were included. Women were contacted via telephone seven to 10 days postpartum and asked about symptoms for infection recommended by the “Surgical Site Infection Surveillance Service.” At 3 months postpartum, participants reported via questionnaire on receiving medical interventions for wound infection and whether a healthcare provider inspected their perineal tear. Results The study sample comprises a total of 748 primi‐ and multiparous women (58.3% primipara, 41.7% multipara). Sixteen participants (2.2%) reported wound infection symptoms. Wound infections requiring medical interventions were identified in seven women (1.1%), all of whom were primipara. This included five cases with an episiotomy and two cases with a second‐degree tear. Half of the participants had their perineal tear inspected during the 6‐week follow‐up visit. Depending on tear category, between 25% and 72% of women who did not undergo an inspection would have preferred one. Conclusions In our population, symptoms of perineal wound infection were 2.2% and infections requiring medical intervention were 1.1%. Half of the participants received a perineal tear inspection at the 6‐week follow‐up visit.

• Khadgi, B.; Stuge, Britt Karin; Bø, Kari; Acharya, R.; Brandt, C. & Stensdotter, Ann-Katrin Irene (2026). Knowledge, self-perception and ability of pelvic floor muscle contraction among Nepalese women with urinary incontinence. Brazilian Journal of Physical Therapy (BJPT). ISSN 1413-3555. 30(3). doi: 10.1016/j.bjpt.2026.101598. Full text in Research Archive
• Simpson, Eloise; Hannington, Madeline; Bø, Kari & Hahne, Andrew (2026). Association Between Diastasis of the Rectus Abdominis Muscles and Musculoskeletal Conditions in the First 2 Years Postpartum: A Cross-Sectional Study. Musculoskeletal Care. ISSN 1478-2189. 24(1). doi: 10.1002/msc.70209. Full text in Research Archive Show summary

  Objective To explore associations between the presence and severity of diastasis of the rectus abdominis muscles (DRAM) and common postpartum musculoskeletal complaints in the first 2 years postpartum. Study Design Cross-sectional survey among women within 2 years of childbirth. Background DRAM commonly affects women during pregnancy and postpartum, but its relationship with musculoskeletal complaints remains unclear. This study investigates the association between DRAM and postpartum musculoskeletal complaints, including low back pain, pelvic girdle pain, abdominal pain, and pelvic floor dysfunction. Methods and Measures Participants were identified from medical records of women who had delivered a baby in the previous 2 years at Southwest Healthcare, Warrnambool, Victoria, Australia. An electronic questionnaire collected data on DRAM presence and severity (self-reported based on self-assessment or prior healthcare professional screening), musculoskeletal complaints, and pelvic floor dysfunction both currently (within the past week) and early postpartum (within the first 3 months). Statistical univariate and multivariate regression analyses explored associations between DRAM presence or severity and reported symptoms adjusted for age, parity, delivery method and time since last delivery. Results Of 177 respondents (from 785 survey invitations), 38% (n = 70) reported DRAM. In multivariate analysis, DRAM presence was significantly associated with current (p = 0.034) and early postpartum (p = 0.037) abdominal discomfort, and urinary urgency symptoms early postpartum (p = 0.033). No significant associations were found between DRAM and low back pain, pelvic girdle pain, or stress urinary incontinence. Conclusion DRAM was weakly associated with abdominal discomfort and urinary urgency symptoms but not with other musculoskeletal complaints. These findings align with limited previous research on this topic. More data are needed to explore the association between DRAM severity and musculoskeletal disorders.

• Gram, Marte Charlotte Dobbertin; Fagerland, Morten & Bø, Kari (2026). PHYSICAL CAPACITY OF HIGH-LEVEL RHYTHMIC GYMNASTS. Science of Gymnastics Journal (ScGYM). ISSN 2232-2639. 18(1), p. 97–111. doi: 10.52165/sgj.18.1.97-111. Full text in Research Archive Show summary

  Overuse injuries in the lower back, knees and hip/groin are common among competitive rhythmic gymnasts. The aetiology and mechanisms are multifactorial, and insufficient physical capacity relative to sport specific requirements may be one of several factors causing overuse injuries. The aims of the present study were to investigate strength and flexibility in the lower back, knees and hip/groin in relation to requirements within rhythmic gymnastics (RG), and to identify possible adverse movement patterns that can be targeted through exercises in future injury prevention research. This was a cross-sectional clinical study where all rhythmic gymnasts in a Northern European country’s national team and their recruitment group were invited to participate. The clinical assessment followed a standardized test protocol and consisted of selected tests on strength, flexibility and RG-specific movements. Background variables (anthropometrics, weekly training hours, previous injuries, present health problems and other health measures) were collected in an electronic questionnaire. Twenty of 24 rhythmic gymnasts (83%), aged 12-19 years, participated. Seven selected tests not previously tested for reliability underwent a test-retest of intra-rater reliability in 10 gymnasts. Intraclass correlation coefficient (ICC) values ranged from 0.84 to 0.98 and Cohen’s kappa values ranged from 0.74 to 1.0. The clinical tests identified insufficient strength and ability to transform passive range of motion into active range of motion. In addition, adverse movement patterns related to lower back (one-segment hyperextension) and knee (valgus) were observed. Randomized controlled trials are needed to study the effect of incorporating these findings into an injury prevention program within RG.

• Bjurulf, Clara; Meng, Lingge; Budgett, David; Kruger, Jennifer & Bø, Kari (2026). Can Pre-Contraction of the Pelvic Floor Muscles Exceed Increases in Intra-Abdominal Pressure During Strength Exercises? International Urogynecology Journal. ISSN 0937-3462. 37, p. 1709–1720. doi: 10.1007/s00192-026-06540-8. Full text in Research Archive Show summary

  Introduction and Hypothesis: A recent study found that young power and weightlifters reported a high prevalence of pelvic floor disorders (PFDs) with urinary incontinence (UI) 50%, anal incontinence 80% and pelvic organ prolapse 23%. Performing “the knack”, a voluntary pre-contraction of the pelvic floor muscles (PFMs), before and during stressful events, can prevent UI during coughing and daily activities. However, the effect of this manoeuvre has not been investigated during strenuous exercises. This study was aimed at investigating the feasibility of using the femfit® to measure intra-abdominal pressure (IAP) and PFM pressure during strength exercises and at discovering if a voluntary pre-contraction of the PFMs can exceed increases in IAP during strength exercises. Methods: This was a short-term, cross-sectional, experimental study. Eleven participants were tested in squat, deadlift, leg press and curl up, performed in a random order with and without voluntary pre-contraction of the PFMs. Assessment of the ability to contract the PFMs was conducted by suprapubic 2D ultrasound. IAP and PFM pressure were measured with the femfit®. Wilcoxon Signed Rank Test was used to estimate differences in change between IAP and PFM pressure with and without voluntary pre-contraction during the strength exercises. Results: No participants reported displacement or discomfort from the femfit® device. Voluntary pre-contraction of the PFMs did not exceed the rise in IAP during squat, deadlift, leg press and curl up. Conclusions: The PFM pressure was not significantly higher than the IAP during strength exercises. Further longitudinal studies are warranted to investigate if systematic PFM training can improve the strength of the voluntary pre-contraction.

• Fretta, Tatiana de Bem; Bø, Kari; Mendes, Pauliana Carolina de Souza; Dias, Mirella; Roza, Daiane Leite da & Jorge, Cristine Homsi (2026). Telerehabilitation reduced urinary incontinence, pelvic pain and dyspareunia in women after treatment for gynaecological cancer: a randomised trial. Journal of Physiotherapy. ISSN 1836-9553. 72(1), p. 53–60. doi: 10.1016/j.jphys.2025.12.007. Full text in Research Archive Show summary

  Question: How effective is a telerehabilitation program in reducing reports of pelvic floor dysfunction in women after gynaecological cancer treatment? Design: Randomised controlled trial with blinded assessors, concealed allocation and intention-to-treat analysis. Participants: Fifty-eight women reporting urinary incontinence (UI) after treatment for gynaecological cancer. Interventions: Experimental group participants were allocated to undertake telerehabilitation sessions including pelvic floor muscle training once a week for 12 weeks. The control group received usual care. Outcome measures: The primary outcome was the prevalence of UI on the International Consultation on Incontinence Questionnaire - Urinary Incontinence Short Form (ICIQ-UI-SF). The secondary outcomes were: the impact of UI on quality of life (ICIQ-UI-SF), sexual function (Female Sexual Function Index), dyspareunia (numerical assessment scale), self-esteem (Rosenberg), pain (numerical assessment scale), faecal incontinence, stool consistency, vaginal stenosis, quality of life (European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire) and level of physical activity. After 12 weeks, the telerehab group also responded about treatment satisfaction, adherence and system usability. Results: After 12 weeks, the experimental group had better outcomes than the control group in several areas: prevalence of UI (RD –0.45, 95% CI –0.62 to –0.23); total ICIQ-UI-SF score (MD –9.5, 95% CI –11.8 to –7.1); pelvic pain (MD –3.1, 95% CI –4.7 to –1.4); self-esteem (MD 2.9, 95% CI 0.7 to 5.1); and measures of vaginal stenosis and quality of life. Conclusion: A 12-week telerehabilitation program was effective in reducing reports of UI, severity of UI, pelvic pain and dyspareunia in women after the treatment of gynaecological cancer. Registration: Brazilian Clinical Trials Registry (ReBEC) RBR-8ht5nqq.

• Rohde, Meghan; Brumitt, Jason; Sandvik, Jodi & Bø, Kari (2025). Prevalence of Stress Urinary Incontinence in Female Strength Athletes. The Internet Journal of Allied Health Sciences & Practice. 23(3). doi: https:/nsuworks.nova.edu/ijahsp/vol23/iss3/31/. Full text in Research Archive Show summary

  Background: Stress urinary incontinence (SUI) is a symptom during pregnancy and in the postpartum period, but a high prevalence of SUI is experienced in sports involving running and jumping. Objectives: Identify the scope of the problem of SUI in women participating in strength sports, movement patterns that elicit SUI, and the impact on quality of life in female athletes with SUI. Study Design: Survey mixed methods with qualitative focus groups. Methods: The International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF) and a sport-specific and obstetric/gynecological history questionnaire were sent to women who are United States citizens, age 18-65, and members of USA Weightlifting, USA Powerlifting, and/or CrossFit affiliates. Polychoric and Spearman correlations were conducted for survey analysis. Logistic regression was performed to estimate predictors of the likelihood of women experiencing urine leakage with exercise. Wald chi-square tests were used to calculate odds ratios for each outcome. Following the survey, respondents were able to volunteer to participate in two focus groups for qualitative data. Results: Three hundred forty-two respondents completed the online survey. Sixty four percent reported any leakage and 44.8% (n=155) of those reported leakage during training. Parous women were more likely to report SUI than nulliparous women and there was a moderate correlation between parity, hours of training, and urinary leakage both during and outside of exercise. Olympic lifters had a greater risk of SUI than CrossFit athletes (OR 1.227 (95% 1.04-1.45, p=.01)). Qualitative reports demonstrated feelings of embarrassment, frustration, and hopelessness with urine leakage during and outside exercise. Women reported double unders, deadlift, running/jumping, front squats, cleans, and push press as offending movements that cause leakage during training. The athletes also reported adjustments to, or elimination of, training exercises and that urinary leakage is an acceptable side effect of training. Conclusion: Women in strength sports experience SUI with a moderate correlation between parity, hours of training, and leakage during and outside of training, negatively affecting sport performance.

• Davenport, Margie H; Christopher, Shefali; Deering, Rita E.; Prevett, Christina; Dufour, Sinead & Forte, Milena [Show all 22 contributors for this article] (2025). International Delphi study of clinical and exercise professionals’ opinion of physical activity prescreening and contraindications for participating in postpartum physical activity. British Journal of Sports Medicine. ISSN 0306-3674. 59(8), p. 527–538. doi: 10.1136/bjsports-2024-109104. Full text in Research Archive Show summary

  Objective To establish expert consensus on prescreening and contraindications to moderate-to-vigorous intensity physical activity (MVPA) during the first year postpartum. Methods A Delphi survey of clinical and exercise professionals working with postpartum women and people was conducted until consensus was reached (≥75% agreement). Round I consisted of questions about relative and absolute contraindications to MVPA. Rounds II and III included additional questions based on the thematic coding of open-ended responses from the previous rounds. The results were used to develop a postpartum MVPA preparticipation screening tool. Results 120 participants completed round I, 105 completed round II and 95 completed round III. Consensus was reached in 46/49 (94%) statements. Twenty-four relative contraindications to MVPA were identified: (loss of consciousness; neurological symptoms; kidney disease; calf pain or swelling suggestive of deep vein thrombosis; severe abdominal pain; vaginal bleeding not associated with menses; postpartum cardiomyopathy; caesarean section with symptoms that worsen with MVPA; unstable hypertension; eating disorder; malnutrition; anaemia; excessive fatigue; fractures or other significant musculoskeletal injuries; haemodynamic instability; breathing difficulties; acute systemic infection accompanied by fever, body aches, or swollen lymph glands; the new onset of chest pain, discomfort, and other angina-like symptoms with exertion; dizziness or lightheadedness during MVPA; new symptoms of heart disease, stroke; and other medical or physical conditions that may affect the ability to be physically active. Key biopsychosocial barriers to MVPA were identified. Conclusion This Delphi study recommends relative contraindications to MVPA for the first year postpartum that were incorporated into a postpartum MVPA pre-participation screening tool the Get Active Questionnaire for Postpartum.

• ShahAli, Shabnam; Bø, Kari; Hejazi, Anahita; Hashemi, Hamideh & Kharaji, Ghazal (2025). Effect of pelvic floor muscle training on pelvic floor muscle morphometry in subjects with pelvic organ prolapse: a systematic review and meta-analysis. BMC Women's Health. 25. doi: 10.1186/s12905-025-04095-2. Full text in Research Archive Show summary

  Background Pelvic organ prolapse (POP) is common among women and is associated with bladder, bowel, and sexual dysfunction, reducing quality of life. Pelvic floor muscle training (PFMT) is recommended as a first-line conservative therapy, but its effects on pelvic floor muscle (PFM) morphometry remain unclear. This is the first systematic review and meta-analysis to evaluate the effects of PFMT on PFM morphometric parameters in women with POP. Methods A comprehensive search of PubMed/MEDLINE, Scopus, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, the Cochrane Library, and the Physiotherapy Evidence Database (PEDro) was conducted. The study was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The search strategy covered all records from database inception to July 9, 2025. Randomized controlled trials (RCTs) and clinical trials assessing PFMT effects on PFM morphometry were included. Methodological quality was assessed using the PEDro scale. Meta-analyses were performed using random-effects and fixed-effects models. Results Eight studies with 579 women (POP stages I–III) were included. Meta-analyses based on excellent to low quality evidence demonstrated significant reductions in levator hiatus area (LHA) at rest (MD = − 1.97; 95% CI: −2.79 to − 1.15; p < 0.0001; 3 studies) and, based on good to low quality evidence, during the Valsalva maneuver (MD = − 2.30; 95% CI: −3.36 to − 1.25; p < 0.0001; 2 studies). Furthermore, excellent to low quality evidence indicated that PFMT improved bladder neck position (MD = 0.16; 95% CI: 0.08 to 0.23; p < 0.0001; 3 studies). Narrative synthesis suggested improvements in PFM strength, while effects on the POP stage were inconsistent across studies. Based on PEDro ratings, the included studies comprised three excellent, one good, two moderate, and two low-quality trials. Conclusion PFMT may improve PFM morphometry, POP stage, and muscle strength in women with POP. However, the evidence remains limited due to the small number of studies, the low quality of some studies, and the inclusion of women with POP stages I–III. High-quality RCTs are needed to address these limitations and identify patient subgroups most likely to benefit.

• Lilleberg, Hanne Sether; Siafarikas, Franziska; Starck, Marianne; Rotstein, Emilia; Bø, Kari & Engh, Anna Marie Ellström (2025). Perineal Body Anatomy in Primiparas Assessed by Three-Dimensional Endovaginal and Endoanal Ultrasound: A Reliability Study. International Urogynecology Journal. ISSN 0937-3462. doi: 10.1007/s00192-025-06379-5. Full text in Research Archive Show summary

  Abstract Introduction and Hypothesis The integrity of the perineal body (PB) is essential for pelvic floor function. Anatomical deviations in the PB anatomy after childbirth can lead to pelvic floor symptoms, but the reliability of ultrasound assessments for these deviations is unclear. This study evaluates the intra- and inter-rater reliability of detecting deviations in the muscles fusing into the PB and measuring its size using three-dimensional endovaginal (3D EVUS) and endoanal ultrasound (3D EAUS) 1 year postpartum. Methods Forty primiparous women underwent 3D EVUS and 3D EAUS 1 year after birth. The transverse perineal, puboperinealis, and puboanalis muscles were identified where they fuse into the PB. Deviations were defined as discontinuities in or absence of muscle fibers on the right, left, or center. Measurements of PB height, length, and area were taken in the mid-sagittal plane. Intra- and inter-rater reliability for muscle deviations were assessed using percentage agreement and Cohen’s kappa, while PB size measurements were evaluated using the intra-class correlation coefficient. Results Kappa values indicated excellent intra- and inter-rater reliability for the transverse perineal muscle ( κ = 0.881, κ = 0.871) and puboperinealis muscle ( κ = 0.849, κ = 0.810) in 3D EVUS. For the puboanalis muscle, intra-rater reliability was excellent ( κ = 1.00) and inter-rater reliability was good ( κ = 0.658). Similar kappa values were found using 3D EAUS. Percentage agreement for deviations ranged from 90% to 100% for both ultrasound methods. PB measurement also showed good to excellent reliability: 0.76-0.97 for 3D EVUS and 0.90–0.99 for 3D EAUS. Conclusion 3D EVUS and 3D EAUS are reliable methods for assessing PB muscle deviations and its size 1 year postpartum.

• Culleton-Quinn, Elizabeth; Bø, Kari; Fleming, Neil; Cusack, Cinny & Daly, Déirdre (2025). Elite female Gaelic sports athletes’ experience of urinary incontinence: A qualitative study. Women's Health. ISSN 1745-5057. 21, p. 1–11. doi: 10.1177/17455057251406949. Full text in Research Archive Show summary

  Background: Urinary incontinence (UI) is known to be prevalent among elite female athletes. A need for additional sports-specific research has been identified, along with a need to understand female athletes’ experience of UI. There is a dearth of research on elite Female Gaelic (Irish) sports players competing in national competitions. Aim: To investigate elite female Gaelic sports (Camogie and Football players) athletes’ experiences of UI. Design: A qualitative descriptive design using one-to-one interviews. Methods: Following University ethics approval, purposive sampling was used to recruit elite female Gaelic sports athletes aged 18 years or older playing at the county level between November 2022 and August 2023. Data were analysed thematically using reflexive thematic analysis, a six-phase process. Findings: Nine players consented to and completed an interview. Four key themes and nine sub-themes were generated. Four themes were: (1)‘Oh, that happened me’ (when and why of UI); (2) ‘Then I can manage it that way’ (what to do about UI); (3) ‘It is frustrating. . . and it bothers me’ (impact of UI) and (4) ‘No one ever talked’ (talking about UI). High-intensity and high-impact activities were identified by all players as triggers for UI, suggesting stress urinary incontinence. Strategies to manage UI were used by all nine players and included extra and frequent pre-match voiding, wearing protection, and modifying their clothing or fluid intake. Players minimised the extent of their UI; however, all spoke of experiencing either a physical or an emotional impact because of the UI. Conclusions: This study provided qualitative evidence on elite female athletes’ experience of UI. Players used strategies to self-manage their UI, few spoke about, or sought help for their UI whilst many expressed a desire for education. Findings suggest a need for education programmes among players to include information about the condition of UI as well as available treatment options.

• Lilleberg, Hanne Sether; Siafarikas, Franziska; Bø, Kari & Engh, Anna Marie Ellström (2025). Severity of perineal tears and deviations in perineal body anatomy: A three‐dimensional ultrasound study. Acta Obstetricia et Gynecologica Scandinavica. ISSN 0001-6349. doi: 10.1111/aogs.70114. Full text in Research Archive Show summary

  Abstract Introduction Perineal tears are classified into four degrees based on severity. Second‐degree tears, which involve the muscles fusing into the perineal body, but not the anal sphincter, vary in extent and have recently been subcategorized. However, knowledge about their long‐term anatomical impact on the perineal body remains limited, as postpartum evaluation has largely relied on inspection and palpation. This study aimed to examine the association between the severity of perineal tears not affecting the anal sphincter, diagnosed at delivery, and deviations in the muscles fusing into the perineal body, assessed by three‐dimensional ultrasound 1 year after vaginal delivery. Material and Methods This prospective cohort study included 384 primiparous women with vaginal deliveries at Akershus University Hospital, Norway, from January 2021 to July 2022. Perineal tears were classified and sutured according to international standards at delivery. In addition, second‐degree tears were subclassified according to the percentage of the perineal body damage (<50% = 2A, ≥50% = 2B, entire perineal body without anal sphincter = 2C). Women with third‐ or fourth‐degree tears were excluded. One year after delivery, participants underwent three‐dimensional endovaginal and endoanal ultrasound examinations. The transverse perineal, puboperinealis, and puboanalis muscles were examined at their fusion into the perineal body. A deviation was defined as a muscle discontinuity or absence in at least one of the muscles. Results The proportion of women with sonographically detected muscle deviations increased with tear severity: 22% for first‐degree ( n  = 24), 52.7% for 2A ( n  = 29), 60% for 2B ( n  = 21) and 86.2% for 2C ( n  = 25). Among women with episiotomies ( n  = 126), 60.6% had one or more muscle deviations. A higher number of muscles were affected in the 2C tear group compared to 2B and 2A. Conclusion Sonographic deviations in the muscles fusing into the perineal body increase with the severity of perineal tears.

• Dalhaug, Emilie Frederikke Mass; Sanda, Birgitte; Bø, Kari; Brown, Wendy & Haakstad, Lene Annette Hagen (2025). Pushing limits: the acute effects of a heavy-load resistance protocol and supine exercise on fetal well-being. BMJ Open sport & exercise medicine. 11(3), p. 1–8. doi: 10.1136/bmjsem-2025-002639. Full text in Research Archive Show summary

  Objectives To explore the acute effects of a heavy-load resistance protocol and exercise in the supine position on fetal heart rate (FHR) and uteroplacental blood flow. Method In this experimental laboratory study, 48 healthy pregnant athletes (elite: n=7; recreational: n=41) completed 3×8 repetitions with one repetition in reserve in sumo deadlift, bench press and incline bench press. FHR and umbilical and uterine artery pulsatility index (PI) were assessed before and after exercise. Symptoms of vena cava syndrome were recorded following the supine exercise. Results Pre- and post-exercise FHR remained within the normal range (110–160 bpm), but there were statistically significant increases after sumo deadlifts (p=0.002) and incline bench press (p=0.008), with no significant change after bench press (p=0.122). Umbilical artery PI did not change, while uterine artery PI significantly decreased after the sumo deadlift (p=0.005), bench press (p<0.001) and incline bench press (p<0.001). No fetal bradycardia was observed after the sumo deadlift or incline bench press, but one case occurred after bench press, resolving shortly after 3 min. Fetal tachycardia (>160 bpm) occurred in four cases after sumo deadlift, five after bench press and three after incline bench press, though none exceeded pathological levels (>180 bpm). One recreational athlete experienced symptoms of vena cava syndrome after the supine exercise, coinciding with a slight decrease in umbilical artery PI, but with stable FHR. Conclusion The results indicate that highly active women, especially those with resistance training experience, can safely engage in a heavy-load resistance protocol, including supine exercise, without jeopardising fetal well-being.

• Gabrielsen, Rakel; Tellum, Tina; Bø, Kari; Engh, Anna Marie Ellström; Frawley, Helena & Tveito, Synne Nedregård [Show all 7 contributors for this article] (2025). Supervised exercise and pelvic floor muscle training eases current pelvic and genital pain but not worst pelvic and genital pain in women with endometriosis: a randomised trial. Journal of Physiotherapy. ISSN 1836-9553. 71(4), p. 246–253. doi: 10.1016/j.jphys.2025.09.012. Full text in Research Archive Show summary

  Question: How much does adding supervised group and independent individual exercise including pelvic floor muscle training (PFMT) to multidisciplinary pain management affect pelvic and genital pain in women with endometriosis? How much does it affect dyspareunia, dysuria, quality of life (with emphasis on psychological distress, including symptoms of depression and anxiety), symptoms of chronic constipation and pelvic floor muscle (PFM) function? Design: A two-armed, parallel-group, randomised controlled trial with concealed allocation, intention-to-treat analysis and blinded assessment of some outcomes. Participants: Women aged 18 to 45 years with laparoscopically confirmed endometriosis experiencing pelvic/genital pain. Intervention: All participants attended a pain management course. The exercise group (n = 41) then performed weekly supervised general exercise training including PFMT for 4 months, and home training two to three times/week. The control group (n = 40) received no further intervention. Outcome measures: Primary outcomes were the change in worst pelvic/genital pain over 1 month and current pelvic/genital pain measured on a numerical rating scale at 4 and 12 months. Secondary outcomes measured at the same time points were: location and concerns related to dyspareunia; presence of dysuria; symptoms of chronic constipation assessed with the Knowles-Eccersley-Scott-Symptom scale; and quality of life with emphasis on psychological distress, including symptoms of depression and anxiety assessed with Hopkins Symptom Checklist-5. PFM function was measured with surface electromyography and manometry at baseline and 4 months. Results: The intervention did not improve worst pelvic/genital pain but it did have a clear benefit on current pelvic/genital pain at the end of the intervention (MD 1.1, 95% CI 0.2 to 2.1). This benefit was still present at the 12-month follow-up (MD 1.5, 95% CI 0.2 to 2.7). The effects on other outcome measures were unclear. Conclusion: Adding supervised group and independent individual exercise including PFMT to pain management did not improve worst pelvic/genital pain but improved current pelvic/genital pain. Effects on other outcomes warrant further investigation.

• Anklesaria, Sanya; Padiyar, Rukmini; Solomon, John M.; Bø, Kari; Pai, Aparna R. & Rao, Chythra R. [Show all 8 contributors for this article] (2025). Physiotherapy interventions for pelvic floor dysfunctions in stroke survivors – a scoping review of literature. Topics in Stroke Rehabilitation. ISSN 1074-9357. 32(7), p. 744–756. doi: 10.1080/10749357.2025.2463284. Full text in Research Archive Show summary

  Background Pelvic floor dysfunction (PFD) are common following stroke. Physiotherapy interventions such as pelvic floor muscle training (PFMT) seems to be effective in the general population with PFD, but its usefulness in stroke patients has rarely been addressed. Objectives We aimed to explore existing physiotherapy interventions and their influence in managing PFD in men and women stroke survivors. Methods Eight major databases were searched from inception to date using appropriate keywords and search strings. We included experimental studies comparing physiotherapy to control interventions/alternate treatments. PFD were grouped under urinary incontinence (UI), bowel dysfunction (BD), and sexual dysfunctions (SD) based on the studies. Two reviewers independently screened the title and abstract, to determine the included studies and the third author resolved disputes. Results Fourteen studies were identified of which ten focused on the management of UI, one on BD, and three on the management of SD. PFMT was predominantly used to manage UI independently or combined with other forms of treatment such as timed voiding, intermittent catheterization, acupuncture, and drug therapy. BD was managed using anal sphincter strengthening exercises, PFMT, and bowel training. Management of SD for both men and women included comfortable and safe sexual position training, stretching, and PFMT. Studies found significant improvement in terms of symptoms of bladder and bowel incontinence, number of incontinence episodes and muscle strength on digital palpation of the pelvic floor muscles. Conclusion Physiotherapy interventions including PFMT may help in managing the symptoms and improving the quality of life of stroke survivors with PFD.

• Gram, Marte Charlotte Dobbertin; Fagerland, Morten & Bø, Kari (2025). Pelvic floor muscle training by competitive rhythmic gymnasts at regular training sessions did not reduce urinary incontinence: a cluster-randomised trial. Journal of Physiotherapy. ISSN 1836-9553. 71(2), p. 117–124. doi: 10.1016/j.jphys.2025.03.006. Full text in Research Archive Show summary

  Question What is the effect of an expanded warm-up program including pelvic floor muscle training (PFMT) compared with usual warm-up on bother and prevalence of urinary incontinence (UI) among rhythmic gymnasts? What is the self-perceived effect of PFMT, including its progression over time, assessed via the global rating of change? Design A cluster-randomised controlled trial with concealed allocation and intention-to-treat analysis. Participants Gymnasts had to be ≥ 12 years of age and training in rhythmic gymnastics ≥ 3 days/week. Twenty-three rhythmic gymnastics clubs were randomised to an experimental group (12 clubs, 119 gymnasts) or a control group (11 clubs, 86 gymnasts). Intervention The experimental group performed one set of 8 to 12 near-maximum pelvic floor muscle contractions and exercises for the knees, lower back and hip/groin as warm-up before each training session for 8 months. The control group continued rhythmic gymnastics training as usual without PFMT or additional lower back and lower limb exercises. Outcome measures Primary outcomes were bother from UI (score 0 to 21) and prevalence of UI, each measured by the International Consultation on Incontinence Questionnaire - Urinary Incontinence Short Form (ICIQ-UI-SF). The secondary outcome measure was the self-perceived effect and its progress over time, assessed using the global rating of change (–5 to 5). Results The difference between the groups in the ICIQ-UI-SF total score (ie, UI bother) was clearly negligible (MD –0.48, 95% CI –1.27 to 0.31). The prevalence of UI reduced from 46 to 41% in the experimental group and increased from 32 to 34% in the control group; despite this, the risk difference at 8 months was negligible (RD 0.07) and the confidence interval spanned mainly negligible effects (95% CI –0.08 to 0.21). Experimental group participants rated their global change at a mean of 2.1 (SD 1.7). Conclusion Eight months of warm-up before rhythmic gymnastics training sessions that included one set of 8 to 12 near-maximum PFM contractions did not reduce UI bother. The effect on UI prevalence was also likely to be negligible, despite experimental group participants perceiving benefit from the intervention.

• Gram, Marte Charlotte Dobbertin; Fagerland, Morten & Bø, Kari (2025). Efficacy of a Rhythmic Gymnastics-Specific Injury Prevention Program: An Assessor-Blinded Cluster-Randomized Controlled Trial. Scandinavian Journal of Medicine & Science in Sports. ISSN 0905-7188. 35(2). doi: 10.1111/sms.70022. Full text in Research Archive Show summary

  Overuse injuries are common among competitive rhythmic gymnasts, with an estimated weekly prevalence of 37% and with the knees, lower back, and hip/groin as the most common injury locations. Reduced physical capacity (e.g., strength and flexibility) has been hypothesized to contribute to the high prevalence of overuse injuries. The primary objective of this trial was to assess if exercises targeting reduced physical capacity in the knees, lower back, and hip/groin reduce the prevalence of overuse injuries compared with usual training. Twenty-three rhythmic gymnastics clubs were cluster-randomized to an intervention group (IG: 12 clubs and 119 gymnasts) and a control group (CG: 11 clubs and 86 gymnasts). Included gymnasts had to be ≥ 12 years of age and training ≥ 3 days per week. The IG performed a targeted injury prevention program (IPP) during training/warm-up for 8 months (November 2022 to June 2023). The CG performed usual training. The prevalence of overuse injuries in the targeted locations was measured monthly in both groups using the Oslo Sports Trauma Research Centre Questionnaire on Health Problems (OSTRC-H2). The response rate to OSTRC-H2 was 94%. There was no difference in the prevalence of overuse injuries in the targeted locations between the two groups; odds ratio = 0.86 (95% CI 0.32 to 2.29); p = 0.77 for intervention vs. control. The results suggest that a targeted IPP alone is not enough to prevent overuse injuries in the knees, lower back, and hip/groin among competitive rhythmic gymnasts. Other measures (e.g., load management and proper training planning) might be targeted in future studies.Trial Registration:ClinicalTrials.gov: NCT05506579

• Dalhaug, Emilie Frederikke Mass; Sanda, Birgitte; Bø, Kari; Brown, Wendy J.; Sundgot-Borgen, Jorunn & Haakstad, Lene Annette Hagen (2025). Exceeding the guidelines: A descriptive study of exercise, pregnancy, maternal and neonatal health outcomes in elite and recreational athletes. BMC Pregnancy and Childbirth. 25(1). doi: 10.1186/s12884-025-07572-6. Full text in Research Archive Show summary

  Background Exercise during pregnancy is associated with numerous health benefits. However, guidelines for elite and recreational athletes, who often exceed general recommendations regarding intensity, duration, and frequency are lacking, and potential risks remain unclear. The aim of the study was to describe exercise levels, pregnancy, and maternal and neonatal health outcomes in elite and recreational athletes. Method This study was part of the Strong Mama research project, which was carried out in Oslo, Norway, between October 2022 and February 2024. Sixty athletes (10 elite and 50 recreational) participated in the study. They completed an online survey during late pregnancy and participated in a structured telephone interview six weeks postpartum. The survey and interview collected data on exercise habits, pregnancy experiences, and maternal and neonatal health outcomes. Results The athletes maintained high exercise levels during pregnancy, with elite athletes exercising an average of 11.6 h per week (SD 3.2) and recreational athletes exercising 7.0 h per week (SD 2.4). Most athletes resumed exercising within six weeks postpartum. Almost all pregnancies were planned, including six which involved fertility treatment. Most women (76.7%) had spontaneous onset of labor and vaginal deliveries to term (between 36 and 42 weeks). The mean birthweight was 3487 (SD 519.4, range 2600–4775) grams. Two of the elite athletes were diagnosed with gestational diabetes mellitus and two with hypertension during pregnancy. None of the 50 recreational athletes reported any pregnancy complications. Conclusion High levels of exercise during pregnancy did not seem to negatively impact maternal or neonatal health in this descriptive sample of Norwegian elite and recreational athletes. However, more research is needed to confirm these findings

• Dalhaug, Emilie Frederikke Mass; Sanda, Birgitte; Bø, Kari; Brown, Wendy J.; Øvstedal, Kaia & Brevik-Persson, Anna Sofia [Show all 7 contributors for this article] (2025). Is fetal well-being jeopardised during high-intensity interval training? BMJ Open sport & exercise medicine. 11(2). doi: 10.1136/bmjsem-2025-002496. Full text in Research Archive Show summary

  Objectives: To explore the acute effects of highintensity interval training on fetal heart rate (FHR) and uteroplacental blood flow. Method: Elite (n=10) and recreational athletes (n=50) participated in an experimental laboratory study involving 5×5min intervals of high-intensity exercise on both a treadmill and cycle ergometer, with a 4min pause between intervals for measurement of FHR and uteroplacental blood flow. Target intensity was 17 on Borg’s rating of perceived exertion (RPE) scale and 90% of estimated maximal maternal heart rate (MHRmax). Results: Mean exercise intensity was 16.4 (SD 1.0) RPE and 89.4 (SD 3.8) % of MHRmax during running and 16.0 (SD 1.0) RPE and 84.6 (SD 5.0) % of MHRmax during cycling. Mean FHR was 140.9 (SD 27.4) beats per minute (bpm) during pauses between running bouts and 148.9 (SD 16.0) bpm during pauses between cycling bouts. Six cases of prolonged fetal bradycardia (3min) occurred during running, leading to the termination of exercise. The mothers exercised at 17–18 on Borg’s RPE scale and 86.4%–92.6% of MHRmax in these cases. All cases were normalised within 8min of ending the protocol. There were no cases of prolonged fetal bradycardia during cycling. Exercise was terminated for three women during running and two women during cycling due to fetal tachycardia (≥180 bpm for >4min during rest). Conclusion: Despite cases of fetal bradycardia and tachycardia, our results indicate that highly active women can engage in multiple intervals of high-intensity interval training without apparent harm to fetal well-being.

• Antón-Plaza, Andrea; Bø, Kari; Torres-Pasutti, Catalina; Díez-Fisher, Lucía; Minguez-Esteban, Isabel & Villafañe, Jorge H. [Show all 8 contributors for this article] (2025). Abdominal muscles’ thickness and bladder neck position in regular runners and controls: A comparative ultrasonography study. Journal of Bodywork & Movement Therapies. ISSN 1360-8592. 42, p. 477–481. doi: 10.1016/j.jbmt.2025.01.002. Full text in Research Archive Show summary

  Aim The aim of the present study was to compare and quantify with transabdominal ultrasound the IRD, the thickness of the external oblique (EO), internal oblique (IO), transversus abdominis (TrA), rectus anterior (RA) and the location of the bladder neck between runners and controls at rest and during response to different exercises. Methods A total of 38 women, aged 18–45 years, were recruited from a private rehabilitation center specializing in sports health, and divided into two groups: runners (n = 19) and sedentary women (n = 19). Thickness measurements, using suprapubic ultrasongraphy in B-Mode, of the EO, IO, TrA and RA muscles were taken at rest and during active contraction. Location of the bladder neck at rest and during pelvic floor muscle (PFM) contraction was taken with the transducer located suprapubically in M-Mode. Results There were no significant differences in EO TrA or RA muscle thickness at rest and during muscle contraction between runners and controls. For the IO muscle, significant differences were observed during ASLR, with runners showing greater muscle thickness (p = 0.032). Bladder neck displacement during a voluntary PFM contraction demonstrated statistically larger cranial movement for the runners of mean 0.76 ± 0.31 cm than mean 0.40 ± 0.26 cm for the sedentary group (p = 0.001). Conclusions regular running is associated with increased thickness of the IO during ASLR, and significantly greater cranial bladder neck displacement during PFM contraction.

• Theodorsen, Nina-Margrethe Tennebekk; Moe-Nilssen, Rolf; Bø, Kari & Haukenes, Inger (2025). Associations with the inter-recti distance at gestation week 37: a prospective cohort study among healthy pregnant women. BMC Pregnancy and Childbirth. 25. doi: 10.1186/s12884-025-07741-7. Full text in Research Archive Show summary

  Background During pregnancy the inter-recti distance (IRD) increases. There is, however, limited knowledge of what factors may contribute to this increase. Objective To investigate associations between sociodemographic characteristics, co-existing health conditions and pregnancy related factors in pregnant women before gestation week 20, and IRD at gestation week 37. Methods One hundred and twenty pregnant women provided baseline information on sociodemographic characteristics, co-existing health conditions, and pregnancy-related factors. Baseline IRD (gestation week 16–19) and IRD at gestation week 37 (outcome) were measured with ultrasound 2 cm above the umbilicus. Associations between baseline variables and IRD at gestation week 37 were investigated with bivariable regression analyses, and only variables statistically significantly associated with outcome were included in a multivariable linear regression analysis. The level of significance was set at 0.05. Results Bivariable associations between baseline variables and IRD at gestation week 37 were statistically significant for BMI, waist circumference, parity, stretch marks (striae), varicose veins and IRD. In the final multivariable linear regression analysis only baseline IRD was significantly associated with IRD at gestation week 37 (B = 0.8, SE = 0.1, 95% CI = 0.6–1.0, P-value < 0.001, R2 = 0.384). Conclusion No sociodemographic characteristics, co-existing health conditions or other significant related factors present before gestation week 20 other than baseline IRD was significantly associated with IRD at gestation week 37, with the clinical implication that for each 1 mm increase in baseline IRD, there was an average increase of 0.8 mm in IRD at gestation week 37. Approximately 38% of the variance in IRD at gestation week 37 is explained by baseline IRD and other included variables.

• Gabrielsen, Rakel; Bø, Kari; Engh, Anna Marie Ellström & Tennfjord, Merete Kolberg (2025). Is Pelvic Floor Muscle Resting Activity Associated with Pelvic and Genital Pain, Dyspareunia, and Pelvic Floor Muscle Contraction? A Cross-Sectional Study of Women with Endometriosis. International Urogynecology Journal. ISSN 0937-3462. 36(11), p. 2277–2285. doi: 10.1007/s00192-025-06190-2. Full text in Research Archive Show summary

  Introduction and Hypothesis A link between pelvic and genital pain, dyspareunia, and increased pelvic floor muscle (PFM) tone is an area of controversy. Additionally, it has been postulated that increased PFM tone can limit the ability to further activate the PFM. We aimed to investigate the association between PFM resting activity and pelvic and genital pain and dyspareunia, and whether there is an association between PFM resting activity and activation during attempts at PFM maximal voluntary contractions (MVCs) in women with endometriosis. Methods This cross-sectional study included 80 women with endometriosis and pelvic and genital pain. An electronic questionnaire included background information, pelvic and genital pain (numeric rating scale 0–10) and questions about location and concerns of dyspareunia. Associations between variables were analyzed using multiple linear regression. PFM resting activity was registered as the mean microvolt (μV) during rest before and between five voluntary MVCs of the PFM. Results Mean age was 29 years (SD 6.2), and 9 (11%) were parous. No significant association between resting activity, pelvic and genital pain or location and concerns of dyspareunia was found. A significant positive association between PFM resting activity and activation during attempts at MVCs of the PFM (β = 0.130, p = 0.009, 95% CI = 0.034–0.229) was found. Conclusion No association was found between PFM resting activity and pelvic and genital pain or location and concerns of dyspareunia. Contrary to the hypothesis, higher PFM resting activity resulted in more activation of the PFM during attempts at MVCs.

• Risløkken, Jeanette; Macedo, Marthe Dalevoll; Bø, Kari; Engh, Anna Marie Ellström & Siafarikas, Franziska (2025). The severity of second-degree perineal tears and dyspareunia during one year postpartum: A prospective cohort study. Acta Obstetricia et Gynecologica Scandinavica. ISSN 0001-6349. 104(5), p. 968–975. doi: 10.1111/aogs.15084. Full text in Research Archive
• Marken, Marlene Zahl; Dalhaug, Emilie Frederikke Mass; Thing, Lone Friis; Abrahamsen, Frank Eirik; Bø, Kari & Haakstad, Lene Annette Hagen (2025). Experiences and perspectives on pregnancy and motherhood in elite athletes–a qualitative study. Sexual and Reproductive Health Matters (SRHM). 33(1), p. 1–16. doi: 10.1080/26410397.2025.2501832. Full text in Research Archive Show summary

  Elite athletes routinely undertake strenuous training routines, which often involve high-intensity sessions. However, there are knowledge gaps in how they experience training during pregnancy and subsequent return to sport. Combined with inadequate financial and contractual safety, female athletes may jeopardise their careers when starting families. This study aimed to describe female athletes’ experiences and perspectives related to pregnancy and motherhood within the context of elite sports in Norway. We interviewed five world-class athletes between October 2022 and April 2023, using a descriptive qualitative approach. Full interview transcripts were analysed based on a reflexive thematic analysis model. Five overarching themes were identified: (1) uncertainty, (2) lack of supportive networks, (3) physical capacity, (4) the impact of postpartum return to sports on maternal health, and (5) combining motherhood and elite sports. Our findings emphasise the challenges that Norwegian pregnant and postpartum athletes face in balancing motherhood with successful careers, highlighting the importance of providing adequate support systems to ensure their health and the well-being of their child.

• Bø, Kari; Engh, Anna Marie Ellström; Teig, Catherine Joyce & Tennfjord, Merete Kolberg (2025). Do Women with Urinary Incontinence and Pelvic Organ Prolapse Receive Optimal First-Line Treatment? International Urogynecology Journal. ISSN 0937-3462. 36(1), p. 117–123. doi: 10.1007/s00192-024-05990-2. Full text in Research Archive Show summary

  Introduction and Hypothesis: There is scant knowledge on previous pelvic floor muscle training (PFMT) in women with urinary incontinence (UI) and pelvic organ prolapse (POP) referred to hospitals. We hypothesized that women with predominately UI and POP had not received optimal primary care conservative management. Methods: This was a descriptive, cross-sectional survey among women attending a gynecological outpatient’s clinic. The questionnaire included questions about demographics, PFMT dosage, whether ability to contract had been assessed and whether the patients had used precontraction before increase in intra-abdominal pressure (“the knack”). Results: One hundred two women, mean age 52.5 (SD 13.4) years, responded; 37.3% had never been treated previously. There was no statistically significant difference in age, BMI, level of education, parity, time since last birth, SUI, or POP between the women who had been treated conservatively or not before the hospital visit. Thirty-three percent had trained with a physiotherapist and > 35% reported that their ability to contract had not been assessed or were unsure whether it had been assessed; 37% were not able to stop their urine stream; 52% reported that they performed “the knack,” with 15.7% reporting it to be effective. Reasons for not having trained the PFM before visiting the hospital included not being motivated, not knowing how to do PFMT, not being told/advised to do PFMT and not believing PFMT would help. Conclusion: The results of this study indicated that there is a need for improvement within first-line health care service for women with predominately UI and POP.

• Lilleberg, Hanne Sether; Siafarikas, Franziska; Starck, Marianne; Bø, Kari; Rotstein, Emilia & Engh, Anna Marie Ellström (2025). Association Between Sonographic Deviations in the Perineum and Symptoms of a Deficient Perineum in Primiparous Women One Year After Birth: A Prospective Cohort Study. BJOG: An International Journal of Obstetrics and Gynaecology. ISSN 1470-0328. 132(8), p. 1114–1121. doi: 10.1111/1471-0528.18135. Full text in Research Archive Show summary

  Objectives This study aimed to investigate whether primiparous women with sonographic deviations in the muscles fusing into the perineal body reported more symptoms of deficient perineum than women without deviations 1 year after birth. Design Non-consecutive prospective cohort study. Setting Akershus University Hospital, Norway. Population Three hundred and eighty-eight primiparas. Methods Women were examined 1 year after birth using three-dimensional endovaginal and endoanal ultrasound with a high-resolution probe. In the blinded analysis, the transverse perineal, the puboperinealis and the puboanalis muscles were identified where they fuse into the perineal body and assessed for deviations. Symptoms of deficient perineum were evaluated using the ‘Karolinska Symptoms After Perineal Teras Inventory’ (KAPTAIN). Main Outcome Measures Symptoms of a deficient perineum, assessed using two outcomes: the median total score of KAPTAIN and a KAPTAIN score ≥ 8 1 year postpartum. Results Sonographic deviations in one or more of the muscles fusing into the perineal body 1 year after birth were observed in 168 participants (43.3%). Of these, 54 (32.1%) reported a KAPTAIN score ≥ 8. The median KAPTAIN score was 6.0 (IQR 3.0–9.0) in the group with sonographic deviations and 4.0 (IQR 2.0–6.0) in women with a sonographically intact perineum (p > 0.001). The unadjusted and adjusted odds ratio (OR) for reporting a KAPTAIN score ≥ 8 was 2.9 (95% CI 1.7–4.7) and 2.3 (95% CI 1.2–4.2), respectively, when comparing women with sonographic deviations to those with no sonographic deviations. Conclusion Our results indicate that sonographic deviations of the perineal body are associated with symptoms of a deficient perineum in primiparous women 1 year after birth.

• Bø, Kari (2024). Mechanisms for pelvic floor muscle training: Morphological changes and associations between changes in pelvic floor muscle variables and symptoms of female stress urinary incontinence and pelvic organ prolapse—A narrative review. Neurourology and Urodynamics. ISSN 0733-2467. 43(8), p. 1977–1996. doi: 10.1002/nau.25551. Full text in Research Archive Show summary

  Today there is Level 1, recommendation A for pelvic floor muscle training (PFMT) to be effective in treatment of stress urinary incontinence (SUI) and pelvic organ prolapse (POP). However, the mechanisms of action are discussed. The aim of the present overview was to give an update of studies evaluating the effect of PFMT on pelvic floor morphology and associations between changes in PFM strength and symptoms of female SUI and POP. Materials and Methods: This was a narrative review retrieving studies from systematic reviews of PFMT for SUI and POP. In addition, an open search on PubMed with the search terms PFMT and morphology was conducted. Both randomized controlled trials (RCTs) and pre–posttest design studies were included. PEDro rating scale (0–10) was used to assess risk of bias. Results: Ten studies were found reporting on morphological changes after PFMT. The four RCTs had PEDro score between 5 and 8/10. The studies found significant higher bladder neck position and narrower levator hiatus dimensions, thicker external urethral sphincter, increased cross-sectional area of PFM, improvement in PFM tears and blood flow. Twenty studies analyzed associations between changes in different PFMT variables and SUI and POP. Eleven studies found a positive weak to moderate association and six studies reported no association. Studies comparing responders and nonresponders to PFMT found statistically significant better PFM variables in responders. Conclusion: PFMT can change pelvic floor muscle and external urethral sphincter anatomy. This contributes to the understanding on how PFMT can be effective in prevention and treatment of SUI and POP.

• Risløkken, Jeanette; Macedo, Marthe Dalevoll; Bø, Kari; Engh, Anna Marie Ellström & Siafarikas, Franziska (2024). The severity of second-degree perineal tears and perineal pain during three months postpartum: A prospective cohort study. Midwifery. ISSN 0266-6138. 131. doi: 10.1016/j.midw.2024.103930. Full text in Research Archive Show summary

  Background: Second-degree perineal tears are common and can vary widely in the extent of tissue trauma. Therefore, a better understanding of perineal pain based on tissue trauma severity in second-degree tears is needed. Aim: The primary aim of this study was to assess differences in perineal pain according to the severity of perineal tears, with a focus on subcategories of second-degree tears, during the first three months postpartum. The secondary aim was to assess the use of pain medication and breastfeeding patterns according to the severity of the second-degree tears. Methods: In this observational cohort study, nulli- and multiparous women with singleton pregnancies were included during pregnancy. After birth, perineal tears were classified using the latest international classification system. In addition, second-degree tears were subcategorised according to percentage of damage to the perineum (<50 %=2A,>50 % but less than entire perineum=2B, affecting entire perineum, anal sphincter not involved=2C). Perineal pain, use of pain medication and breastfeeding patterns were assessed during a phone interview seven to ten days postpartum and through an electronic questionnaire three months postpartum. Findings: Out of 880 vaginal births, 852 participants completed the phone interview and 715 answered the electronic questionnaire. During the first three months postpartum, women with 2C-tears reported statistically significantly higher pain scores and more frequent use of pain medication compared to women with 2A-tears. There was no statistically significant difference between the number of participants not breastfeeding between second-degree tear subcategories. Conclusion: Women with 2C-tears reported higher perineal pain scores and more use of pain medication compared to those with less severe tears during three months postpartum.

• Culleton-Quinn, Elizabeth; Bø, Kari; Fleming, Neil; Cusack, Cinny & Daly, Déirdre (2024). Prevalence and Experience of Urinary Incontinence Among Elite Female Gaelic Sports Athletes. International Urogynecology Journal. ISSN 0937-3462. 35(12), p. 2357–2365. doi: 10.1007/s00192-024-05893-2. Full text in Research Archive Show summary

  Introduction and Hypothesis: This study was aimed at identifying the prevalence and experience of urinary incontinence (UI) among elite female Gaelic sports athletes in Ireland. Methods: A cross-sectional study comprising an anonymous online survey of elite Gaelic sports (Camogie and Ladies Gaelic Football) players. Players were asked about their background information, knowledge of the pelvic floor and practice of pelvic floor muscle training (PFMT), as well as their experiences of UI. The prevalence and severity of UI was assessed using the International Consultation on Incontinence Questionnaire-UI Short Form (ICIQ-UI-SF) questionnaire. Logistic regression was used to evaluate risk factors. Results: A total of 185 players responded (25 ± 5 years) and 95.3% (n = 176) were nulliparous. Forty-one percent (n = 75) of players had learned about PFMT and 13% (n = 24) had performed PFMT within the last 4 weeks. The ICIQ-UI-SF was completed by 159 players, with UI reported by 61.6% (n = 98), 52% (n = 51) of whom experienced stress urinary incontinence (SUI). A significant association was found between UI and longer weekly sporting activity time (OR 1.05, 95% CI 1.002 to 1.008). Parous players were more likely to experience UI (p = 0.025). Jumping and sprinting activities were the most commonly reported triggers, with pre-voiding and wearing protection (liners, pads) the most commonly adopted UI management strategies. Only ten players reported receiving treatment for UI. Conclusions: Urinary incontinence is prevalent among this cohort of elite female Gaelic sports athletes. Many players used strategies to manage their UI whereas few sought help for what is a treatable condition. Findings suggest the need for education of players regarding pelvic floor health and treatment options available.

• Schulz, Marina; Bø, Kari & Gram, Marte Charlotte Dobbertin (2024). Knowledge and Communication About the Menstrual Cycle Among Rhythmic Gymnasts, Ballerinas, and Dancers. International Journal of Environmental Research and Public Health (IJERPH). ISSN 1661-7827. 22(1). doi: 10.3390/ijerph22010013. Full text in Research Archive Show summary

  While moderate exercise supports regular menstrual cycle (MC) function, many female athletes experience MC symptoms that negatively influence their training and performance. Hereby, knowledge and communication about this topic are important to promote an athlete’s health and wellbeing. Hence, this study aimed to assess the knowledge and communication surrounding the MC among Norwegian rhythmic gymnasts, ballerinas, and dancers. In total, 116 rhythmic gymnasts, ballerinas, and dancers aged ≥ 16 years training ≥ 3 days per week completed an electronic questionnaire. Of these, 63% (n = 73) reported a lack of knowledge about the MC’s influence on physical fitness and performance, and 39% (n = 45) rated their coaches’ or pedagogues’ knowledge as low. With only 32% of participants discussing the MC with their coaches/pedagogues, communication was found to be limited. Seventy-three percent felt uncomfortable during training or competition due to their attire and recommended darker colors and more options in size and layering. The study highlights a significant gap in knowledge and communication about the MC among female athletes and coaches/pedagogues in aesthetic sports. It also recommends improving athletes’ choice of attire for greater comfort and confidence.

• Tennfjord, Merete Kolberg; Gabrielsen, Rakel; Bø, Kari; Engh, Marie Ellström & Molin, Marianne (2024). Can general exercise training and pelvic floor muscle training be used as an empowering tool among women with endometriosis? Experiences among women with endometriosis participating in the intervention group of a randomized controlled trial. BMC Women's Health. 24. doi: 10.1186/s12905-024-03356-w. Full text in Research Archive Show summary

  Background: The potential benefit of exercise in alleviating symptoms of endometriosis is unclear. Still, exercise may be used to empower women and manage disease symptoms. The purpose of this study was to explore how regular supervised group- and individual exercise training, including pelvic floor muscle training (PFMT), is experienced among women with endometriosis after participating in a randomized controlled trial (RCT). Methods: Among 41 women randomized to exercise training for four months, ten women were interviewed about their experiences with exercise training after participation in the trial. The weekly group training was led by women’s health physiotherapists and included individualized and progressive muscular strength training of large muscle groups and the pelvic floor muscles, in addition to endurance-, flexibility, and relaxation training. An individual training program followed the same principles as the group training and was to be performed 3–5 times per week, depending on the level of intensity. PFMT was recommended daily. The women also received a group pain management course emphasizing exercise training as self-management. Using inductive reflexive thematic analysis, responses to the question “Did participation in the study change your view of exercise as part of the treatment for endometriosis?“ were analyzed. Results: The women brought forward the importance of knowledge about the benefits of exercise to make informed decisions in disease management. Further, the women described how exercise training was perceived as less frightening and manageable when exposed to various intensities, dosages, and types of exercises in a safe and supportive environment. PFMT was especially brought forward as something new and appreciated, and for some of the women, to be performed on days when their bodies could not handle the general exercise training. They also expressed that the supervised exercise brought an extra dimension of belonging through group participation. Conclusions: Individualization and regular supervision seem important to empower women with knowledge about exercise training as self-management and to experience exercise training as safe and non-threatening. Further, creating a sense of belonging through group training may improve social support and build active coping strategies that are essential for disease management of endometriosis.

• Marcellou, Effimia G.; Stasi, Sophia; Giannopapas, Vasileios; Bø, Kari; Bakalidou, Daphne & Konstadoulakis, Manousos [Show all 7 contributors for this article] (2024). Effect of pelvic floor muscle training on urinary incontinence symptoms in postmenopausal women: A systematic review and meta-analysis. European Journal of Obstetrics, Gynecology, and Reproductive Biology. ISSN 0301-2115. 304, p. 134–140. doi: 10.1016/j.ejogrb.2024.11.040. Full text in Research Archive
• Starzec-Proserpio, Małgorzata; Frawley, Helena; Bø, Kari & Morin, Mélanie (2024). Effectiveness of nonpharmacological conservative therapies for chronic pelvic pain in women: a systematic review and meta-analysis. American Journal of Obstetrics and Gynecology. ISSN 0002-9378. 232(1), p. 42–71. doi: 10.1016/j.ajog.2024.08.006. Full text in Research Archive Show summary

  Objective: To evaluate the effectiveness of nonpharmacological conservative therapies for women with CPP. Data sources: A systematic search of electronic databases (Amed, CINAHL, PsycINFO, SportDiscuss, Medline, PubMed, Embase, and Cochrane Central Register of Controlled Trials) was performed in January 2023, and updated in December 2023. Study eligibility criteria: Randomized controlled trials comparing a nonpharmacological conservative therapy to inert (eg, placebo, usual care) or nonconservative (eg, surgical, pharmacological) treatment were included. Conservative therapies of interest to this review were: multimodal physical therapy, predominantly psychological approaches, acupuncture, and other tissue-based monotherapies (eg, electrophysical agents, manual stretching). Study appraisal and synthesis methods: All study data were aggregated, and analyses of the included studies were performed. Effects on pain; sexual measures; psychological and physical function; health-related quality of life; symptom severity/bother; pelvic floor muscle function and morphometry; perceived improvement; and adverse events were analyzed. Meta-analyses (random effects model) were conducted using postintervention scores for data that included similar interventions and outcomes. Standardized mean differences were calculated. A narrative summary of findings that could not be included in the meta-analysis is provided. The quality of the evidence was assessed with the Physiotherapy Evidence Database scale and the certainty of evidence with Grading of Recommendations, Assessment, Development, and Evaluations criteria. Results: Of 5776 retrieved studies, 38 randomized controlled trials including 2168 women (mean age 35.1±8.6) were included. Meta-analyses revealed that multimodal physical therapy resulted in lower pain intensity compared to inert or nonconservative treatments in both the short (standardized mean difference −1.69, 95% confidence interval −2.54, −0.85; high certainty) and intermediate-terms (standardized mean difference −1.82, 95% confidence interval −3.13, −0.52; moderate certainty), while predominantly psychological approaches resulted in no difference in pain intensity (standardized mean difference −0.18, 95% confidence interval −0.56, 0.20; moderate certainty) and a slight difference in sexual function (standardized mean difference −0.28, 95% confidence interval −0.52, −0.04; moderate certainty). The level of evidence regarding the meta-analysis of the effects of acupuncture on pain intensity (standardized mean difference 1.08, 95% confidence interval −1.38, 3.54, nonstatistically significant results in favor of control treatment) precluded any statement of certainty. A limited number of trials investigated individual tissue-based monotherapies, providing a restricted body of evidence. Conclusion: This systematic review with meta-analysis revealed that multimodal physical therapy is effective in women with chronic pelvic pain with a high certainty of evidence.

• Bø, Kari; Lillegård, Ragnhild Haug & Skaug, Kristina Lindquist (2024). Pelvic Floor Muscle Training on Stress Urinary Incontinence in Power- and Weightlifters: a Pilot Study. International Urogynecology Journal. ISSN 0937-3462. 35(6), p. 1291–1298. doi: 10.1007/s00192-024-05801-8. Full text in Research Archive Show summary

  Introduction and hypothesis: Stress urinary incontinence (SUI) is defined as involuntary leakage of urine on physical effort and is prevalent among power- and weightlifters. However, there is scant knowledge on treatment options for this population. The aim of this pilot study was to evaluate the potential outcomes and feasibility of a pelvic floor muscle training (PFMT) program on SUI in nulliparous female power- and weightlifters. Methods: This was a case-series study, including one weightlifter and two powerlifters aged 21–32 years. The participants conducted 12 weeks of PFMT at home, with weekly follow-up by a physiotherapist. Change in total score of the International Consensus of Incontinence Questionnaire Urinary Incontinence Short Form (ICIQ-UI-SF) was the primary outcome. Secondary outcome was perceived change assessed by the Patient Global Impression of Improvement (PGI-I) Scale and impact on sport participation. PFM strength, endurance, and resting pressure was measured using vaginal manometry. Feasibility was evaluated as adherence to training and self-efficacy (Self Efficacy Scale for Practicing Pelvic Floor Exercises). Results: One athlete reduced their ICIQ-UI-SF score and experienced improvement in symptoms. One athlete reported no change, and one reported a worsening of symptoms. All three participants improved PFM strength and endurance, completed the testing, and 12 weeks of PFMT, but adherence varied between 40 and 80%. Participants reported a lack of time and energy and forgetting to perform the exercises, as reasons for low adherence. Conclusion: There were varying effects of a 12-week PFMT program on SUI in three strength athletes. The results can create the basis for a future randomized controlled trial.

• Siafarikas, Franziska; Stær-Jensen, Jette; Reimers, Cathrine; Bø, Kari & Engh, Anna Marie Ellström (2024). Levator ani muscle avulsion and subsequent vaginal delivery: 8-year longitudinal follow-up. Ultrasound in Obstetrics and Gynecology. ISSN 0960-7692. 64(1), p. 112–119. doi: 10.1002/uog.27599. Full text in Research Archive Show summary

  Objectives: The aim of this study is to assess the evolution of levator avulsion from 1 year to 8 years after first delivery in women with subsequent vaginal deliveries compared to women without subsequent vaginal deliveries. Further, we aim to assess whether women with full and partial avulsion 8 years after first delivery have larger levator hiatus area and more symptoms of pelvic organ prolapse compared to women with normal levator insertion. Methods: In this single center longitudinal study 195 initially primiparous women were included and underwent transperineal ultrasound 1 year and 8 years after first delivery. Muscle insertion was assessed by tomographic ultrasound imaging in the axial plane. Full levator avulsion was defined as abnormal muscle insertion in all three central slices. Partial levator avulsion was defined as abnormal muscle insertion in one but less than three central slices. Eight years after first delivery levator hiatus area was assessed at rest, during maximum pelvic floor muscle contraction, and maximum Valsalva maneuver. To assess symptoms of pelvic organ prolapse the vaginal symptoms module from the International Consultation on Incontinence Questionnaire was used. Results: At 1 year follow-up, 25 women (12.8%) showed signs of avulsion, 20 women fulfilled sonographic criteria for full avulsion and 5 women fulfilled sonographic criteria for partial avulsion. Eight years after first delivery, 35 (17.9%) women were diagnosed with avulsion, of them 25 women were diagnosed with full avulsion and 10 women were diagnosed with partial avulsion. No women with partial and full avulsion at 1 year improved on their avulsion status at 8-year follow-up. In the subsequent vaginal delivery group, 21 women (14%) were diagnosed with partial and full levator avulsion 1 year after first delivery, and 31 women (20.7%) were diagnosed with partial and full avulsion 8 years after first delivery. Of the 45 women without subsequent vaginal delivery, one woman with partial avulsion 1 year after first delivery was diagnosed as full avulsion at 8-year follow-up. All women with full avulsion at 1-year follow-up were diagnosed as full avulsion at 8 years regardless of subsequent vaginal delivery. At 8-year follow-up women with full avulsion had statistically significant larger levator hiatus area compared to women with normal muscle insertion. Vaginal symptoms scores ranged between 5.5 (SD 5.7) and 6.0 (SD 4.0) and vaginal symptom quality of life scores ranged between 0.9 (SD 1.4) and 1.5 (SD 2.2) and did not differ statistically significantly between women with normal muscle insertion and women with partial and full avulsion at 8-year follow-up. Conclusion: More avulsions 8 years after first delivery compared to one year after first delivery were found in women with subsequent vaginal delivery. Except one primipara, none of the women without subsequent vaginal delivery changed on their levator status from 1 to 8 years after first delivery. Larger levator hiatus area was found in women with full avulsion compared to women with normal muscle insertion at 8-year follow-up. Vaginal symptoms scores were low and did not differ between women with normal muscle insertion, partial and full avulsion at 8-year follow-up.

• Jorge, Christine Homsi; Bø, Kari; Catai, Camila Chiazuta; Brito, Luiz gustavo Oliveira; Driusso, Patricia & Tennfjord, Merete Kolberg (2024). Pelvic floor muscle training as treatment for female sexual dysfunction: a systematic review and meta-analysis. American Journal of Obstetrics & Gynecology MFM (AJOG MFM). 231(1), p. 51–66.e1. doi: 10.1016/j.ajog.2024.01.001. Full text in Research Archive Show summary

  Objectives: To investigate the efficacy of pelvic floor muscle training (PFMT) in treating female sexual dysfunction. Data Sources: A systematic review of databases, including PubMed, Ovid Medline, CINAHL, Embase, BVSalud, Scopus, and Cochrane Library, was performed in July 2021 and updated in May 2023. Study eligibility criteria: Full-text articles of randomized controlled trials (RCTs) comparing PFMT and no intervention or another conservative treatment in at least one arm to improve women’s sexual function or treat sexual dysfunction were included. Study appraisal and synthesis methods: The data for this review was extracted and analyzed by two independent reviewers. Data on the characteristics of each intervention was extracted using the Consensus on Exercise Reporting Template (CERT). The risk of bias and certainty of evidence was assessed using the Physiotherapy Evidence Database (PEDro) scale and the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) criteria, respectively. A meta-analysis was conducted considering the post-treatment mean score difference of female sexual function index (FSFI) between the control and treatment groups. Results: Twenty-one RCTs were included in this review. The CERT revealed a varying quality of the PFMT protocols. Four studies were included in the meta-analysis showing that PFMT improved arousal (1.49; 95% confidence interval [CI]: 0.13 to 2.85), orgasm (1.55; 95%CI: 0.13 to 2.96), satisfaction (1.46; 95%CI: 0.14 to 2.77), pain (0.74; 95%CI: 0.11 to 1.37), and the FSFI overall score (7.67; 95%CI: 0.77 to 14.57). The GRADE showed a very low certainty of evidence due to the data’s high clinical and statistical heterogeneity. No side effects of the interventions were reported. Conclusion: This systematic review with meta-analysis showed that PFMT improved female FSFI total score and several subscales; however, the certainty of the evidence is low.

• Deering, Rita E.; Donnelly, Gráinne; Brockwell, Emma; Bø, Kari; Davenport, Margie H & Vivo, Marlize De [Show all 12 contributors for this article] (2024). Clinical and exercise professional opinion on designing a postpartum return-to-running training programme: an international Delphi study and consensus statement. British Journal of Sports Medicine. ISSN 0306-3674. 58(4), p. 183–195. doi: 10.1136/bjsports-2023-107490. Full text in Research Archive Show summary

  Returning to running postpartum presents challenges such as musculoskeletal pain and pelvic floor dysfunction for some females, but there is little guidance on developing and progressing postpartum training programmes. This study aims to establish expert consensus recommendations on designing and modifying a postpartum return-to-running training programme, highlight costs and access to qualified professionals as potential barriers and discuss clinical, research and sports policy implications. A three-round Delphi survey of clinical and exercise professionals working with postpartum runners was conducted. Round I consisted of open-ended questions related to designing the training plan, modifications based on biopsychosocial factors, key muscle groups to train and referral and payment sources. Rounds II and III involved Likert-scale voting to identify consensus (≥75% agreement). 118 participants completed Round I, 107 completed Round II (response rate 90.6%) and 95 completed Round III (response rate 80.5%). Consensus was reached in 42/47 (89%) statements, including recommendations for a period of relative rest, gradual increases in duration and intensity, starting with a walk-run protocol and incorporating strength training. Training should be modified based on musculoskeletal or pelvic symptoms, sleep, mental health, lactation or energy availability concerns. Cost and access to experienced postpartum running professionals were identified as potential barriers for runners to receive care. Consensus recommendations for a postpartum return-to-running programme include an individualised exercise prescription, gradual increases in physical activity, walk-run protocols and targeted muscle strengthening. Further research and improved access to clinical and exercise professionals are needed to inform and facilitate best practices.

• Skaug, Kristina Lindquist; Engh, Anna Marie Ellström & Bø, Kari (2024). Pelvic floor muscle training in female functional fitness exercisers: An assessor-blinded randomised controlled trial. British Journal of Sports Medicine. ISSN 0306-3674. 58(9), p. 486–493. doi: 10.1136/bjsports-2023-107365. Full text in Research Archive Show summary

  Objective: Stress urinary incontinence (SUI) is common among females during functional fitness training, such as CrossFit. The aim of this study was to assess the effect of pelvic floor muscle training (PFMT) on SUI in female functional fitness exercisers. Methods: This was an assessor-blinded randomised controlled trial with a PFMT group (n=22) and a control group (n=25). The PFMT group followed a 16-week home-training programme with 3 sets of 8–12 maximum pelvic floor muscle (PFM) contractions daily and weekly follow-up/reminders by phone. The primary outcome was change in a total score of the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI-SF). The secondary outcomes were perceived change of symptoms of SUI, change of PFM strength measured by vaginal manometry and symptoms of anal incontinence (AI) and pelvic organ prolapse (POP). Results: 47 women, mean age of 33.5 years (SD: 8.1), participated. At 16 weeks, there was a mean difference between groups of −1.4 (95% CI: −2.6 to −0.2) in the change of the ICIQ-UI-SF score in favour of the PFMT group. The PFMT group completed a mean of 70% (SD: 23) of the prescribed protocol. 64% in the PFMT group versus 8% in the control group reported improved symptoms of SUI (p＜0.001, relative risk: 7.96, 95% CI, 2.03 to 31.19). There were no group differences in the change of PFM strength or AI/POP symptoms. Conclusion: A 16-week home-training programme of the PFM led to improvements in SUI in female functional fitness exercisers. However, PFM strength and AI and POP symptoms did not improve significantly in the PFMT group compared with the control group.

• Theodorsen, Nina-Margrethe Tennebekk; Bø, Kari; Fersum, Kjartan Vibe; Haukenes, Inger & Moe-Nilssen, Rolf (2024). Pregnant women may exercise both abdominal and pelvic floor muscles during pregnancy without increasing the diastasis recti abdominis: a randomised trial. Journal of Physiotherapy. ISSN 1836-9553. 70(2), p. 142–148. doi: 10.1016/j.jphys.2024.02.002. Full text in Research Archive Show summary

  Question: What is the effect of a 12-week abdominal and pelvic floor muscle exercise program during pregnancy on the inter-recti distance (IRD) in women with diastasis recti abdominis immediately after the 12-week intervention period and at follow-up 6 weeks postpartum? Design: An exploratory, parallel-group, randomised controlled trial with concealed allocation, assessor blinding and intention-to-treat analysis. Participants: Ninety-six pregnant women aged ≥ 18 years, either primigravida or multigravida, in gestation week 24 with an IRD of ≥ 28 mm measured at rest and/or a protrusion on initial assessment. Intervention: The experimental group participated in a 12-week abdominal and pelvic floor muscle exercise program during pregnancy. The control group received no intervention. Outcome measures: Change (mm) in IRD 2 cm above and below the umbilicus at rest from pre-intervention to immediately post-intervention and to 6 weeks follow-up measured with ultrasonography. Results: The IRD increased for both groups from baseline to immediately after the intervention and decreased from after the intervention to the follow-up at 6 weeks postpartum. The IRD was smallest for both groups at the follow-up. At 2 cm above the umbilicus, the intervention effect was 2 mm (95% CI –2 to 7) immediately after the intervention and –1 mm (95% CI –4 to 3) at follow-up. At 2 cm below the umbilicus, the intervention effect was –5 mm (95% CI –10 to 0) immediately after the intervention and 0 mm (95% CI –4 to 4) at follow-up. Conclusion: Abdominal and pelvic floor muscle training during pregnancy have a negligible effect on the IRD immediately after 12 weeks of intervention and at 6 weeks post-partum.

• McCarthy-Ryan, Molly; Perkins, Joanna; Donnelly, Gráinne M.; Caithriona, Yeomans; Liston, Mairead & Leahy, Karina [Show all 9 contributors for this article] (2024). Stress urinary incontinence prevalence and risk factors in female rugby players: a common health problem across four nations. BMJ Open sport & exercise medicine. 10(1). doi: 10.1136/bmjsem-2023-001832. Full text in Research Archive Show summary

  Objectives: Female athletes engaging in high-impact sports have a higher prevalence of experiencing stress urinary incontinence (SUI). However, the prevalence of sport-specific SUI and associated risk factors in female rugby players is relatively unknown. We aimed to determine the prevalence of general and rugby-related SUI and identify associated risk factors and inciting events in female rugby players. Methods: Observational, cross-sectional study of 396 female rugby players (age 28±8 years, mass 80±18 kg, height 1.90±0.19 m, playing years 7±6 years) participating in rugby across UK and Ireland completed an electronic questionnaire regardless of SUI status. Results: 63 to 88% of players had SUI, and 43% had rugby-related SUI. There was an association with players reporting a change in incontinence status due to playing rugby (p﹤0.001). Players who experienced constipation (OR 2.33 (95% CI 1.49 to 3.66)), had given birth (OR 2.36 (95% CI 1.18 to 4.73)) or who had a higher body mass index (BMI) (OR 1.04 (95% CI 1.01 to 1.08)), were identified as having increased odds of rugby-related SUI. For rugby-specific risk factors, playing as a forward (OR 1.97 (95% CI 1.29 to 3.01)) increased the odds, whereas playing at a national compared with amateur level (OR 0.44 (95% CI 0.20 to 0.97)) decreased the odds of rugby-related SUI. The most prevalent inciting SUI events were being tackled (75%), tackling (66%), running (63%) and jumping/landing (59%). Conclusion: Rugby-related SUI was prevalent in female rugby players. Risk factors were having constipation, a high BMI, being postpartum, playing position and level. Player welfare strategies addressing pelvic floor dysfunction and postpartum rehabilitation are warranted.

• Bø, Kari (2024). Is there evidence for pelvic floor muscle relaxation training in nonneurogenic female bladder outlet obstruction?—A narrative review. Neurourology and Urodynamics. ISSN 0733-2467. doi: 10.1002/nau.25241. Full text in Research Archive Show summary

  Introduction: Functional bladder outlet obstruction (BOO) in women is postulated to be caused by pelvic floor muscle (PFM) dyssynergia or increased tone. The aim of the present review was to investigate the effect of PFM relaxation training on PFM tone and female BOO symptoms. Materials and Methods: This was a narrative review using an open search strategy on PubMed with the search terms “Bladder outlet obstruction” AND “female” AND (“pelvic floor muscles” OR “Kegel”). The risk of bias of the randomized controlled trials (RCTs) was scored with the Physiotherapy Evidence Database (PEDro) scale (0–10). Results: Only three RCTs were found. All three RCTs compared different types of exercise, and no trial compared relaxation training with no or sham treatment. None of the trials reported the effect between groups on the reduction of PFM tone. There was a tendency toward positive effect of PFM relaxation training to improve BOO symptoms in women. PEDro score varied between 4 and 7. Few studies yielded information on the immediate effect of any type of PFM relaxation technique on PFM tone. Conclusion: Few RCTs have been conducted on the effect of PFM relaxation training on PFM tone and functional female BOO symptoms. There is an urgent need for RCTs with high methodological and interventional quality in addition to basic research on mechanisms of different relaxation techniques on PFM activity.

• Donnelly, G.M.; Bø, Kari; Forner, L.B.; Rankin, A. & Moore, I.S. (2024). Up for the tackle? The pelvic floor and rugby. A review. European Journal of Sport Science (EJSS). ISSN 1746-1391. doi: 10.1002/ejsc.12121. Full text in Research Archive Show summary

  The pelvic floor and its associated disorders are a unique and often overlooked aspect of women's rugby. This review discusses relevant biopsychosocial considerations specific to the pelvic floor and rugby. Pelvic floor disorders can present at any time across the female lifespan but are more prevalent during pregnancy and postpartum. This is due to the substantial physiological and anatomical changes experienced during pregnancy and vaginal childbirth. Consequently, pelvic floor disorders can impact a player's ability to perform, maintain engagement with, or return to, rugby due to symptoms. Players need to be informed, supported, and guided through focused pelvic floor muscle training to condition the muscles and ‘ready’ them for the varied demands of rugby. Health and fitness professionals should understand the risk of pelvic floor disorders across the female lifespan and screen players for symptoms when supporting them to maintain or return to rugby. Rugby players who are symptomatic of pelvic floor disorders should be signposted to specialist services and/or resources to manage their symptoms. Once engaging in rugby training, ongoing evaluation of player load tolerance and implementation of individualized strategies to support managing rugby-related loads to the pelvic floor should be considered. Finally, surveillance and research focusing specifically on rugby players and pelvic floor function are needed.

• Zhang, Dingfeng; Bø, Kari; Montejo, Rocío; Sánchez-Polán, Miguel; Silva-José, Cristina & Palacio, Montse [Show all 7 contributors for this article] (2023). Influence of pelvic floor muscle training alone or as part of a general physical activity program during pregnancy on urinary incontinence, episiotomy and third- or fourth-degree perineal tear: Systematic review and meta-analysis of randomized clinical trials. Acta Obstetricia et Gynecologica Scandinavica. ISSN 0001-6349. 103(6), p. 1015–1027. doi: 10.1111/aogs.14744. Full text in Research Archive Show summary

  Introduction: The complex process of pregnancy and childbirth significantly influences the well-being of both mother and child. Today all pregnant women without medical contraindications are recommended to start or continue regular aerobic and strength training for at least 150 min per week to prevent pregnancy-related diseases and conditions. Urinary incontinence in pregnancy, episiotomy and third- or fourth-degree perineal tear during labor can greatly impact womens’ health, quality of life and ability to be physically active. The aim of this study was to examine the efficacy of pelvic floor muscle training (PFMT) during pregnancy in the prevention of urinary incontinence, episiotomy, and third- or fourth-degree perineal tear. Material and methods: A systematic review and meta-analysis (CRD42022370600) was performed. Only randomized clinical trials published between 2010 and 2023 were included. The following databases were examined: EBSCO (including Academic Search Premier, Education Resources Information Center, MEDLINE, SPORTDiscus and OpenDissertations databases), Clinicaltrials.gov, Web of Science, Scopus, Cochrane Database of Systematic Reviews and Physiotherapy Evidence Database (PEDro). Three meta-analyses to investigate the effect of PFMT exclusively or implemented as a section within a physical activity program during pregnancy on urinary incontinence, episiotomy, and third- or fourth-degree perineal tear were conducted. Results: Thirty studies were analyzed (N = 6691). An effective preventive action of PFMT was found for urinary incontinence (z = 3.46; p ＜ 0.0005; relative risk [RR] = 0.72, 95% confidence interval [CI]: 0.59, 0.87, I2 = 59%) and third- or fourth-degree perineal tear (z = 2.89; p = 0.004; RR = 0.50, 95% CI: 0.31, 0.80, I2 = 48%) but not for episiotomy (z = 0.80; p = 0.42; RR = 0.95, 95% CI: 0.85, 1.07, I2 = 75%). Conclusions: PFMT during pregnancy proves to be an effective preventive intervention for reducing the risk of urinary incontinence and the occurrence of third- or fourth-degree perineal tears. These findings highlight the importance of incorporating PFMT into antenatal care and training programs to improve maternal well-being and overall childbirth outcomes.

• Farag, Fawzy; Sakalis, Vasileios I.; Arteaga, Serenella Monagas; Sihra, Néha; Karavitakis, Markos & Arlandis, Salvador [Show all 20 contributors for this article] (2023). What Are the Short-term Benefits and Potential Harms of Therapeutic Modalities for the Management of Overactive Bladder Syndrome in Women? A Review of Evidence Under the Auspices of the European Association of Urology, Female Non-neurogenic Lower Urinary Tract Symptoms Guidelines Panel. European Urology. ISSN 0302-2838. 84(3), p. 302–312. doi: 10.1016/j.eururo.2023.05.014. Full text in Research Archive Show summary

  Context: Overactive bladder syndrome (OAB) is highly prevalent among women and has a negative impact on their quality of life. The current available treatments for OAB symptoms include conservative, pharmacological, or surgical modalities. Objective: To provide an updated contemporary evidence document regarding OAB treatment options and determine the short-term effectiveness, safety, and potential harms of the available treatment modalities for women with OAB syndrome. Evidence acquisition: The Medline, Embase, and Cochrane controlled trial databases and clinicaltrial.gov were searched for all relevant publications up to May 2022. The risk of bias assessment followed the recommended tool in the Cochrane Handbook for Systematic Reviews of Interventions, and quality of evidence was assessed using the modified Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria. A meta-analysis was performed where appropriate. Evidence synthesis: Antimuscarinics and beta-3 agonists were significantly more effective than placebo across most outcomes, with beta-3 agonists being more effective at reducing nocturia episodes and antimuscarinics causing significantly higher adverse events. Onabotulinumtoxin-A (Onabot-A) was more effective than placebo across most outcomes, but with significantly higher rates of acute urinary retention/clean intermittent self-catheterisation (six to eight times) and urinary tract infections (UTIs; two to three times). Onabot-A was also significantly better than antimuscarinics in the cure of urgency urinary incontinence (UUI) but not in the reduction of mean UUI episodes. Success rates of sacral nerve stimulation (SNS) were significantly higher than those of antimuscarinics (61% vs 42%, p = 0.02), with similar rates of adverse events. SNS and Onabot-A were not significantly different in efficacy outcomes. Satisfaction rates were higher with Onabot-A, but with a higher rate of recurrent UTIs (24% vs 10%). SNS was associated with 9% removal rate and 3% revision rate. Conclusions: Overactive bladder is a manageable condition, with first-line treatment options including antimuscarinics, beta-3 agonists, and posterior tibial nerve stimulation. Second-line options include Onabot-A bladder injections or SNS. The choice of therapies should be guided by individual patient factors. Patient summary: Overactive bladder is a manageable condition. All patients should be informed and advised on conservative treatment measures in the first instance. The first-line treatment options for its management include antimuscarinics or beta-3 agonists medication, and posterior tibial nerve stimulation procedures. The second-line options include onabotulinumtoxin-A bladder injections or sacral nerve stimulation procedure. The therapy should be chosen based on individual patient factors.

• Skaug, Kristina Lindquist; Engh, Anna Marie Ellström & Bø, Kari (2023). Acute Effect of Heavy Weightlifting on the Pelvic Floor Muscles in Strength-Trained Women: An Experimental Crossover Study. Medicine & Science in Sports & Exercise. ISSN 0195-9131. 56(1), p. 37–43. doi: 10.1249/MSS.0000000000003275. Full text in Research Archive Show summary

  Introduction/Purpose: Heavy lifting may produce strain on the pelvic floor muscles (PFM) due to high increases in intraabdominal pressure, but knowledge of the impact of weightlifting on the PFM is lacking. Therefore, this study aimed to investigate acute effects of heavy weightlifting on the PFM in strength-trained women and whether general strength in whole-body exercises correlated to PFM strength. Methods: Forty-seven nulliparous women between 18-35 years who regularly performed weightlifting and were able to lift their own body weight x 1.2 in back squat and 1.5 in deadlift were included in this experimental crossover study. They participated in baseline evaluations (questionnaire/measurements of background characteristics and pelvic floor disorders, 1 repetition maximum (1RM) tests in back squat and deadlift) and one test day where they were randomized to start with 60 minutes of weightlifting (4 sets of 4 repetitions at 75-85% of 1RM in back squat and deadlift) or seated rest of 60 minutes. Vaginal pressure measurements of PFM resting pressure, strength, and endurance and sEMG-measurements of PFM resting activity were performed before/after weightlifting and rest. Results: No statistically significant differences were found when comparing the change in PFM resting pressure, strength, endurance, and resting activity after heavy weightlifting and rest. There were no statistically significant correlations between PFM strength and maximum (1RM) or relative strength (1RM/bodyweight) in either back squat or deadlift. Conclusions: Our results imply that heavy weightlifting is well tolerated by the PFM in short-term among young, nulliparous, and strength-trained women. Strength in whole-body exercises was not correlated to PFM strength.

• Gluppe, Sandra L.; Engh, Anna Marie Ellström & Bø, Kari (2023). Curl-up exercises improve abdominal muscle strength without worsening inter-recti distance in women with diastasis recti abdominis postpartum: a randomised controlled trial. Journal of Physiotherapy. ISSN 1836-9553. 69(3), p. 160–167. doi: 10.1016/j.jphys.2023.05.017. Full text in Research Archive Show summary

  Question: What is the effect of a 12-week, home-based, abdominal exercise program containing head lifts and abdominal curl-ups on inter-recti distance (IRD) in women with diastasis recti abdominis (DRA) 6 to 12 months postpartum? What is the effect of the program on: observed abdominal movement during a curl-up; global perceived change; rectus abdominis thickness; abdominal muscle strength and endurance; pelvic floor disorders; and low back, pelvic girdle and abdominal pain? Design: This was a two-arm, parallel-group, randomised controlled trial with concealed allocation, assessor blinding and intention-to-treat analysis. Participants: Seventy primiparous or multiparous women 6 to 12 months postpartum, having a single or multiple pregnancy following any mode of delivery, with a diagnosis of DRA (IRD > 28 mm at rest or > 25 mm during a curl-up). Intervention: The experimental group was prescribed a 12-week standardised exercise program including head lifts, abdominal curl-ups and twisted abdominal curl-ups 5 days a week. The control group received no intervention. Outcome measures: The primary outcome measure was change in IRD measured with ultrasonography. Secondary outcomes were: observed abdominal movement during a curl-up; global perceived change; rectus abdominis thickness; abdominal muscle strength and endurance; pelvic floor disorders; and low back, pelvic girdle and abdominal pain. Results: The exercise program did not improve or worsen IRD (eg, MD 1 mm at rest 2 cm above the umbilicus, 95% CI –1 to 4). The program improved rectus abdominis thickness (MD 0.7 mm, 95% CI 0.1 to 1.3) and strength (MD 9 Nm, 95% CI 3 to 16) at 10 deg; its effects on other secondary outcomes were trivial or unclear. Conclusion: An exercise program containing curl-ups for women with DRA did not worsen IRD or change the severity of pelvic floor disorders or low back, pelvic girdle or abdominal pain, but it did increase abdominal muscle strength and thickness.

• Theodorsen, Nina-Margrethe Tennebekk; Moe-Nilssen, Rolf; Bø, Kari & Haukenes, Inger (2023). Effect of exercise on the inter-rectus distance in pregnant women with diastasis recti abdominis: an experimental longitudinal study. Physiotherapy. ISSN 0031-9406. 121, p. 13–20. doi: 10.1016/j.physio.2023.08.001. Full text in Research Archive Show summary

  Objective: To investigate the effect of acute contraction of the pelvic floor muscles (PFM) and abdominal exercises on the inter-rectus distance (IRD) compared to resting values, and differences between gestation weeks 27 and 37, in pregnant women with diastasis recti abdominis (DRA). Design: Experimental longitudinal design. Setting: Physiotherapy clinic, primary health care. Participants: Thirty-eight pregnant women with DRA ≥ 2.8 cm. Interventions: Two-dimensional ultrasound images of IRD 2 cm above and below the umbilicus were taken at rest and during PFM and abdominal exercises at gestation week 27 and 37. Repeated measures analyses of variance (ANOVAs) with post hoc tests was performed for each exercise for both locations and timepoints. Main Outcome measures: Change in IRD. Results: There was a mean increase of the IRD from rest during a PFM contraction (2 mm, 95% CI: 2, 3), drawing-in (4 mm, 95% CI: 3, 5) and a combination of these (5 mm, 95% CI: 4, 6) There was a mean decrease of the IRD from rest during the headlift (-3 mm, 95% CI: -4, -2), the curl-up (-3 mm, 95% CI: -4, -2) and the diagonal curl up (-4 mm, 95% CI: -5, -3). Effect of time from gestation week 27 to 37 was a mean increase of 8 mm (95% CI: 6, 9). Conclusion: Pelvic floor and drawing-in exercise increased the IRD, whilst headlift, curl up and diagonal curl up decreased the IRD in pregnant women with DRA at gestation week 27 and 37.

• Bø, Kari; Driusso, Patricia & Jorge, Cristine Homsi (2023). Can you breathe yourself to a better pelvic floor? A systematic review. Neurourology and Urodynamics. ISSN 0733-2467. 42(6), p. 1261–1276. doi: 10.1002/nau.25218. Full text in Research Archive Show summary

  Introduction: Some authors suggest that breathing exercises should be recommended instead of or in combination with pelvic floor muscle training (PFMT) to prevent and treat urinary incontinence (UI) and pelvic organ prolapse (POP). Aims: The primary aim of the present study was to investigate the evidence for breathing as an intervention alone or in addition to PFM contraction in treatment of UI and POP. Materials & Methods: This systematic review included short-term experimental studies and randomize controlled trials (RCTs) indexed on PubMed, EMBASE, and PEDro database. A form was used to extract data that was analyzed qualitatively due to the heterogeneity in interventions and outcome measures of the included studies. The individual methodological quality of RCTs was analyzed using the PEDro scale. Results: A total of 18 studies were included, 374 participants from short-term experimental studies and 765 from nine RCTs. PEDro score varied from 4 to 8. Activation of the PFM during expiration was significantly less than during a PFM contraction. In general, the RCTs showed that training the PFM is significantly more effective to improve PFM variables and UI and POP than breathing exercises, and that adding breathing exercises to PFMT have no additional effect. Conclusion: This systematic review indicates that the evidence for incorporating breathing exercise in clinical practice in addition to or instead of PFMT is scant or non-existing, both based on short-term experimental studies and small RCTs.

• Mota, Patrícia; Theodorsen, Nina-Margrethe Tennebekk; Gluppe, Sandra L. & Bø, Kari (2023). On "The Impact of Hypopressive Abdominal Exercise on Linea Alba Morphology in Women Who Are Postpartum: A Short-Term Cross-Sectional Study." Arranz-Martín B, Navarro-Brazález B, Sánchez-Sánchez B, McLean L, Carazo-Díaz C, Torres-Lacomba M. Phys Ther. 2022;102:pzac086. https://doi.org/10.1093/ptj/pzac086. Physical Therapy. ISSN 0031-9023. 103(4). doi: 10.1093/ptj/pzad018. Full text in Research Archive
• Mota, Patrícia; Costa, Ana; Santos, Diana; Santo, Susana; Barros, Joana G. & Bø, Kari (2023). Pelvic floor muscle function after grade II tears—Surface electromyography test–retest and differences between nulliparous and primiparous. Neurourology and Urodynamics. ISSN 0733-2467. 42(5), p. 1162–1168. doi: 10.1002/nau.25180. Full text in Research Archive Show summary

  Background: Vaginal birth is a risk factor for weakening of the pelvic floor muscles (PFM) and development of pelvic floor dysfunction (PFD). Perineal tears may decrease PFM function. PFM tone can be assessed with surface EMG (sEMG), but reliability studies of sEMG in women with perineal tears are lacking. The aims of this study were to evaluate test–retest and intrarater reliability of sEMG and compare PFM activation between nulliparous and primiparous. Methods: A sEMG test–retest was performed in 21 women (12 nulliparous and 9 primiparous with grade II tears) to assess intra-rater reliability during rest and maximal voluntary contraction (MVC) of the PFM. Intraclass Correlation Coefficient (ICC), standard error of measurement (SEM) and minimal detectable change (MDC) were tested. A comparison between nulliparous' and primiparous' PFM activation during rest and MVC was performed. Results: sEMG demonstrated fair reliability in nulliparous (ICC: 0.239; SEM: 5.2; MDC: 14.5) and moderate reliability in primiparous (ICC: 0.409; SEM: 1.5; MDC: 4.2) during rest. For peak MVC very good intrarater reliability was found in nulliparous (ICC: 0.92; SEM: 8.0; MDC: 22.2) and in primiparous (ICC: 0.823; SEM: 8.0; MDC: 22.2). Statistically significant lower PFM activation was found in primiparous women with perineal tear grade II than in nulliparous at rest (mean difference 9.1 µV, 95% confidence interval [CI] 3.0–19.0, p = 0.001), and during MVCpeak (mean difference 50.0 µV, 95% CI 10.0–120.0 p = 0.021). Conclusions: sEMG is reliable when measuring PFM activation in primiparous women with perineal tears grade II. Women with perineal tears grade II have lower PFM activation both during rest and MVC.

• Bø, Kari; Anglès-Acedo, Sònia; Batra, Achla; Brækken, Ingeborg Hoff; Chan, Yi Ling & Jorge, Cristine Homsi [Show all 9 contributors for this article] (2023). Strenuous physical activity, exercise, and pelvic organ prolapse: a narrative scoping review. International Urogynecology Journal. ISSN 0937-3462. 34, p. 1153–1164. doi: 10.1007/s00192-023-05450-3. Full text in Research Archive Show summary

  Introduction and hypothesis: High-intensity physical activity and exercise have been listed as possible risk factors for pelvic organ prolapse (POP). The aim of the present study is to conduct a literature review on the prevalence and incidence of POP in women who engage in regular physical activity. In addition, we review the effects of a single exercise or a single session of exercise on pelvic floor support. Finally, the effect of exercises on POP in the early postpartum period is reviewed. Methods: This is a narrative scoping review. We searched PubMed and Ovid Medline, the Physiotherapy Evidence Database (PEDro), and the Cochrane Database of Systematic Reviews up to May 2022 with the following MeSH terms: “physical activity” AND “exercise” AND “pelvic floor” AND “pelvic organ prolapse”. Results: Eight prevalence studies were retrieved. Prevalence rates of symptomatic POP varied between 0 (small study within different sports) and 23% (Olympic weightlifters and power lifters). Parity was the only factor associated with POP in most studies. Three studies evaluated the pelvic floor after a single exercise or one session of exercise and found increased vaginal descent or increased POP symptoms. One prospective cohort study reported the development of POP after 6 weeks of military parashot training, and one randomized trial reported increased POP symptoms after transverse abdominal training. There is scant knowledge on exercise and POP in the postpartum period. Conclusions: Prevalence of POP in sports varies widely. Experimental and prospective studies indicate that strenuous exercise increased POP symptoms and reduced pelvic floor support.

• Sigurdardottir, Thorgerdur; Steingrimsdóttir, Thora; Geirsson, Reynir T.; Halldorsson, Thorhallur I.; Aspelund, Thor & Bø, Kari (2023). Postpartum pelvic organ prolapse and pelvic floor muscle training: secondary analysis of a randomized controlled trial of primiparous women. International Urogynecology Journal. ISSN 0937-3462. 34, p. 1319–1326. doi: 10.1007/s00192-023-05502-8. Full text in Research Archive Show summary

  Introduction and Hypothesis: Pelvic floor dysfunction is common after childbirth. We hypothesize that physiotherapist-guided pelvic floor muscle training (PFMT) is effective regarding pelvic organ prolapse (POP) symptoms during the first postpartum year. Methods: This was a secondary analysis from a randomized controlled trial (RCT), carried out at a physiotherapy clinic, Reykjavik. Participants were eighty-four primiparous women with a singleton delivery. They were screened for eligibility 6–13 weeks postpartum. Women in a training group conducted 12 weekly individual sessions with a physiotherapist within an RCT, starting on average 9 weeks postpartum. Outcomes were assessed after the last session (short term) and at approximately 12 months postpartum (long term). The control group received no instructions after the initial assessment. Main outcome measures were self-evaluated POP symptoms by the Australian Pelvic Floor Questionnaire. Results: Forty-one and 43 women were in the training and control groups, respectively. At recruitment, 17 (42.5%) of the training group and 15 (37%) of the control group reported prolapse symptoms (p = 0.6). Five (13%) from the training group and nine (21%) controls were bothered by the symptoms (p = 0.3). There was a gradual decrease in the number of women with symptoms and no significant short-term (p = 0.08) or long-term (p = 0.6) differences between the groups regarding rates of women with POP symptoms. The difference between groups regarding bother in the short (p = 0.3) or longer term (p = 0.4) was not significant. Repeated-measures analyses using Proc Genmod in SAS did not indicate a significant effect of the intervention over time (p > 0.05). Conclusions: There was an overall decrease in postpartum symptoms of POP and bother during the first year. Physiotherapist-led PFMT did not change the outcomes.

• Ramachandra, Preetha; Kumar, Pratap; Bø, Kari & Maiya, G. Arun (2023). Comparison of static postural sway characteristics between pregnant and non-pregnant women. Journal of Biomechanics. ISSN 0021-9290. 154. doi: 10.1016/j.jbiomech.2023.111618. Full text in Research Archive Show summary

  The present study aimed to compare the postural sway between pregnant and non-pregnant women during eight different sensory conditions including those in which vision, proprioception, and base of support are compromised. Forty primigravidae at the 32nd week of pregnancy and forty non-pregnant women who were matched for age and anthropometric measurements participated in this cross-sectional comparison study. Static posturography equipment was used to record the anteroposterior sway velocity, mediolateral sway velocity, and velocity moment during normal stance and when vision, proprioception, and base of support were compromised. Pregnant women (mean age: 25.4) demonstrated a larger median velocity moment and mean anteroposterior sway velocity compared to non–pregnant women (mean age:24.4) across all tested sensory conditions (p<0.05). Although mediolateral sway velocity did not show any statistically significant difference, the ANCOVA results suggested that there was a statistically significant difference in mediolateral sway velocity in Eyes open feet apart condition on the firm surface [F (1,77, p=0.030, ηp2=0.121] and Eyes closed feet apart condition on the firm surface [F (1,77, p=0.015, ηp2=0.15] between pregnant and non-pregnant women. There was a larger velocity moment and anteroposterior postural sway velocity in pregnant women in their third trimester compared to non-pregnant women when exposed to different sensory conditions.

• Christopher, Shefali Mathur; Donnelly, Gráinne; Brockwell, Emma; Bø, Kari; Davenport, Margie H & Vivo, Marlize De [Show all 12 contributors for this article] (2023). Clinical and exercise professional opinion of return-to-running readiness after childbirth: An international Delphi study and consensus statement. British Journal of Sports Medicine. ISSN 0306-3674. 58(6), p. 299–312. doi: 10.1136/bjsports-2023-107489. Full text in Research Archive Show summary

  Female athletes have identified a lack of guidance as a barrier to successfully returning to running postpartum, and existing guidelines are vague. Our aim was to define the current practice of determining postpartum run-readiness through a consensus survey of international clinicians and exercise professionals in postpartum exercise to assist clinicians and inform sport policy changes. A three-round Delphi approach was used to gain international consensus from clinicians and exercise professionals on run-readiness postpartum. Professionals who work with postpartum runners participated in an online survey to answer open-ended questions about the following postpartum return-to-running topics: definitions (runner and postpartum), key biopsychosocial milestones that runners need to meet, recommended screening, timeline to initiate running, support items, education topics and factors that contribute to advising against running. Consensus was defined as ≥75% participant agreement. One hundred and eighteen professionals participated in round I, 107 participated in round II (response rate 90.6%) and 95 participated in round III (response rate 80.5%). Responses indicated that, following a minimum 3-week period of rest and recovery, an individualised timeline and gradual return to running progression can be considered. Screening for medical and psychological concerns, current physical capacity, and prior training history is recommended prior to a return to running. This study proposes recommendations for the initial guidance on return-to-running postpartum, framed in the context of current research and consensus from professionals. Future research is needed to strengthen and validate specific recommendations and develop guidelines for best practice when returning-to-running after childbirth.

• Bø, Kari (2023). Pelvic floor muscle training with and without biofeedback for urinary incontinence and pelvic organ prolapse. In Azadi, Ali; Cornella, Jeffery L.; Dwyer, Peter & Felicia, Lane L. (Ed.), Ostergard’s Textbook of Urogynecology. Wolters Kluwer. ISSN 9781975162337. p. 244–250. Full text in Research Archive
• Haakstad, Lene Annette Hagen; Benvenuti, Maria Beatrice; Dalhaug, Emilie Frederikke Mass & Bø, Kari (2023). Lumbopelvic pain and sick leave during pregnancy: A comparison of Italy and Norway. Women's Health. ISSN 1745-5057. 19. doi: 10.1177/17455057231218197. Full text in Research Archive Show summary

  Background: Pregnancy-related lumbopelvic pain is a frequently reported musculoskeletal disorder, but few studies have compared data between countries. Objectives: Examine prevalence, severity, and sick leave and explore potential risk factors associated with pregnancy-related lumbopelvic pain in Italian women and compare the results to a similar study in Norway, utilizing the same questionnaire. Design: Cross-sectional Methods: Italian (n = 481) and Norwegian women (n = 435) were allocated from two public hospitals in Rome (Fatebenefratelli San Giovanni Calibita-Isola Tiberina) and Oslo (Oslo University Hospital), as well as four antenatal clinics in Modena (Italy). The questionnaire was completed between gestation weeks 32 and 36, addressing women’s experiences of pregnancy-related lumbopelvic pain and sick leave in current week, and retrospectively for prepregnancy, first and second trimesters. Results: In Italy and Norway, 39% and 57% of pregnant women reported pregnancy-related lumbopelvic pain, respectively, with 11% and 25% experiencing severe pregnancy-related lumbopelvic pain. Pregnancy-related lumbopelvic pain was associated with sick leave in Norway (p < 0.01), but not in Italy (p = 0.66) at late gestation. In both countries, women with pregnancy-related lumbopelvic pain versus those with no pregnancy-related lumbopelvic pain were more likely to be multiparous (Italy: 40% versus 31%, p = 0.06 and Norway: 53% versus 38%, p < 0.01), and have gestational weight gain above guidelines (Italy: 21% versus 13%, p = 0.02% and Norway: 27% versus 14%, p < 0.01) and previous experience of pregnancy-related lumbopelvic pain (Italy: 15% versus 2%, p < 0.01 and Norway: 31% versus 4%, p < 0.01). Maternal exercise (⩾2 times weekly) was associated with less pregnancy-related lumbopelvic pain (Italy: odds ratio = 0.33, 95% confidence interval = 0.11–1.0, p = 0.05 and Norway: odds ratio = 0.55, 95% confidence interval = 0.29–1.0, p = 0.06). Conclusion: We observed high rates of pregnancy-related lumbopelvic pain in Italy and Norway, with Norwegian women reporting the highest prevalence and severity level. While both countries had similar rates of sick leave in late gestation, an association between pregnancy-related lumbopelvic pain and sick leave was observed among Norwegian women only. Health care providers should be proactive in addressing pregnancy-related lumbopelvic pain through open communication and seeking input from pregnant individuals. However, it is essential to acknowledge that the current evidence on effective treatments remains limited and inconclusive, highlighting the need for further research in this field.

• Moore, Isabel S.; Crossley, Kay M.; Bø, Kari; Mountjoy, Margo; Ackerman, Kathryn E. & Antero, Juliana da Silva [Show all 25 contributors for this article] (2023). Female athlete health domains: A supplement to the International Olympic Committee consensus statement on methods for recording and reporting epidemiological data on injury and illness in sport. British Journal of Sports Medicine. ISSN 0306-3674. 57(18), p. 1164–1174. doi: 10.1136/bjsports-2022-106620. Full text in Research Archive Show summary

  The IOC made recommendations for recording and reporting epidemiological data on injuries and illness in sports in 2020, but with little, if any, focus on female athletes. Therefore, the aims of this supplement to the IOC consensus statement are to (i) propose a taxonomy for categorisation of female athlete health problems across the lifespan; (ii) make recommendations for data capture to inform consistent recording and reporting of symptoms, injuries, illnesses and other health outcomes in sports injury epidemiology and (iii) make recommendations for specifications when applying the Strengthening the Reporting of Observational Studies in Epidemiology-Sport Injury and Illness Surveillance (STROBE-SIIS) to female athlete health data. In May 2021, five researchers and clinicians with expertise in sports medicine, epidemiology and female athlete health convened to form a consensus working group, which identified key themes. Twenty additional experts were invited and an iterative process involving all authors was then used to extend the IOC consensus statement, to include issues which affect female athletes. Ten domains of female health for categorising health problems according to biological, life stage or environmental factors that affect females in sport were identified: menstrual and gynaecological health; preconception and assisted reproduction; pregnancy; postpartum; menopause; breast health; pelvic floor health; breast feeding, parenting and caregiving; mental health and sport environments. This paper extends the IOC consensus statement to include 10 domains of female health, which may affect female athletes across the lifespan, from adolescence through young adulthood, to mid-age and older age. Our recommendations for data capture relating to female athlete population characteristics, and injuries, illnesses and other health consequences, will improve the quality of epidemiological studies, to inform better injury and illness prevention strategies.

• Hilde, Gunvor; Stær-Jensen, Jette; Siafarikas, Franziska; Engh, Anna Marie Ellström & Bø, Kari (2022). Postpartum pelvic floor muscle training, levator ani avulsion and levator hiatus area: a randomized trial. International Urogynecology Journal. ISSN 0937-3462. 34(2), p. 1–11. doi: 10.1007/s00192-022-05406-z. Full text in Research Archive Show summary

  Introduction and hypothesis Vaginal delivery may lead to tearing of the levator ani (LA) muscle from its bony insertions (complete LA avulsion) and increased levator hiatus (LH) area, both risk factors for pelvic foor dysfunctions. Early active rehabilitation is standard treatment after musculo-skeletal injury. We hypothesized that pelvic foor muscle training (PFMT) early postpartum would reduce the presence of LA avulsions and reduce LH area. Methods We carried out a planned secondary analysis from a randomized controlled study. Primiparous women (n=175) giving birth vaginally were included 6 weeks postpartum, stratifed on complete LA avulsion, and thereafter randomized to PFMT or control. The training participants (n=87) attended a supervised PFMT class once a week and performed home-based PFMT daily for 16 weeks. The control participants (n=88) received no intervention. Presence of complete LA avulsion, LH area at rest, maximal contraction, and maximal Valsalva maneuver were assessed by transperineal ultrasound. Betweengroup comparisons were analyzed by analysis of covariance for continuous data, and relative risk (RR) for categorical data. Results Six months postpartum, the number of women who had complete LA avulsion was reduced from 27 to 14 within the PFMT group (44% reduction) and from 28 to 17 within the control group (39% reduction). The between-group diference was not signifcant, RR 0.85 (95% CI 0.53 to 1.37). Further, no signifcant between-group diferences were found for LH area at rest, during contraction, or Valsalva. Conclusions Supervised PFMT class combined with home exercise early postpartum did not reduce the presence of complete LA avulsion or LH area more than natural remission.

• Culleton-Quinn, Elizabeth; Bø, Kari; Fleming, Neil; Mockler, David; Cusack, Cinny & Daly, Deirdre (2022). Elite female athletes’ experiences of symptoms of pelvic floor dysfunction: A systematic review. International Urogynecology Journal. ISSN 0937-3462. 33(10), p. 2681–2711. doi: 10.1007/s00192-022-05302-6. Full text in Research Archive Show summary

  Introduction and aims: Pelvic floor dysfunction (PFD) is a collection of signs, symptoms and conditions affecting the pelvic floor and urinary incontinence (UI) is the most common type of PFD. Recent systematic reviews have indicated a higher prevalence of UI among female athletes compared to their non-athletic counterparts. To date, no review has been undertaken to investigate female athletes’ experiences of PFD. This review aims to offer insight and understanding, through aggregation, summary, synthesis and interpretation of findings from studies that report elite female athletes’ experiences of symptoms of PFD. Methods: The review protocol was registered in PROSPERO in August 2020. A systematic search was conducted in Embase, MEDLINE (OVID), Cochrane Library, CINAHL, PsycINFO and Web of Science for studies published in the English language reporting elite female athletes’ experiences of symptoms of PFD. This review included primary research studies that involved elite female athletes of any age or ethnicity. Results: Of the 1922 citations retrieved in the search, 32 studies met the methodological criteria for data extraction and analysis. Five main themes emerged: (1) triggers for symptoms of PFD; (2) strategies adopted by athletes to manage/mitigate symptoms of PFD; (3) impact on QOL/daily life; (4) impact on performance; (5) impact on emotions. Conclusions: The findings of this review suggest a need to further explore the experiences of PFD among elite female athletes and it is suggested that future research should adopt qualitative methods or incorporate a qualitative component.

• Nambiar, Arjun K.; Arlandis, Salvador; Bø, Kari; Cobussen-Boekhorst, Hanny; Costantini, Elisabetta & Heide, Monica de [Show all 24 contributors for this article] (2022). European Association of Urology Guidelines on the Diagnosis and Management of Female Non-neurogenic Lower Urinary Tract Symptoms. Part 1: Diagnostics, Overactive Bladder, Stress Urinary Incontinence, and Mixed Urinary Incontinence. European Urology. ISSN 0302-2838. 82(1), p. 49–59. doi: 10.1016/j.eururo.2022.01.045. Full text in Research Archive Show summary

  Context: Female lower urinary tract symptoms (LUTS) are a common presentation in urological practice. Thus far, only a limited number of female LUTS conditions have been included in the European Association of Urology (EAU) guidelines compendium. The new non-neurogenic female LUTS guideline expands the remit to include these symptoms and conditions. Objective: To summarise the diagnostic section of the non-neurogenic female LUTS guideline and the management of female overactive bladder (OAB), stress urinary incontinence (SUI), and mixed urinary incontinence (MUI). Evidence acquisition: New literature searches were carried out in September 2021 and evidence synthesis was conducted using the modified GRADE criteria as outlined for all EAU guidelines. A new systematic review (SR) on OAB was carried out by the panel for the purposes of this guideline. Evidence synthesis: The important considerations for informing guideline recommendations are presented, along with a summary of all the guideline recommendations. Conclusions: Non-neurogenic female LUTS are an important cause of urological dysfunction. Initial evaluation, diagnosis, and management should be carried out in a structured and logical fashion based on the best available evidence. This guideline serves to present this evidence to health care providers in an easily accessible and digestible format.

• Siafarikas, Franziska; Halle, Tuva Kristine Toresdatter; Benth, Jurate Saltyte; Stær-Jensen, Jette; Reimers, Cathrine & Bø, Kari [Show all 7 contributors for this article] (2022). Pelvic floor symptoms from first pregnancy up to 8 years after the first delivery: a longitudinal study. American Journal of Obstetrics and Gynecology. ISSN 0002-9378. 227(4), p. 613.e1–613.e15. doi: 10.1016/j.ajog.2022.06.020. Full text in Research Archive Show summary

  Background: Despite the strong association between vaginal childbirth and pelvic floor dysfunction, genetic factors, pregnancy, advancing age, and lifestyle also play a role. The pelvic floor undergoes substantial changes during pregnancy which may contribute to pelvic floor dysfunction. On the other hand, these changes may be favorable to allow for vaginal delivery. However, there is a lack of studies assessing pelvic floor symptoms over time according to delivery mode, which includes women prior to delivery. Objective: The aim of this study was to describe urinary incontinence, vaginal symptoms, and bowel control symptoms from 21 weeks of gestation in the first pregnancy and up to 8 years after the first delivery, stratified by delivery mode. Study design: This is a longitudinal observational cohort study. 300 nulliparous women were recruited during their first pregnancy. Pelvic floor symptoms were assessed at 21 and 37 weeks of gestation, and 6 weeks, 6 months, 12 months and 8 years after first delivery using the International Consultation on Incontinence Questionnaire (ICIQ) modules: the urinary incontinence sum score; the weighted vaginal symptom sum score; the vaginal-associated quality of life score; the bowel control sum score; and the bowel-associated quality of life sum score. Delivery mode at first delivery defined delivery groups as: normal vaginal, operative vaginal and cesarean delivery. A linear mixed model analysis was used to assess symptom scores over time and to assess the differences in symptom scores between the delivery groups. Results: Of the 300 women included in the study, of which 193 attended the 8-year follow-up. Pelvic floor symptoms differed in women with vaginal and cesarean delivery. The symptom scores showed a non-linear statistically significant trend. In women, who delivered vaginally, there was an increase of urinary incontinence and vaginal symptom scores already during pregnancy. In women, who later delivered by cesarean, there was a decrease of symptoms scores during pregnancy, and overall lower symptom scores compared to women with vaginal delivery until 12 months after first delivery. Pelvic floor symptoms scores increased from 12 months to 8 years after the first delivery and exceeded pregnancy levels in all delivery groups, however overall symptom scores were low. Differences between delivery groups were not statistically significant. Conclusion: Pelvic floor symptoms differed in women with vaginal and cesarean delivery from the first pregnancy up to 8 years after the first delivery. These differences were recognizable already prior to first delivery.

• Bø, Kari; Næss, Karoline; Stær-Jensen, Jette; Siafarikas, Franziska; Engh, Anna Marie Ellström & Hilde, Gunvor (2022). Recovery of pelvic floor muscle strength and endurance 6 and 12 months postpartum in primiparous women—a prospective cohort study. International Urogynecology Journal. ISSN 0937-3462. 33(12), p. 3455–3464. doi: 10.1007/s00192-022-05334-y. Full text in Research Archive Show summary

  Introduction and hypothesis: To date there has been scant knowledge on the natural recovery of the pelvic floor muscles (PFMs) after childbirth. The aims of the present study were to investigate whether PFM variables at 6 and 12 months postpartum had returned to mid-pregnancy levels and assess risk factors for reduced recovery at 12 months postpartum. Methods: This was a prospective cohort study following 235 nulliparous pregnant women from mid-pregnancy to 12 months postpartum. Vaginal resting pressure (VRP), PFM strength and endurance were assessed by manometry at 22 weeks, 6 and 12 months postpartum. Multiple linear regression was used to address factors influencing PFM variables beyond birth mode. Results: Cesarean section was protective for change in PFM variables. From mid-pregnancy to 12 months postpartum there was a 20% reduction in VRP (p<0.001) and a 7.5 % reduction in PFM strength (p=0.007), and an increase of 9% in PFM endurance (p=0.002) in the normal vaginal birth. The instrumental vaginal group had a decline in VRP of 21% (p<0.001) and PFM strength of 15% (p=0.011), but no significant change in PFM endurance. Higher BMI at 12 months postpartum, longer second stage of labor, and major tears of the levator ani muscle had a negative influence on the PFM recovery beyond delivery mode. Conclusions: At 12 months postpartum following vaginal delivery, the PFMs are not fully recovered compared with mid-pregnancy values. More follow-up physical therapy may be warranted in the postpartum period, especially for women with complicated vaginal births and higher BMI.

• Bø, Kari; Anglès-Acedo, Sònia; Batra, Achla; Brækken, Ingeborg Hoff; Chan, Yi Ling & Jorge, Cristine Homsi [Show all 9 contributors for this article] (2022). International urogynecology consultation chapter 3 committee 2; conservative treatment of patient with pelvic organ prolapse: Pelvic floor muscle training. International Urogynecology Journal. ISSN 0937-3462. 33(10), p. 2633–2667. doi: 10.1007/s00192-022-05324-0. Full text in Research Archive Show summary

  Introduction and hypothesis: This manuscript from Chapter 3 of the International Urogynecology Consultation (IUC) on Pelvic Organ Prolapse (POP) describes the current evidence and suggests future directions for research on the effect of pelvic floor muscle training (PFMT) in prevention and treatment of POP. Methods: An international group of four physical therapists, four urogynecologists and one midwife/basic science researcher performed a search of the literature using pre-specified search terms on randomized controlled trials (RCTs) in Ovid Medline, EMBASE, CINAHL, Cochrane, PEDro and Scopus databases for publications between 1996 and 2021. Full publications or expanded abstracts in English or in other languages with abstracts in English were included. The PEDro rating scale (0–10) was used to evaluate study quality. Included RCTs were reviewed to summarize the evidence in six key sections: (1) evidence for PFMT in prevention of POP in the general female population; (2) evidence for early intervention of PFMT in the peripartum period for prevention and treatment of POP; (3) evidence for PFMT in treatment of POP in the general female population; (4) evidence for perioperative PFMT; (5) evidence for PFMT on associated conditions in women with POP; (6) evidence for the long-term effect of PFMT on POP. Full publications in English or in other languages with abstracts in English and expanded abstracts presented at international condition specific societies were included. Internal validity was examined by the PEDro rating scale (0–10). Results: After exclusion of duplicates and irrelevant trials, we classified and included 2 preventive trials, 4 trials in the post-partum period, 11 treatment trials of PFMT for POP in the general female population in comparison with no treatment or lifestyle interventions, 10 on PFMT as an adjunct treatment to POP surgery and 9 long-term treatment trials. Only three treatment studies compared PFMT with the use of a pessary. The RCTs scored between 4 and 8 on the PEDro scale. No primary prevention studies were found, and there is sparse and inconsistent evidence for early intervention in the postpartum period. There is good evidence/recommendations from 11 RCTs that PFMT is effective in reducing POP symptoms and/or improving POP stage (by one stage) in women with POP-Q stage I, II and III in the general female population, but no evidence from 9/10 RCTs that adding PFMT pre- and post -surgery for POP is effective. There are few long-term follow-up studies, and results are inconsistent. There are no serious adverse effects or complications reported related to PFMT. Conclusions: There are few studies on prevention and in the postpartum period, and the effect is inconclusive. There is high-level evidence from 11 RCTs to recommend PFMT as first-line treatment for POP in the general female population. PFMT pre- and post-POP surgery does not seem to have any additional effect on POP. PFMT is effective and safe but needs thorough instruction and supervision to be effective.

• Gluppe, Sandra L.; Engh, Anna Marie Ellström & Bø, Kari (2022). Primiparous women’s knowledge of diastasis recti abdominis, concerns about abdominal appearance, treatments, and perceived abdominal muscle strength 6–8 months postpartum. A cross sectional comparison study. BMC Women's Health. 22, p. 1–11. doi: 10.1186/s12905-022-02009-0. Full text in Research Archive Show summary

  Background: Diastasis recti abdominis (DRA) is a prevalent condition in the postpartum period. To date, there is scant knowledge on how DRA influences physical, mental, and emotional health. This study investigates primiparous women`s knowledge about DRA, concerns about abdominal appearance, and perceived abdominal muscle strength, comparing women with and without reported DRA. Methods: This was a cross-sectional comparison study. Data were collected by a web-based questionnaire, mainly through social media in Norway. To be included in the study women had to be primiparous 6–8 months postpartum. The questionnaire contained questions regarding women`s knowledge about DRA, perceived protrusion, received treatment, concerns with abdominal appearance and muscle strength. Abdominal body image was measured through the shape concern questions from The Eating Disorder Examination questionnaire (EDE-Q 6.0). Demographic and other descriptive variables are presented as means with standard deviations (SD) or as frequencies with percentages. Chi-square test of independence and independent sample t-tests were used to compare differences between women with and without abdominal protrusion for categorical and continuous variables, respectively. Results: Our sample consisted of 460 women. Knowledge about DRA was reported by 415/440 (94.3%) women. A total of 73.3% reported to have been worried during pregnancy about abdominal appearance postpartum. Mean degree of concern about present abdominal appearance was 5.5/10 (SD 2.4). Almost 80% experienced weaker abdominal muscles than pre-pregnancy. Ninety-six women (20.9%) reported a protrusion along the midline of their abdomen. Significantly more women with protrusion reported weaker abdominal muscles than women without protrusion. The most frequent treatment women with protrusion reported were exercises for the abdominal muscles (92.6%). Mean score on the EDE-Q, shape concern questions, was higher in women with reported protrusion (mean score: 2.37 (SD 1.6) than women without protrusion (mean score: 2.14 (SD 1.4), p = 0.175. Conclusion: Primiparous women are concerned about abdominal appearance both during pregnancy and after birth. Those reporting abdominal protrusion are less satisfied with their abdominal appearance and they report weaker abdominal muscles than women without protrusion. This study may contribute to improved knowledge about women`s health concerns, and assessment of DRA should be part of routine follow-up of postpartum women.

• Arlandis, Salvador; Bø, Kari; Cobussen-Boekhorst, Hanny; Costantini, Elisabetta; Heide, Monica de & Farag, Fawzy [Show all 24 contributors for this article] (2022). European Association of Urology Guidelines on the Management of Female Non-neurogenic Lower Urinary Tract Symptoms. Part 2: Underactive Bladder, Bladder Outlet Obstruction, and Nocturia. European Urology. ISSN 0302-2838. 82(1), p. 60–70. doi: 10.1016/j.eururo.2022.01.044. Full text in Research Archive Show summary

  Context: Female lower urinary tract symptoms (LUTS) are a common presentation in urological practice. Thus far, only a limited number of female LUTS conditions have been included in the European Association of Urology (EAU) guidelines compendium. The new non-neurogenic female LUTS guidelines expand the remit to include these symptoms and conditions. Objective: To summarise the management of underactive bladder (UAB), bladder outlet obstruction (BOO), and nocturia in females. Evidence acquisition: The literature search was updated in September 2021 and evidence synthesis was conducted using modified GRADE approach as outlined for all EAU guidelines. A new systematic review on BOO was carried out by the panel for purposes of this guideline. Evidence synthesis: The important considerations for informing guideline recommendations are presented, along with a summary of all the guideline recommendations. Conclusions: Non-neurogenic female LUTS are an important presentation of urological dysfunction. Initial evaluation, diagnosis, and management should be carried out in a structured and logical fashion on the basis of the best available evidence. This guideline serves to present this evidence to practising urologists and other health care providers in an easily accessible and digestible format.

• Barcellini, Amelia; Dominoni, Mattia; Mas, Francesca Dal; Biancuzzi, Helena; Venturini, Sara Carla & Gardella, Barbara [Show all 8 contributors for this article] (2022). Sexual Health Dysfunction After Radiotherapy for Gynecological Cancer: Role of Physical Rehabilitation Including Pelvic Floor Muscle Training. Frontiers in Medicine. 8. doi: 10.3389/fmed.2021.813352. Full text in Research Archive Show summary

  Introduction: The present study aims to describe: 1. How the side effects of radiotherapy (RT) could impact sexual health in women; 2. The effectiveness of physical rehabilitation including pelvic floor muscle training (PFMT) in the management of sexual dysfunction after RT. Materials and Methods: Search keys on PubMed, Web of Science, Scopus, PEDro, and Cochrane were used to identify studies on women treated with radical or adjuvant RT and/or brachytherapy for gynecological cancers with an emphasis on vulvo-vaginal toxicities and PFMT studies on sexual dysfunction for this group of women. Results: Regarding the first key question, we analyzed 19 studies including a total of 2,739 women who reported vaginal dryness, stenosis, and pain as the most common side effects. Reports of dosimetric risk factors and dose-effect data for vaginal and vulvar post-RT toxicities are scant. Only five studies, including three randomized controlled trials (RCTs), were found to report the effect of PFMT alone or in combination with other treatments. The results showed some evidence for the effect of training modalities including PFMT, but to date, there is insufficient evidence from high-quality studies to draw any conclusion of a possible effect. Conclusions: Gynecological toxicities after RT are common, and their management is challenging. The few data available for a rehabilitative approach on post-actinic vulvo-vaginal side effects are encouraging. Large and well-designed RCTs with the long-term follow-up that investigate the effect of PFMT on vulvo-vaginal tissues and pelvic floor muscle function are needed to provide further guidance for clinical management.

• Theodorsen, Nina-Margrethe Tennebekk; Fersum, Kjartan Vibe; Moe-Nilssen, Rolf; Bø, Kari & Haukenes, Inger (2022). Effect of a specific exercise programme during pregnancy on diastasis recti abdominis: study protocol for a randomised controlled trial. BMJ Open. 12(2). doi: 10.1136/bmjopen-2021-056558. Full text in Research Archive Show summary

  Introduction: Diastasis recti abdominis (DRA) is a common condition in pregnant and postpartum women. Evidence for the treatment of DRA is both sparse and weak. As this condition occurs during the last two trimesters of pregnancy and there is a paucity of high-quality studies on a pregnant population, we will conduct a randomised trial on the effect of a specific exercise programme during pregnancy on DRA. Methods and analysis: This is an exploratory, assessor-blinded, randomised parallel group trial carried out in a primary healthcare setting in a Norwegian city. 100 pregnant women, both primigravida and multigravida, in gestation week 24 presenting with DRA of ≥28 mm will be included. Participants will be allocated to either an intervention group or a control group by block randomisation. The intervention group will participate in a 12-week specific exercise programme. The control group will not participate in any exercise intervention. Data collection will take place prior to intervention, postintervention at gestation week 37, and 6 weeks, 6 and 12 months postpartum. The primary outcome measure will be change in the inter-recti distance, measured by two-dimensional ultrasonography. Data will be analysed and presented in accordance with international Consolidated Standards of Reporting Trials guidelines and analysed according to the intention-to-treat principle. Ethics and dissemination: Ethical approval has been obtained by the regional ethical committee (76296), and all procedures will be performed in adherence to the Helsinki declaration. The study has been registered with ClinicalTrials.gov. Results from this study will be presented at scientific conferences and in peer-reviewed scientific journals.

• Bø, Kari; Anglès‑Acedo, Sònia; Batra, Achla; Brækken, Ingeborg Hoff; Chan, Yi Ling & Jorge, Cristine Homsi [Show all 9 contributors for this article] (2022). Are hypopressive and other exercise programs effective for the treatment of pelvic organ prolapse? International Urogynecology Journal. ISSN 0937-3462. 34(1), p. 43–52. doi: 10.1007/s00192-022-05407-y. Full text in Research Archive Show summary

  Introduction and hypothesis: Pelvic floor muscle training (PFMT) is effective for the treatment of pelvic organ prolapse (POP), but other exercise programs have also been promoted and used. The aim of this review was to evaluate the effect of hypopressive and other exercise programs besides PFMT for POP. Methods: A literature search was conducted on Ovid Medline, EMBASE, CINAHL, Cochrane, PEDro, and Scopus databases from January 1996 to 30 December 2021. Only randomized controlled trials (RCTs) were included. The keywords were combinations of “pelvic organ prolapse” or “urogenital prolapse,” and “exercise therapy,” “hypopressive exercise,” “Kegel,” “pelvic floor muscle training,” “pelvic floor muscle exercises,” “Pilates,” “treatment,” “yoga,” “Tai Chi.” Methodological quality was assessed using the PEDro rating scale (0–10). Results: Seven RCTs containing hypopressive exercise, yoga or breathing and hip muscle exercises in an inverted position were retrieved and analyzed. PEDro score ranged from 4 to 7. There was no additional effect of adding hypopressive exercise to PFMT, and PFMT was more effective than hypopressive exercise alone. The studies that included the term “yoga” included regular PFMT and thus can be classified as PFMT. Hip exercises in an inverted position added to PFMT vs PFMT alone showed better improvement in some secondary outcomes but not in the primary outcome, POP stage. Conclusions: There are few RCTs assessing the effects of other exercise programs besides PFMT in the treatment of POP. To date, there is no evidence that other exercise programs are more effective than PFMT for POP.

• Bø, Kari; Haakstad, Lene Annette Hagen; Paulsen, Gøran & Rustaden, Anne Mette (2021). Does regular strength training cause urinary incontinence in overweight inactive women? : A randomized controlled trial. International Urogynecology Journal. ISSN 0937-3462. 32. doi: 10.1007/s00192-021-04739-5. Full text in Research Archive Show summary

  Introduction and hypothesis: Urinary incontinence (UI) is common in women who exercise. We aimed to investigate new onset UI in formerly inactive, overweight or obese women (BMI > 25) participating in three different strength training modalities compared with a non-exercising control group. Methods: This was a secondary analysis of an assessor blinded randomized controlled trial investigating the effect of 12 weeks of three strength training concepts for women on muscle strength and body composition. None of the programs included pelvic floor muscle training. International Consensus on Incontinence Questionnaire Urinary Incontinence Short Form (ICIQ-UI-SF) was used to investigate primary outcome; new onset UI, and secondary outcome; ICIQ-UI-SF sum score. Suissa and Shuster’s exact unconditional test was used to analyze difference in new onset UI. Difference in ICIQ-UI-SF sum score is presented as mean with 95% CI. Results: At baseline 40 out of 128 (31.2%) participants reported UI. Three out of 27, 2 out of 17, 2 out of 23, and 0 out of 21 women in the three training and control groups respectively had new onset UI. There were no statistically significant differences in new onset UI across the groups or when collapsing new onset UI in the intervention groups compared with the controls (7 out of 67 vs 0 out of 21), p = 0.124. After the intervention the control group reported worse ICIQ-UI-SF sum score than any of the training groups; mean difference − 6.6 (95% CI: −11.9, −1.27), p = 0.012, but there was no difference in change from baseline to 12 weeks between the groups p = 0.145). Conclusions: There was no statistically significant change in UI after strength training.

• Antônio, Flávia Ignácio; Bø, Kari; Pena, Caroline C.; Bueno, Sabrina M.; Mateus-Vasconcelos, Elaine Cristine Lemes & Fernandes, Ana Carolina Nociti Lopes [Show all 7 contributors for this article] (2021). Intravaginal electrical stimulation increases voluntarily pelvic floor muscle contractions in women who are unable to voluntarily contract their pelvic floor muscles: a randomised trial. Journal of Physiotherapy. ISSN 1836-9553. 68(1), p. 37–42. doi: 10.1016/j.jphys.2021.12.004. Full text in Research Archive Show summary

  Question: In women who are unable to contract their pelvic floor muscles voluntarily, what is the effect of an intravaginal electrical stimulation regimen on their ability to contract the pelvic floor muscles and on self-reported urinary incontinence? Design: Randomised controlled trial with concealed allocation, blinded assessors and intention-to-treat analysis. Participants: Sixty-four women with pelvic floor muscle function assessed by bi-digital palpation to be grade 0 or 1 on the Modified Oxford Scale. Intervention: For 8 weeks, participants randomised to the experimental group received weekly 20-minute sessions of intravaginal electrical stimulation with instructions to attempt pelvic floor muscle contractions during the bursts of electrical stimulation in the final 10 minutes of each session. The control group received no intervention. Outcome measures: The primary outcome was ability to voluntarily contract the pelvic floor muscles, evaluated through vaginal palpation using the Modified Oxford Scale. Secondary outcomes were prevalence and severity of urinary incontinence symptoms assessed by the International Consultation on Incontinence Questionnaire on Urinary Incontinence-Short Form (ICIQ-UI-SF) score from 0 to 21. Results: Sixty-one participants provided outcome data. After the intervention, the ability to contract the pelvic floor muscles was acquired by 36% of the experimental group and 12% of the control group (absolute risk difference 0.24, 95% CI 0.02 to 0.43). The experimental group also improved by a mean of 2 points more than the control group on the ICIQ-UI-SF score (95% CI 0.02 to 3.97). Conclusion: In women who are unable to contract their pelvic floor muscles voluntarily, 8 weeks of intravaginal electrical stimulation with voluntary contraction attempts improved their ability to contract their pelvic floor muscles and reduced the overall severity and impact of urinary incontinence on quality of life. Although the main estimates of these effects indicate that the effects are large enough to be worthwhile, the precision of these estimates was low, so it is not possible to confirm whether the effects are trivial or worthwhile.

• Pena, Caroline C.; Bø, Kari; Ossa, Aura M.P. de la; Fernandes, Ana Carolina Nociti Lopes; Aleixo, Devechio N. & Oliveira, Flávia M.F. de [Show all 7 contributors for this article] (2021). Are visual inspection and digital palpation reliable methods to assess ability to perform a pelvic floor muscle contraction? An intra‐rater study. Neurourology and Urodynamics. ISSN 0733-2467. 40(2), p. 680–687. doi: 10.1002/nau.24609. Full text in Research Archive Show summary

  Aims: To investigate the intrarater reliability of visual inspection and digital palpation to classify women's ability to perform a voluntary pelvic floor muscle (PFM) contraction and the association between the two methods. Methods: This was a test–retest clinical study including 44 women. The ability to perform a PFM voluntary contraction was evaluated two times in all participants using visual inspection and digital palpation. All analyzed participants were assessed with a 7‐day interval between the two assessments and by the same examiner. Kappa's agreement coefficient was used to estimate the intrarater reliability, and Fisher's exact test was used to analyze association between the two methods. Results: This study found a substantial intrarater reliability of visual inspection (k = 0.73; p < .001) and digital palpation (k = 0.74; p < .001). A significant association between visual inspection and digital palpation was found at both time points (p < .001). Conclusion: Both visual inspection and digital palpation have substantial intrarater reliability and visual inspection can be recommended when vaginal palpation is not tolerated.

• Pang, Karl H.; Campi, Riccardo; Arlandis, Salvador; Bø, Kari; Chapple, Christopher R. & Costantini, Elisabetta [Show all 25 contributors for this article] (2021). Diagnostic Tests for Female Bladder Outlet Obstruction: A Systematic Review from the European Association of Urology Non-neurogenic Female LUTS Guidelines Panel. European Urology Focus. doi: 10.1016/j.euf.2021.09.003. Full text in Research Archive Show summary

  Context: Female bladder outlet obstruction (fBOO) is a relatively uncommon condition compared with its male counterpart. Several criteria have been proposed to define fBOO, but the comparative diagnostic accuracy of these remains uncertain. Objective: To identify and compare different tests to diagnose fBOO through a systematic review process. Evidence acquisition: A systematic review of the literature was performed according to the Cochrane Handbook and Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist. The EMBASE/MEDLINE/Cochrane databases were searched up to August 4, 2020. Studies on women ≥18 yr of age with suspected bladder outlet obstruction (BOO) involving diagnostic tests were included. Pressure-flow studies or fluoroscopy was used as the reference standard where possible. Two reviewers independently screened all articles, searched reference lists of retrieved articles, and performed data extraction. The risk of bias was assessed using Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2). Evidence synthesis: Overall, 28 nonrandomised studies involving 10 248 patients were included in the qualitative analysis. There was significant heterogeneity regarding the characteristics of women included in BOO cohorts (ie, mixed cohorts including both anatomical and functional BOO). Pressure-flow studies ± fluoroscopy was evaluated in 25 studies. Transperineal Doppler ultrasound was used to evaluate bladder neck dynamics in two studies. One study tested the efficacy of transvaginal ultrasound. The urodynamic definition of fBOO also varied amongst studies with different parameters and thresholds used, which precluded a meta-analysis. Three studies derived nomograms using the maximum flow rate (Qmax) and voiding detrusor pressure at Qmax. The sensitivity, specificity, and overall accuracy ranges were 54.6–92.5%, 64.6–93.9%, and 64.1–92.2%, respectively. Conclusions_ The available evidence on diagnostic tests for fBOO is limited and heterogeneous. Pressure-flow studies ± fluoroscopy remains the current standard for diagnosing fBOO.

• Gluppe, Sandra L.; Engh, Anna Marie Ellström & Bø, Kari (2021). What is the evidence for abdominal and pelvic floor muscle training to treat diastasis recti abdominis postpartum? A systematic review with meta-analysis. Brazilian Journal of Physical Therapy (BJPT). ISSN 1413-3555. 25(6), p. 664–675. doi: 10.1016/j.bjpt.2021.06.006. Full text in Research Archive Show summary

  Background: Diastasis recti abdominis (DRA) affects a significant number of women in the post- partum period. Objective: To systematically review whether abdominal and pelvic floor muscle (PFM) exercise programs are effective in the treatment of DRA postpartum. Methods: Electronic search was conducted from inception to March 2020. Randomized controlled tri- als (RCT) or pilot RCTs that compared abdominal training, PFM training, or a combination of both in at least one arm of the trial were included. The primary outcome was presence of DRA (numbers/per- centage) or inter-recti distance (IRD) change. GRADE was used to rate the overall quality of evidence. Pooled effect sizes were expressed as mean difference (MD) with 95% confidence intervals (CI). Results: Seven RCTs totaling 381 women were included. Two studies comparing transversus abdominis (TrA) training with minimal intervention provided data to be included in a meta-analy- sis. The results provided very low level quality evidence that TrA training reduced IRD (MD = - 0.63 cm, 95% confidence interval: -1.25, -0.01, I2 = 0%). Two studies included curl-up exercises as part of their intervention. Level of evidence based on single trials of high risk of bias show very low evidence that curl-up training is more effective than minimal intervention for treating DRA. Similarly, analyses based on single trials provided low to very low quality evidence that PFM training is not more effective than minimal intervention for treating DRA. Conclusion: There is currently very low-quality scientific evidence to recommend specific exer- cise programs in the treatment of DRA postpartum

• Dantas, Lucas Ogura; Carvalho, Cristiano; Santos, Beatriz Laryssa de Jesus; Ferreira, Cristine Homsi Jorge; Bø, Kari & Driusso, Patricia (2021). Mobile health technologies for the management of urinary incontinence: A systematic review of online stores in Brazil. Brazilian Journal of Physical Therapy (BJPT). ISSN 1413-3555. 25(4), p. 387–395. doi: 10.1016/j.bjpt.2021.01.001. Full text in Research Archive Show summary

  Background: Urinary incontinence (UI) is a serious condition for which often times insufficient non-surgical treatment options are provided or sought. Mobile health (mHealth) applications (apps) offer potential to assist with the self-management of UI. Objective: To perform a systematic review of available mHealth apps for UI in Brazil. Methods: A search for UI mHealth apps from the Google Play Store and AppStore in Brazil was performed by two independent reviewers on June 4 2020, and the quality of eligible mHealth apps was assessed using the Mobile App Rating Scale (MARS). Results: Of the 1111 mHealth apps found, 12 were eligible for inclusion. Four offered exclusively exercise programs, six offered exercise and educational content, and two offered tools to track patient-reported symptoms. The included apps scored poorly on the MARS quality scale, with a mean ± standard deviation score of 2.7 ± 0.6 on a 0–5 scale. Most apps scored poorly based on credibility, user interface and experience, and engagement. Conclusion: Although there is growing interest in the development of mHealth technologies to support patients with UI, currently available tools in Brazil are of poor quality and limited functionality. Effective collaboration between industry and research is needed to develop new user-centered mHealth apps that can empower patients with UI.

• Skaug, Kristina Lindquist; Engh, Marie Ellström; Frawley, Helena C. & Bø, Kari (2021). Urinary and anal incontinence among female gymnasts and cheerleaders—bother and associated factors. A cross-sectional study. International Urogynecology Journal. ISSN 0937-3462. doi: 10.1007/s00192-021-04696-z. Full text in Research Archive Show summary

  Introduction and hypothesis: Artistic gymnastics, team gymnastics and cheerleading are sports including high-impact activities. It is presumed that the athletes' pelvic floor must be functioning well to prevent urinary (UI) and anal incontinence (AI) during sports. The aim of this study was to investigate the prevalence and risk factors for UI and AI in female artistic gymnasts, team gymnasts and cheerleaders; the influence of UI and AI on daily living and sport performance; and the athletes' knowledge about the pelvic floor muscles (PFM). Methods: All female athletes ≥ 12 years of age competing in ≥ 1 National Championship in artistic gymnastics, team gymnastics or cheerleading in 2018/2019 were invited. International Consensus on Incontinence Questionnaires were used to assess the prevalence/bother of UI and AI. Results: Among the 319 gymnasts and cheerleaders who participated, the prevalence of UI and AI was 67% and 84%, respectively. Age, training ≥ 4 days/week and straining to void were significantly associated with stress urinary incontinence (SUI) and years of training with AI. Eighty-three percent of athletes with SUI reported a negative effect on sports performance, 22% would occasionally avoid training or specific exercises because of leakage, and 28% used pads for protection. Forty-one percent of the athletes had never heard about the PFM, and 74% reported an interest in PFM training to prevent/treat UI or AI. Conclusions: UI and AI were prevalent in female gymnasts and cheerleaders, and SUI negatively influenced sport performance. The athletes' knowledge about the PFM was limited.

• Sigurdardottir, Thorgerdur; Bø, Kari; Steingrimsdóttir, Thora; Halldórsson, Thorhallur Ingi; Aspelund, Thor & Geirsson, Reynir T. (2021). Cross-sectional study of early postpartum pelvic floor dysfunction and related bother in primiparous women 6–10 weeks postpartum. International Urogynecology Journal. ISSN 0937-3462. 32(7), p. 1847–1855. doi: 10.1007/s00192-021-04813-y. Full text in Research Archive Show summary

  Introduction and hypothesis: To study the prevalence of pelvic floor dysfunction and related bother in primiparous women 6–10 weeks postpartum, comparing vaginal and cesarean delivery. Methods: Cross-sectional study of 721 mothers with singleton births in Reykjavik, Iceland, 2015 to 2017, using an electronic questionnaire. Information on urinary and anal incontinence, pelvic organ prolapse and sexual dysfunction with related bother (trouble, nuisance, worry, annoyance) was collected. Main outcome measures were prevalence of pelvic floor dysfunction and related bother. Results: The overall prevalence of urinary and anal incontinence was 48% and 60%, respectively. Bother regarding urinary symptoms was experienced by 27% and for anal symptoms by 56%. Pelvic organ prolapse was noted by 29%, with less than half finding this bothersome. Fifty-five percent were sexually active, of whom 66% reported coital pain. Of all the women, 48% considered sexual issues bothersome. Urinary incontinence and pelvic organ prolapse were more prevalent in women who delivered vaginally compared to cesarean section, but no differences were observed for anal incontinence and coital pain. Compared to women with BMI < 25, obesity was a predictor for urinary incontinence after vaginal delivery (OR 1.94; 95% CI 1.20–3.14). Birthweight > 50th percentile was predictive for urgency incontinence after vaginal delivery (OR 1.53; 95% CI 1.05–2.21). Episiotomy predicted more anal incontinence (OR 2.19; 95% CI 1.30–3.67). No associations between maternal and delivery characteristics were found for pelvic floor dysfunction after cesarean section. Conclusions: Bothersome pelvic floor dysfunction symptoms are prevalent among first-time mothers in the immediate postpartum period.

• Frawley, Helena C.; Shelly, Beth; Morin, Melanie; Bernard, Stéphanie; Bø, Kari & Digesu, Giuseppe Alessandro [Show all 14 contributors for this article] (2021). An International Continence Society (ICS) report on the terminology for pelvic floor muscle assessment. Neurourology and Urodynamics. ISSN 0733-2467. 40(5), p. 1217–1260. doi: 10.1002/nau.24658. Full text in Research Archive Show summary

  Introduction: The terminology for female and male pelvic floor muscle (PFM) assessment has expanded considerably since the first PFM function and dysfunction standardization of terminology document in 2005. New terms have entered assessment reports, and new investigations to measure PFM function and dysfunction have been developed. An update of this terminology was required to comprehensively document the terms and their definitions, and to describe the assessment method and interpretation of the finding, to standardize assessment procedures and aid diagnostic decision making. Methods: This report combines the input of members of the Standardisation Committee of the International Continence Society (ICS) Working Group 16, with contributions from recognized experts in the field and external referees. A logical, sequential, clinically directed assessment framework was created against which the assessment process was mapped. Within categories and subclassifications, each term was assigned a numeric coding. A transparent process of 12 rounds of full working group and external review was undertaken to exhaustively examine each definition, plus additional extensive internal development, with decision making by collective opinion (consensus). Results: A Terminology Report for the symptoms, signs, investigations, and diagnoses associated with PFM function and dysfunction, encompassing 185 separate definitions/descriptors, has been developed. It is clinically based with the most common assessment processes defined. Clarity and user‐friendliness have been key aims to make it interpretable by clinicians and researchers of different disciplines. Conclusion: A consensus‐based Terminology Report for assessment of PFM function and dysfunction has been produced to aid clinical practice and be a stimulus for research.

• Brækken, Ingeborg Hoff; Stuge, Britt; Tveter, Anne Therese & Bø, Kari (2021). Reliability, validity and responsiveness of pelvic floor muscle surface electromyography and manometry. International Urogynecology Journal. ISSN 0937-3462. 32(12), p. 3267–3274. doi: 10.1007/s00192-021-04881-0. Full text in Research Archive Show summary

  Introduction and hypothesis: Vaginal surface electromyography (sEMG) is commonly used to assess pelvic floor muscle (PFM) function and dysfunction but there is a lack of studies regarding the assessment properties. The aim of the study was to test the hypotheses that sEMG has good test-retest intratester reliability, good criterion validity and is responsive to changes compared to manometry. Methods: PFM resting tone, maximum voluntary contraction (MVC) and endurance were measured in 66 women with pelvic floor dysfunction. One assessment by manometry was followed by two testing sessions with sEMG at baseline. After 4 to 42 weeks of supervised PFM strength training, 29 participants were retested with both devices. Results: Median age of the participants was 41 years (range 24-83) and parity 2 (range 0-10). Very good test-retest intratester reliability was found for all three sEMG measurements. The correlation between sEMG and manometry was moderate for vaginal resting tone (r = 0.42, n = 66, p < 0.001) and strong for MVC (r = 0.66, n = 66, p < 0.001) and endurance (r = 0.67, n = 66, p < 0.001). Following the strength training period, participants demonstrated increased MVC and endurance measured with manometry, but not with sEMG. A significant reduction in resting tone was found only with sEMG. Conclusion: sEMG is reliable and correlates well with manometry. However, sEMG is not as responsive as manometry for changes in PFM MVC and endurance. For measurement of PFM resting tone, sEMG seems more responsive than manometry, but this requires further investigation.

• Haakstad, Lene Annette Hagen; Kissel, Iselin Haugland & Bø, Kari (2021). Long-term effects of participation in a prenatal exercise intervention on body weight, body mass index, and physical activity level: a 6-year follow-up study of a randomized controlled trial. Journal of Maternal-Fetal & Neonatal Medicine. ISSN 1476-7058. 34(9), p. 1347–1355. doi: 10.1080/14767058.2019.1636028. Full text in Research Archive Show summary

  Background: Growing evidence supports that physical activity and exercise during pregnancy is favorable for the mother, with persisting benefits in the postpartum period. However, there is scant knowledge of the effect of a prenatal exercise program on long-term health and lifestyle habits. Objectives: This 6-year follow-up study of a randomized controlled trial had two aims: (1) compare body weight, weight retention and body mass index (BMI) in the intervention group and control group, and (2) evaluate effects on physical activity level and recreational exercise. Materials and methods: Out of 105 participants initially randomized to either an intervention group, n = 52 (twice weekly group-exercises and physical activity counselling) or control group, n = 53 (standard prenatal care), 80 women (76.2%) participated in the present long-term follow-up study, performed in a general community in Oslo, Norway. Data were collected through a standardized telephone interview based on the baseline protocol and a modified Physical Activity and Pregnancy Questionnaire (PAPQ). Body weight at 6 years follow-up was self-reported (kg), and calculation of current BMI (kg/m2) was based on self-reported weight and measured height at study inclusion. Investigators were unaware of the original randomization at the time of the interviews. Analyses of covariance were used to examine the difference in change in body weight and BMI between the groups. Even though the MET-values were not normally distributed, differences were examined using a two-sided independent sample t-test due to large sample size (n ≥ 30). Results: At 6 years follow-up there were no differences in mean BMI (kg/m2) (24.0 ± 3.8 versus 24.8 ± 4.0, p = .37), physical activity level (4167 ± 2638 versus 3925 ± 3075 MET-min/week, p = .67) or recreational exercise (630 ± 1290 versus 720 ± 1005 MET-min/week, p = .88) between the intervention and control group, respectively. Subgroup analysis of participants with high adherence during the intervention 6 years ago (≥24 prenatal exercise classes), showed a positive intervention effect at long-term follow up in body weight (kg) (62.8 ± 7.9 versus 70.8 ± 11.8, p = .03) and BMI (kg/m2) (22.5 ± 3.1 versus 24.8 ± 4.0, p = .05), and none (versus 11 in the control group) had gained ≥5 kg compared to prepregnancy weight (p = .02). Conclusions: Women who adhered to the original prenatal exercise intervention demonstrated significantly lower body weight and BMI at 6-year follow-up. Otherwise, no long-term intervention effect was observed.

• Gluppe, Sandra L.; Engh, Marie Ellström & Bø, Kari (2021). Women with diastasis recti abdominis might have weaker abdominal muscles and more abdominal pain, but no higher prevalence of pelvic floor disorders, low back and pelvic girdle pain than women without diastasis recti abdominis. Physiotherapy. ISSN 0031-9406. 111, p. 57–65. doi: 10.1016/j.physio.2021.01.008. Full text in Research Archive Show summary

  Objective: To investigate whether women with diastasis recti abdominis (DRA) have weaker abdominal muscles and higher prevalence of pelvic floor disorders (PFD), low back, pelvic girdle and abdominal pain than women without DRA. Design: Cross sectional study of women with and without DRA. Setting: University study. Participants: Seventy-two parity and age matched women with and without DRA. Main outcome measures: Maximal abdominal muscle strength and endurance were assessed with a dynamometer and with a curl-up test. Women reported whether they experienced PFD, low back pain, pelvic girdle pain or abdominal pain. Those experiencing PFD or pain completed the Pelvic Floor Distress Inventory-short form 20 (PFDI-20), the Oswestry Disability Index (ODI), the Pelvic Girdle Questionnaire (PGQ) or questions about abdominal pain, respectively. Results: Maximal abdominal strength standing with 30° hip flexion was significantly lower in women with DRA (mean difference −12.9 Nm, 95%CI: −24.4 to −1.5; P = 0.028), but adjusted analyses showed no significant difference (mean difference −11.9 Nm, 95%CI: −26.5 to 2.6; P = 0.106). Adjusted analyses showed significant higher prevalence of abdominal pain in women with DRA (OR: 0.02, 95%CI: 0.00 to 0.61, P = 0.026). There was no difference between the groups in PFD, low back and pelvic girdle pain. Conclusion: Women with DRA tend to have weaker abdominal muscles and higher prevalence of abdominal pain, but no higher prevalence of PFD, low back or pelvic girdle pain than women without DRA.

• Peyronnet, Benoit; Lapitan, Marie Carmela; Tzelves, Lazaros; O'Connor, Eabhann; Ríogh, Aisling Nic An & Manso, Margarida [Show all 17 contributors for this article] (2021). Benefits and Harms of Conservative, Pharmacological, and Surgical Management Options for Women with Bladder Outlet Obstruction: A Systematic Review from the European Association of Urology Non-neurogenic Female LUTS Guidelines Panel. European Urology Focus. doi: 10.1016/j.euf.2021.10.006. Full text in Research Archive Show summary

  Context: While the management of bladder outlet obstruction (BOO) in men has been a topic of several systematic reviews and meta-analyses, no such evidence base exists for female BOO. Objective: The aim of this systematic review was to evaluate the benefits and harms of therapeutic interventions for the management of BOO in women. Evidence acquisition: This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. The study protocol was registered with PROSPERO (CRD42020183839). A systematic literature search was performed and updated by a research librarian in May 2021. The study population consisted of adult female patients diagnosed with BOO, who underwent treatment. Evidence synthesis: Out of 6344 records, we identified 33 studies enrolling 1222 participants, of which only six randomized controlled trials (RCTs) were found. One placebo-controlled crossover randomized trial assessed the role of baclofen in 60 female patients with dysfunctional voiding. The trial met its primary endpoint with a significantly greater decrease in the number of voids per day in the baclofen group (–5.53 vs –2.70; p = 0.001). The adverse events were mild and comparable in both groups (25% vs 20%). One placebo-controlled crossover randomized trial assessed the role of sildenafil in 20 women with Fowler’s syndrome. There were significant improvements from baseline in maximum urinary flow rate (Qmax), International Prostate Symptom Score (IPSS), and postvoid residual (PVR), but with no statistically significant difference when compared with placebo. In a large RCT including 197 female patients with functional BOO, the alpha-blocker alfuzosin significantly improved IPSS, Qmax, and PVR compared with baseline, but the differences were not statistically significant compared with the placebo group. Several small single-arm prospective series reported improvement of BOO-related symptoms and voiding parameters with urethroplasty, sling revision, urethral dilation, vaginal pessary, and pelvic organ prolapse repair. Conclusions: Evidence to support the use of conservative, pharmacological, and surgical treatments for BOO is scarce.

• Dantas, Lucas Ogura; Carvalho, Cristiano; Pena, Caroline C.; Breda, Carolina Carreira; Driusso, Patricia & Ferreira, Cristine Homsi Jorge [Show all 7 contributors for this article] (2021). Mobile health technologies for the monitoring of menstrual cycle: A systematic review of online stores in Brazil. Journal of Obstetrics and Gynaecology Research. ISSN 1341-8076. 48(1), p. 5–14. doi: 10.1111/jog.15082. Full text in Research Archive Show summary

  Aim: To perform a systematic review of available mHealth apps for menstrual cycle monitoring in Brazil. Methods: A search for menstrual cycle mHealth apps from the Google Play Store and AppStore in Brazil was performed by two independent reviewers on October 2020, and the quality of eligible mHealth apps was assessed using the Mobile App Rating Scale (MARS). Results: Our review identified 2400 potentially relevant mHealth apps, of which 56 were eligible for inclusion. The majority of the apps offered tools to track menstruation symptoms (63%) and educational content for users (32%). The mean ( ±SD) MARS app quality score for the 28 evaluated apps in Android was 3.5 ± 0.6 on a 0–5 scale. For the 28 evaluated apps in iOS, the mean app quality score was 3.8 ± 0.4. Most of the included apps, for both systems, scored average for credibility, user interface, and engagement. Conclusion: The majority of available tools in Brazil are of moderate quality and limited functionality for menstrual cycle monitoring. This study highlights the top three mHealth apps available on each online store for individuals seeking menstrual cycle monitoring options.

• Benvenuti, Maria Beatrice; Bø, Kari; Draghi, Simonetta; Tandoi, Elisabetta & Haakstad, Lene Annette Hagen (2021). The weight of motherhood: Identifying obesity, gestational weight gain and physical activity level of Italian pregnant women. Women's Health. ISSN 1745-5057. 17. doi: 10.1177/17455065211016136. Full text in Research Archive Show summary

  Objective: Pre-pregnancy obesity and suboptimal gestational weight gain are on the rise globally and are independently associated with several maternal and neonatal complications. A healthy lifestyle, including regular physical activity, may improve health and reduce these complications, but many women are less active and willing to engage in physical activity with advancing gestation. Therefore, the inclusion of a wider range of physical activity such as domestic chore, occupational activity and active commuting may help pregnant women to meet the physical activity recommendations of 150 min/week. Very little is known about these issues in Italy, a country with strong traditional roles regarding pregnancy and motherhood, including “la famiglia” (the family). Primary objective describes health and lifestyle behavior of pregnant Italian women. Secondary objective reports total physical activity level, recreational exercise and context of these activities from pre-pregnancy and throughout gestation in regard to gestational weight gain management. Study design: Cross-sectional study performed in one public hospital and four antenatal clinics in Italy. Participants (n = 513) completed a validated self-administered questionnaire, the Physical Activity Pregnancy Questionnaire, in gestation week 36.01 (standard deviation 2.0). Pre-pregnancy body weight (kg) was self-reported, whereas maternal weight (kg) was measured at gestation week 36. In line with current American College of Obstetricians and Gynecologists guidelines (2020), participants were categorized into regular physical activity (⩾150 min/week) or non-regular physical activity (<150 min/week). Results: Mean pre-pregnancy body-mass index was 22.8 kg/m2 (standard deviation 3.9), with 14.4% of women entering motherhood overweight and 5.3% obese. Mean gestational weight gain was 11.9 kg (standard deviation 4.1). Among those with a body-mass index ⩾25, 46.5% gained above the Institute of Medicine recommendations. With respect to recreational exercise/sport, 4.7% were active according to guidelines, whereas 82.7% accumulated ⩾150 min/week when combining exercise/sport with daily-life physical activity (commuting and occupational). Exercising ⩾150 min/week and working 100% in third trimester were associated with gestational weight gain within Institute of Medicine recommendations (p = 0.06 and p = 0.03). Conclusion: Italian pregnant women have a low exercise level, still over 80% achieved a total physical activity level ⩾150 min/week when adding occupational and commuting activities. Nearly 50% of overweight and obese women exceeded the recommended gestational weight gain during pregnancy.

• Bø, Kari; Haakstad, Lene Annette Hagen; Paulsen, Gøran & Rustaden, Anne Mette (2021). DOES REGULAR STRENGTH TRAINING CAUSE URINARY INCONTINENCE IN OVERWEIGHT INACTIVE WOMEN? A randomized controlled trial. International Urogynecology Journal. ISSN 0937-3462. doi: 10.1007/s00192-021-04739-5. Full text in Research Archive
• Haakstad, Lene Annette Hagen; Gjestvang, Christina; Lamerton, Tayla & Bø, Kari (2020). Urinary incontinence in a fitness club setting?is it a workout problem? International Urogynecology Journal. ISSN 0937-3462. doi: 10.1007/s00192-020-04253-0. Full text in Research Archive Show summary

  Introduction: The aims of the present study were to report longitudinal data on the prevalence of urinary incontinence (UI) in a fitness club setting and to investigate whether gym members are educated about and exercise their pelvic floor muscles. Methods: New members (125 women) from 25 fitness clubs in Oslo, Norway, filled in a 25-min online questionnaire (SurveyXact) at four time points (onset, 3, 6 and 12 months of fitness club membership). The questionnaire covered background/health information, membership dropout and exercise habits, including pelvic floor muscle training (PFMT). A modified Subjective Health Complaints Inventory (SHC Inventory) and the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) were used to gather repeated measures of UI. Results: At onset, 3, 6 and 12 months of fitness club membership, 16.8%, 13.8%, 19.6% and 18.7% reported UI, respectively (p = 0.11). Of these, 57.1% to 76.2% reported leakage during exercise and perceived the UI to be slight. Less than 8% had received information about PFMT by the fitness club staff. Adherence to regular exercise and PFMT throughout the follow-up period (minimum two sessions/week) did not show any association with absent or present UI at 12 months (p = 0.48 and p = 0.63) and was reported by 30% and 22.2% of the participants, respectively. Conclusions: About 17% reported UI at onset of fitness club membership, with no changes in proportions throughout the first year. Adherence to regular exercise and PFMT did not show any association with absent or present UI at 12 months. Few had been taught PFMT.

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• Bø, Kari; Berghmans, Bary; Mørkved, Siv & Kampen, Marijke Van (2023). Evidence-Based Physical Therapy for the Pelvic Floor Bridging Science and Clinical Practice. Elsevier. ISBN 9780702083082. 772 p. Full text in Research Archive

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• Bø, Kari (2024). Reply to: Uncertainties of the Impacts of Strenuous Physical Activity, Exercise, and Parity on Pelvic Organ Prolapse. International Urogynecology Journal. ISSN 0937-3462. doi: 10.1007/s00192-024-05751-1. Full text in Research Archive
• Gabrielsen, Rakel; Bø, Kari; Engh, Marie Ellström & Tennfjord, Merete Kolberg (2024). Pelvic floor muscle resting activity, ability to activate high tone pelvic floor muscles and association between pelvic floor muscle tone and pelvic and genital pain. A cross-sectional study of women with endometriosis. Full text in Research Archive
• Gabrielsen, Rakel; Bø, Kari; Tellum, Tina; Frawley, Helena; Engh, Marie Ellström & Tennfjord, Merete Kolberg (2024). Effectiveness of Supervised Exercise and Pelvic Floor Muscle Training in Alleviating Genito-Pelvic Pain in Women with Endometriosis: A Randomized Controlled Trial. Full text in Research Archive
• Tennfjord, Merete Kolberg; Bø, Kari; Engh, Marie Ellström & Gabrielsen, Rakel (2023). Women’s health physiotherapists clinical practice and endometriosis patients views of general exercise - a mixed-methods study. Full text in Research Archive
• Tennfjord, Merete Kolberg; Bø, Kari; Engh, Marie Ellström & Gabrielsen, Rakel (2023). Women’s health physiotherapists clinical practice and endometriosis patients views of general exercise – a mixed-methods study. Full text in Research Archive
• Gabrielsen, Rakel; Engh, Anna Marie Ellström; Bø, Kari & Tennfjord, Merete Kolberg (2023). Spectrum of symptoms among women suffering endometriosis and the relationship with physical activity and exercise. Full text in Research Archive
• Gram, Marte Charlotte Dobbertin; Clarsen, Benjamin Matthew & Bø, Kari (2021). Injuries and illnesses among competitive Norwegian rhythmic gymnasts during preseason - a prospective cohort study of prevalence, incidence and risk factors. British Journal of Sports Medicine. ISSN 0306-3674. 55, p. A11–A11. doi: 10.1136/bjsports-2021-IOC.25. Full text in Research Archive
• Gram, Marte Charlotte Dobbertin; Clarsen, Benjamin Matthew & Bø, Kari (2021). Injuries and illnesses among competitive Norwegian rhythmic gymnasts during preseason - a prospective cohort study of prevalence, incidence and risk factors. Full text in Research Archive
• Mota, Patrícia & Bø, Kari (2021). ACOG Committee Opinion No. 804: Physical Activity and Exercise During Pregnancy and the Postpartum Period. Obstetrics and Gynecology. ISSN 0029-7844. 137(2), p. 376–376. doi: 10.1097/AOG.0000000000004267. Full text in Research Archive

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