Exercise regimens other than pelvic floor muscle training cannot increase pelvic muscle strength-a systematic review

Low-Value Practices for Pelvic Floor Dysfunction-Choosing Wisely Recommendations from the Brazilian Association of Physiotherapy in Women's Health: Observational Study

INTRODUCTION AND HYPOTHESIS

The Choosing Wisely campaign is an international initiative that is aimed at promoting a dialog between professionals, helping the population to choose an evidence-based, truly necessary and risk-free care. The aim of the study was to develop the Choosing Wisely Brazil list on Women's Health Physiotherapy in the area of the pelvic floor.

METHODS

A observational study was carried out between January 2022 and July 2023, proposed by the Brazilian Association of Physiotherapy in Women's Health, and developed by researchers working in the area of the pelvic floor. The development of the list consisted of six stages: a panel of experts, consensus building, national research, a review by the Choosing Wisely Brazil team, preparation of the list, and publication of the recommendations. Descriptive and content analyses were carried out in order to include evidence-based recommendations with over 80% agreement by physiotherapists in Brazil.

RESULTS

The expert panel was made up of 25 physiotherapists who submitted 63 recommendations. Seven physiotherapists/researchers carried out a critical analysis of the literature and refined the recommendations, resulting in 11 recommendations that were put to a national vote, in which 222 physiotherapists took part. After a review by the Choosing Wisely Brazil team, five recommendations with an average agreement of 88.2% agreement were chosen for publication.

CONCLUSIONS

The Choosing Wisely Brazil team in Physiotherapy in Women's Health/Pelvic Floor proposed a list of five recommendations that showed a high agreement among Brazilian physiotherapists working in the area.

Pelvic floor muscle training in telerehabilitation: a systematic review and meta-analysis

PURPOSE

This systematic review aims to identify, critically appraise, and summarize current evidence regarding the feasibility and efficacy of pelvic floor muscle training in telerehabilitation.

METHODS

Three bibliographic databases, PubMed, Embase, and Scopus were searched from inception to October 1, 2023. Clinical trials assessing the feasibility and efficacy of pelvic floor muscle training in telerehabilitation were eligible for inclusion. The Physiotherapy Evidence Database scale and National Institutes of Health Study Quality Assessment Tool were used for methodological quality assessment. Study selection, data extraction, and quality assessment were completed by two independent reviewers. Meta-analyses were performed to determine the effects of pelvic floor muscle training in telerehabilitation.

RESULTS

Five randomized controlled trials and three single cohort clinical trials were included in this review. Four studies were evaluated as good quality, and four as fair. Pelvic floor telerehabilitation was well tolerated and demonstrated good patient compliance and satisfaction. Pooled analysis indicated significant effects of pelvic floor telerehabilitation on the severity of urinary incontinence with a large effect size, pelvic floor muscle strength with a large effect size, and quality of life with a medium effect size.

CONCLUSION

This systematic review demonstrates that pelvic floor muscle training in telerehabilitation is a feasible and effective approach and highlights its efficacy in patients with urinary incontinence. This review supports the application of pelvic floor muscle training in telerehabilitation and informs further clinical and research endeavors to incorporate digital health technologies in managing pelvic floor dysfunction.

Comparative analysis of pelvic floor muscle training and Pilates in managing urinary incontinence among postmenopausal women: a randomized controlled trial

INTRODUCTION AND HYPOTHESIS

This study is aimed at comparing the effectiveness of pelvic floor muscle training (PFMT) and Pilates on the improvement of urinary incontinence (UI), strength, and endurance of the pelvic floor muscles (PFMs), and the impact of UI on the quality of life in postmenopausal women.

METHODS

Forty postmenopausal women were randomly divided in to two groups: PFMT (n = 20) and Pilates (n = 20). The participants were followed for 12 weeks, three times a week on nonconsecutive days. UI was assessed using the pad test and the voiding diary, PFM strength and resistance using bidigital assessment and manometry, and the impact of UI on quality of life using the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF), before and after the 3-month treatment.

RESULTS

There was a significant intra-group improvement in both groups for the pad test, mean daily urinary loss, and ICIQ-SF. The strength was significantly improved only in the PFMT group, and the endurance in both groups. Peak strength manometry was significantly improved only in the Pilates group, and the mean strength manometry in both groups. There was also an improvement in both groups for peak endurance manometry and mean endurance manometry. In the inter-group comparison, there was a significant improvement only in muscle strength, which was positive for group.

CONCLUSIONS

There was no difference between Pilates and PFMT for the management of women in post-menopause with stress urinary incontinence, provided that voluntary contraction of the PFMs is performed. However, further randomized clinical trials need to be carried out.

Effects of hypopressive exercises on pelvic floor and abdominal muscles in adult women: A systematic review of randomized clinical trials

INTRODUCTION

Hypopressive exercises (HE) are postural and breathing exercises that activate deep muscles in the abdomen and pelvic floor. Despite this, there is still no consensus in the literature on its real effectiveness. The objective was to analyze the effects of HE on the abdominal and pelvic floor muscles in women with or without dysfunctions in these regions.

METHODS

This is a systematic review of randomized clinical trials found in the PEDro, PubMed, Cochrane, LILACS, and Embase databases. We include studies that evaluate the effects of HE (with or without other techniques) on the pelvic floor and abdominal region for 8 weeks or more, in women over 18 years old, with or without dysfunction in these regions, with the presence of a control group (active or passive).

RESULTS

HE were effective in improving strength, tone, and reducing symptoms of pelvic floor dysfunctions, in magnitude less than (in two studies) or equal (in one study) to the pelvic floor muscle training (PFMT). When HE were performed with PFMT in the same group, no additional benefits were found. Only one study evaluated abdominal muscles activation, where HE were effective in improving postural control and activation of the transversus abdominis muscle.

CONCLUSIONS

The HE presented positive results to the evaluated parameters. However, the information is still preliminary and scarce. There are methodological divergences regarding the execution, follow-up and standardization of the method, which could affect the results. According to the existing information, HE cannot yet be reliably indicated for the treatment of the pelvic floor, despite pointing out relevant results in some studies. More randomized clinical trials and long-term studies are needed to analyze the effects of HE not only for pelvic floor, but also for other regions, such as abdominal muscles and related dysfunctions.

The added value of devices to pelvic floor muscle training in radical post-prostatectomy stress urinary incontinence: A systematic review with metanalysis

PURPOSE

To investigate the role of pelvic floor devices (e.g., biofeedback, electrical stimulation, magnetic stimulation, or their combination) as adjunctive treatments in pelvic floor muscle training (PFMT) in stress urinary incontinence (SUI) after radical prostatectomy.

MATERIALS AND METHODS

A systematic review with meta-analysis. We searched for randomised controlled trials (RCTs) and prospective non-randomised studies investigating the effectiveness of pelvic floor devices as an adjunctive treatment for SUI symptoms assessed with weight pad-test or standardised questionnaires. To assess the risk of bias (RoB) and overall certainty of evidence, the RoB 2.0 or the ROBINS-I, and the GRADE approach were used.

RESULTS

Eleven RCTs met our eligibility criteria. One was at a 'low' RoB, one had 'some concerns', while nine were at a 'high' RoB. Two meta-analyses were conducted to analyse the pooled results of six RCTs included. Specifically, two RCTs reported at week 4 with a 1h pad test a mean difference of 0.64 (95% CI = [-13.09, 14.36]), and four RCTs reported at week 12 with a 24h pad test a mean difference of -47.75 (95% CI = [-104.18, 8.69]). The heterogeneity was high in both analyses (I2 = 80.0%; I2 = 80.6%). The overall level of certainty was very low.

CONCLUSIONS

In line with our results, we cannot conclude whether pelvic floor devices add any value as adjunctive treatment in the management of SUI after radical prostatectomy. Future studies require more comprehensive and standardised approaches to understand whether these devices are effective.

Does multiple-component intensive pelvic floor muscle training decrease muscle fatigue and symptoms in women with urinary incontinence?

INTRODUCTION AND HYPOTHESIS

A multiple-component intensive pelvic floor muscle training (MCI-PFMT) protocol was developed as a neurophysiological-based rehabilitation model to improve neuroplasticity. This study aimed to investigate the effects of the MCI-PFMT protocol on muscle fatigue and symptoms in women with urinary incontinence.

METHODS

This randomized controlled trial included 49 female patients with mixed urinary incontinence. Participants were divided into the MCI-PFMT group and the control group. The MCI-PFMT group performed supervised intensive pelvic floor muscle training, while the control group received bladder training and standard pelvic floor muscle training as a home program. Both training sessions were conducted 5 days a week for a single week. Participants' symptoms were evaluated with questionnaires, bladder diary, and pad tests. Superficial electromyography, ultrasonography, and the PERFECT scale were used to evaluate pelvic floor and abdominal muscle functions.

RESULTS

In the post-treatment evaluation, symptoms were decreased in both groups, with a significant decrease in the MCI-PFMT group (p < 0.05). While average and peak work values of pelvic floor muscles, transversus abdominus, and internal oblique muscles increased in both groups, maximum voluntary contraction values of these muscles decreased (p < 0.05). A 12.7% decrease was observed in the maximum voluntary contraction values of pelvic floor muscles in the control group, while a 9.6% decrease was observed in the MCI-PFMT group.

CONCLUSIONS

The MCI-PFMT protocol can lead to pelvic floor and abdominal muscle fatigue. However, it may be effective at decreasing symptoms in women with urinary incontinence. Additional studies on this issue are needed.

Exercise Position to Improve Synergy Between the Diaphragm and Pelvic Floor Muscles in Women With Pelvic Floor Dysfunction: A Cross Sectional Study

OBJECTIVE

This study aimed to investigate the synergy between the diaphragm and pelvic floor muscles (PFM) according to different exercise positions in women with pelvic floor dysfunction. Our secondary aim was to determine the short-term effects of single-week pelvic floor muscle training (PFMT) program on diaphragmatic function.

METHODS

The cross-sectional study included 64 women with pelvic floor dysfunction. The participants' diaphragm and abdominal muscle functions during voluntary PFM contraction and relaxation were assessed by surface electromyography and ultrasonography. The surface electromyography assessments were performed in supine (P1), crawling (P2) and sitting (P3) positions. A single week-PFMT was conducted on women who agreed to determine the short-term responses of the diaphragm function. The muscle functions according to exercise positions were compared with Friedman Analysis of Variance, and the short-term effects of single-week PFMT on diaphragm function was analyzed with Wilcoxon Signed-Ranks Test.

RESULTS

The diaphragm activity during voluntary PFM contraction was highest in P2 before and after single-week PFMT (P < .001). Positive significant correlations were found between the activities diaphragm and abdominal muscles in different exercise positions (P < .05). After single-week PFMT, diaphragm thickness increased (P = .030) in P1, but diaphragm activity did not change in all 3 exercise positions (P > .05).

CONCLUSION

The synergy between the diaphragm and PFM was greater in the crawling position in women with pelvic floor dysfunction. The abdominal muscles seemed to contribute to maintaining this synergy. Therefore, PFMT combined with diaphragmatic breathing exercises in the crawling position should be considered. In addition, single-week PFMT may positively affect diaphragm function in the short-term.

Effect of monopolar capacitive resistive radiofrequency in treating stress urinary incontinence: A pilot randomized control trial

Objective

To assess the effectiveness of 448 kHz monopolar capacitive resistive radiofrequency (MCRR) in the treatment of females with stress urinary incontinence (SUI).

Materials and methods

Forty females with SUI complaints were separated randomly into two equal groups. Group A with 20 females received the MCRR therapy for 20 min and performed pelvic floor exercises for 20 min. Group B with 20 females received placebo treatment by applying the same application as in Group A without emitting any waves for 20 min, three times a week, for 4 weeks. The patients in both groups were instructed to pause the treatment during their menstruation; the patients were instructed to maintain home pelvic floor exercises. Both groups were assessed by a perineometer that was used to assess the strength of the pelvic floor muscles (PFM), the visual analogue scale (VAS), and the Incontinence Symptom Severity Index to assess the frequency of urinary incontinence symptoms as described by each patient before treatment and after 4 weeks of treatment.

Results

There was a significant reduction (p < 0.05) in VAS and the Incontinence Symptom Severity Index and a significant increase in the strength of the PFM in both groups post-treatment compared with the pre-treatment. Regarding between-subject effects, there was a significant difference in VAS, the Incontinence Symptom Severity Index, and the perineometer between both groups (p < 0.05), and this significant improvement favored Group A.

Conclusion

MCRR and pelvic floor exercises are more effective methods for the treatment of SUI than just pelvic floor exercises of females with SUI.

Clinical Trial Registration

ClinicalTrials.gov. Identifier: NCT04612205.

Understanding long-term continence rates after robot-assisted laparoscopic prostatectomy - one-year follow-up on "Cognitive ability as a non-modifiable risk factor for post-prostatectomy urinary incontinence"

Purpose

To evaluate long-term continence rates (12 months) in patients after robot-assisted laparoscopic prostatectomy (RALP) in relation to their cognitive ability (CoAb), which proved to be a predictor for early post-prostatectomy incontinence.

Material & Methods

This is the 12-month follow-up evaluation of our previously published observational single-center, prospective evaluation of 84 patients who underwent RALP as treatment of their localized prostate cancer between 07/2020 and 03/2021. Post-prostatectomy incontinence (PPI) was measured by asking patients about their 24 h pad usage, whereby 0 pads were considered continent and ≥1 pad was considered incontinent. CoAb was evaluated by performing the Mini-Mental State Examination prior to surgery. Possible predictors for PPI were evaluated using univariate and multivariable logistic regression models.

Results

Multivariable logistic regression analyses identified early incontinence status and nerve sparing (NS) as independent predictors for PPI after 12 months, resulting in a 5.69 times higher risk for PPI when the loss of urine was between 10 and 50 ml during the early performed pad test (one day after catheter removal) compared to 0-1 ml loss of urine [95% confidence interval (CI): 1.33-28.30, p = 0.024] and a 6.77 times higher risk for PPI, respectively, when only unilateral NS was performed compared to bilateral NS (95% CI: 1.79-30.89, p = 0.007). CoAb lost its predictive value for long-term PPI (p = 0.44).

Conclusion

The results of this study suggest that PPI is a dynamic, rather than a static condition with a dynamically changing pathophysiology within the first 12 months after RALP. Coping methods and therapies should adapt to this circumstance.

The Perception of Pelvic Floor Muscle Function amongst Exercising Women Who Are Repeatedly Instructed to Contract Their Pelvic Floor Muscles

In this study, the self-perception of pelvic floor muscle (PFM) contractions amongst women receiving repeated verbal instructions during exercise classes was examined. The prevalence and severity of urinary stress incontinence were also assessed. This cross-sectional observational study included 46 women (mean age 48 (±8.6)), who regularly participated in Pilates classes where repeated instruction was given to contract PFM (“instruction group”; N = 22) or not (controls, N = 24). PFM function was evaluated using transabdominal ultrasound. Simultaneously, the participant described her personal evaluation of her PFM contraction ability. The International Consultation on Incontinence Questionnaire–Short Form was also utilized. Most women (80%) correctly contract PFM; however, 95% did not perform a voluntary contraction during leg movement, without differences observed between groups. A higher perception of PFM contraction was found in the “instruction group” when performing knee flexion towards the chest without specific verbal instruction. Women who were instructed to contract their PFM suffered less incontinence and had a lower degree of severity than the controls. Most women performing Pilates exercises correctly contracted their PFM. However, there was no PFM voluntary contraction during leg movement. Exposure to repeated verbal instructions to contract PFM, over time, might lead to an improvement in women’s perception of their ability to contract PFM. Verbal instructions for PFM contraction were found to be effective in reducing urinary incontinence.

Preliminary Effectiveness of mHealth App-Based Pelvic Floor Muscle Training among Pregnant Women to Improve Their Exercise Adherence: A Pilot Randomised Control Trial

This pilot randomised control trial (RCT) aimed to evaluate the feasibility and preliminary effectiveness of conducting a full-powered trial for a newly developed pelvic floor muscle training (PFMT) app among pregnant women with urinary incontinence (UI) in Malaysia. This was a prospective, single-centre, single-blind, parallel, randomised controlled, pilot feasibility study—the Kegel Exercise Pregnancy Training app (KEPT app) trial. In total, 26 pregnant women with urinary incontinence from an urban healthcare clinic were recruited and randomly assigned to either intervention or waitlist control group. The intervention group received the KEPT app, while the control group received usual antenatal care (waitlist control). Of the 26 pregnant women, 16 (61.5%) completed the two-month follow-up. The recruitment rate was 54.2%, and the retention rate was 62.5% in the intervention group and 60% in the control group. There was a significant difference between intervention and control groups’ baseline measurement in the severity of UI (p = 0.031). The app improved their knowledge (p = 0.011) and self-efficacy (p = 0.038) after the first month and attitude (p = 0.034) after two months of intervention, compared with the control group. This study supports the feasibility of our future cluster RCT. The KEPT app demonstrates a promising effect in improving PFMT attitude and self-efficacy and potentially enhancing exercise adherence among pregnant women with UI. Trial registration: This study was prospectively registered on ClinicalTrials.gov on 19 February 2021 (NCT04762433).