This study will evaluate whether adding mental rehearsal of pelvic floor muscle contractions to pelvic floor muscle training improves stress urinary incontinence in postmenopausal women. Stress urinary incontinence is urine leakage during activities such as coughing, sneezing, or physical exertion. Mental rehearsal involves imagining the sensation of a movement without physically performing it.
The study will include 60 women aged 45 to 65 years who have completed natural menopause and have stress urinary incontinence. Participants will be randomly assigned to one of two groups. Both groups will receive the same supervised pelvic floor muscle training twice a week for 12 weeks. Before performing the pelvic floor exercises, one group will imagine contracting and relaxing the pelvic floor muscles. The other group will imagine making and opening a fist with their dominant hand.
Assessments will take place before treatment and at the end of 12 weeks. The main outcome will be urinary incontinence symptom severity. Additional assessments will examine urine leakage frequency and amount, incontinence-related quality of life, and pelvic floor muscle electrical activity.
Women aged 45 to 60 years.
Natural postmenopause, defined as the absence of menstruation for at least 12 consecutive months without a pathological, pharmacological, or surgical cause.
Physician-diagnosed stress urinary incontinence.
Sufficient cognitive and communication abilities to understand instructions in Turkish and complete the questionnaires and a three-day bladder/leakage diary.
Urgency, mixed, overflow, or neurogenic urinary incontinence.
Stage III or IV pelvic organ prolapse according to the Pelvic Organ Prolapse Quantification (POP-Q) system.
Inability to correctly and voluntarily contract the pelvic floor muscles.
Active urinary tract or vaginal infection, unexplained hematuria, or postmenopausal vaginal bleeding.
Parallel
Pelvic Floor Muscle Training
BehavioralBoth groups will receive the same progressive, supervised pelvic floor muscle training program, including slow and fast contractions, graded contractions, and pre-contraction before coughing or physical effort (the Knack). Training will progress across three four-week phases, with increasing contraction demands and progression toward standing and functional activities. The program will be delivered as part of 24 supervised sessions over 12 weeks, twice weekly on nonconsecutive days. Each session, including the assigned motor imagery component, will last approximately 30 minutes. No additional home exercise program will be prescribed.
Pelvic-Floor-Specific Kinesthetic Motor Imagery
BehavioralParticipants will mentally rehearse the sensation of closing, squeezing, and lifting the pelvic floor muscles around the urethra and vagina, followed by relaxation, without physically contracting during imagery. Kinesthetic imagery will be performed immediately before each corresponding physical pelvic floor contraction. This component will be integrated into all 24 supervised sessions over 12 weeks. Imagery duration and therapist contact will be matched to the dominant-hand imagery condition.
Dominant-Hand Kinesthetic Motor Imagery
BehavioralParticipants will mentally rehearse the sensation of making and opening a fist with their dominant hand, without actual hand movement. This imagery will be performed immediately before each physical pelvic floor contraction and will be integrated into all 24 supervised sessions over 12 weeks. Imagery duration and therapist contact will be matched to the pelvic-floor-specific imagery condition. Participants will receive the same physical pelvic floor muscle training program as the experimental group.
International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) Total Score
Urinary incontinence severity will be assessed using the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF). The questionnaire assesses the frequency and amount of urinary leakage and its impact on everyday life over the previous four weeks. The total score is calculated by summing three scored items and ranges from 0 to 21, with higher scores indicating greater urinary incontinence severity.
Mean Daily Stress Urinary Leakage Episodes
The mean number of stress urinary leakage episodes per day will be calculated using a bladder diary completed over three consecutive days before each assessment. Participants will record leakage associated with coughing, sneezing, laughing, lifting, or physical exertion. The total number of stress urinary leakage episodes recorded over three days will be divided by three. Results will be expressed as episodes per day, with higher values indicating more frequent leakage.
Urinary Loss Measured by the 24-Hour Pad Test
Urinary loss will be measured using a 24-hour pad test. Pads will be weighed before and after use using a calibrated scale, and the same pad type will be used at both assessments. The differences between used and dry pad weights will be summed to calculate total urinary loss over 24 hours. Results will be expressed in grams per 24 hours, with higher values indicating greater urinary loss.
Incontinence Quality of Life Questionnaire (I-QOL) Total Score
Incontinence-related quality of life will be assessed using the 22-item Incontinence Quality of Life questionnaire (I-QOL). The questionnaire covers avoidance and limiting behaviors, psychosocial impacts, and social embarrassment. The total score will be transformed to a scale ranging from 0 to 100, with higher scores indicating better incontinence-related quality of life.
Mean Pelvic Floor Muscle Electrical Activity During Voluntary Contractions
Pelvic floor muscle electrical activity will be assessed using intravaginal surface electromyography. Following a 60-second resting recording, participants will perform three maximal voluntary contractions lasting 10 seconds each, separated by 20-second rest intervals. The mean electrical activity during each contraction will be calculated, and the average of the three contraction values will be reported in microvolts. Assessments will be performed with an empty bladder in a supine position with the knees flexed, using standardized probe placement and device settings.
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