Ultrasound-Based Biofeedback for Pelvic Floor Rehabilitation: A Systematic Review of Randomized Controlled Trials

Pelvic floor dysfunctions are highly prevalent and can substantially impair quality of life. Physiotherapy is considered a first-line conservative treatment, and the integration of technologies such as ultrasound may enhance outcomes through visual biofeedback. Objectives: To evaluate the effectiveness of ultrasound as a biofeedback tool in physiotherapeutic interventions for pelvic floor dysfunctions across different populations. Methods: A systematic review was conducted following PRISMA guidelines and registered in PROSPERO (CRD420261278982). The literature search was conducted between February and March 2025 in PubMed, Web of Science, Scopus, Medline, and PEDro. Randomized controlled trials using ultrasound as biofeedback in physiotherapy interventions were included. Methodological quality was assessed using the PEDro scale, and risk of bias was evaluated with the RoB 2 tool. Results: Two randomized controlled trials involving 75 women were included. One study investigated older women with urinary incontinence, whereas the other included postpartum women with pregnancy-related pelvic girdle pain. In Galea et al., transabdominal ultrasound biofeedback was not superior to conventional feedback based on vaginal palpation for urinary leakage, incontinence frequency, or quality of life, although the ultrasound group showed a significant within-group reduction in leakage episodes. In Kuo et al., ultrasound-guided biofeedback combined with pelvic floor and stabilization exercises reduced pain and disability compared with education alone and improved walking performance, but it was not consistently superior to exercise without biofeedback and did not significantly improve pelvic floor muscle contractility. The small number of studies, heterogeneity of populations and interventions, and low to very low certainty of the evidence limited the strength of the findings. Conclusions: Ultrasound-based biofeedback may be a useful adjunct to pelvic floor physiotherapy, particularly for facilitating correct muscle contraction and supporting motor learning. However, the available evidence does not demonstrate a consistent additional clinical benefit over conventional feedback or exercise alone. These findings should therefore be interpreted cautiously. Further high-quality randomized controlled trials with larger samples, standardized protocols, and longer follow-up are required.