Multimodal pelvic floor rehabilitation in chronic stroke survivors: Long-term efficacy, optimal protocols, and adjunctive therapies for comprehensive pelvic floor dysfunction: A multicenter randomized controlled trial

Background Pelvic floor dysfunction (PFD), encompassing urinary incontinence, fecal incontinence/constipation, and sexual dysfunction, is a prevalent yet often overlooked complication in chronic stroke survivors profoundly impacting quality of life, social participation, and caregiver burden. Prior research has highlighted gaps in long-term outcome data, optimal dosing protocols, adjunctive therapies (biofeedback and neuromuscular electrical stimulation [NMES]), and comprehensive coverage of bowel and sexual domains. Objective This multicenter randomized controlled trial aimed to evaluate the long-term efficacy of multimodal pelvic floor muscle training (PFMT), optimize intervention protocols, assess adjunctive biofeedback and NMES, develop domain-specific approaches for bowel and female sexual dysfunction, examine partner impacts, integrate standardized assessments, correlate improvements with quality-of-life outcomes, and identify prognostic factors. Methods Four hundred twenty chronic stroke survivors with PFD were randomized into four groups: standard PFMT, intensified PFMT, PFMT + biofeedback, or PFMT + NMES. Interventions lasted 16 weeks (supervised), followed by self-managed home maintenance with monthly coaching up to 12 months. Primary outcomes included pelvic floor muscle strength (Modified Oxford scale and perineometry), urinary symptoms (ICIQ-UI SF), and bowel symptoms (Wexner score). Secondary outcomes encompassed sexual function (FSFI/IIEF-5),partner satisfaction, quality of life (SF-36, SIS), and adherence. Results At 12 months, 84% of participants sustained ≥ 80% of gains achieved at 16 weeks. All groups showed significant improvements in muscle strength and urinary symptoms, with convergence across groups long-term. PFMT + NMES demonstrated superiority in bowel outcomes (greater Wexner score reduction and remission rates; p = 0.002), while PFMT + biofeedback excelled in female sexual function (notably lubrication and arousal; p < 0.01). Perineometry exhibited higher reliability than digital palpation. Objective gains correlated moderately with enhanced quality of life, emotional well-being, and social participation. Poorer responders were predicted by hemorrhagic stroke, severe disability, and left-sided lesions. Conclusion Multimodal PFMT yields durable, domain-specific benefits in chronic stroke-related PFD, with NMES and biofeedback providing targeted advantages for bowel and female sexual recovery, respectively. Routine PFD screening and multimodal interventions should be incorporated into stroke rehabilitation guidelines. Clinical Implications: Implementing standardized PFD screening and multimodal PFMT during sub-acute stroke phases could significantly reduce long-term health issues, lessen caregiver burden, and improve interpersonal relationships. Trial registration : ClinicalTrials.govNCT06234567,retrospectively registered on 29 ^th December,2025