Background Group exercise-based programmes for urinary incontinence appear to be promising low-cost interventions for women in developing countries, but no evidence exists to support whether they could be implemented or effective in such populations. We aimed to evaluate whether a group intervention that comprised pelvic floor muscle training, mobility exercises, and bladder education would be more effective than education alone, and report changes between villages (ie, clusters) rather than between individual participants. Methods In this cluster randomised trial, we recruited women from 16 pairs of villages in Bangladesh, with each pair comprising similar villages from the same sub-district. Women aged 60-75 years were interviewed to establish eligibility. Women were eligible if they had current urinary incontinence, and were excluded if they had a third degree or higher uterine prolapse, if they were unable to walk or stand without help, or if they had insufficient intellectual capacity to understand questions and follow instructions. The villages were randomly assigned within each pair to either exercise plus education or education-only intervention by use of a random number generator from a fixed seed. Women were excluded after consenting if they lived too far from the centre of the village. The exercise intervention was a physiotherapist-led group exercise class that was held twice weekly for 12 weeks, with home exercises between classes and to 24 weeks. Both groups received bladder-health education. Participants were followed up for 24 weeks. A 3-day continence record was collected at recruitment and every 4 weeks up until 24 weeks. This record involved the participant tying a knot in ribbons worn under the clothing each time they had an episode of urinary leakage. The primary outcome was change in number of knots (recorded leakage episodes) from recruitment to 24 weeks. Safety was assessed in all participants in the exercise intervention group. The trial is registered at ClinicalTrials.gov, number NCT02453100.

Aims: Pelvic floor and mobility exercises were shown to be effective in managing incontinence in a cluster-randomized trial (CRT) of village women aged 60 to 75 years in Bangladesh. The present analysis examines continence 12 months after the CRT and exercise program implementation with village paramedics as preceptors.Methods: Women from nine villages in the exercise arm of the CRT were followed-up 12 months after the 6-month intervention. They provided information about exercise since the CRT and a 3-day continence record (3DCR). Posttrial, a further 6-month exercise intervention led by village paramedics was initiated in 20 villages. Women completed the two-item Sandvik severity questionnaire before and after the intervention. Paramedics kept a record of each woman's attendance at the 48 exercise sessions Results: A total of 130 of 150 women from the CRT completed the 12-month follow-up; 61.5% were dry on the 3DCR at follow-up. Total continence was related to the continuation of exercises carried out in the home and absence of urinary tract infection at follow-up. Those exercising at follow-up had an odds ratio (OR) of 3.49 (95% confidence interval [CI], 1.86-6.58) of being continent at follow-up. Higher end-of-CRT body mass index was associated with greater follow-up leakage. In the 20-village roll-out, with 316 incontinent women, improvement in both severity and total continence on the Sandvik questionnaire were related to a total number of sessions attended (OR = 1.09; 95% CI, 1.05-1.13). At roll-out, 38.6% achieved continence, comparable to 43.0% in the CRT using physiotherapy preceptors Conclusions: Group exercise classes led by paramedics resulted in a marked improvement in continence but maintenance requires exercise postintervention. K E Y W O R D Sadherence, Bangladesh, group exercises, paramedics, PFMT, rural health, urinary incontinence