Pelvic floor muscle training in female functional fitness exercisers: an assessor-blinded randomised controlled trial.

OBJECTIVE: Stress urinary incontinence (SUI) is common among females during functional fitness training, such as CrossFit. The aim of this study was to assess the effect of pelvic floor muscle training (PFMT) on SUI in female functional fitness exercisers. METHODS: This was an assessor-blinded randomised controlled trial with a PFMT group (n=22) and a control group (n=25). The PFMT group followed a 16-week home-training programme with 3 sets of 8-12 maximum pelvic floor muscle (PFM) contractions daily and weekly follow-up/reminders by phone. The primary outcome was change in a total score of the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI-SF). The secondary outcomes were perceived change of symptoms of SUI, change of PFM strength measured by vaginal manometry and symptoms of anal incontinence (AI) and pelvic organ prolapse (POP). RESULTS: 47 women, mean age of 33.5 years (SD: 8.1), participated. At 16 weeks, there was a mean difference between groups of -1.4 (95% CI: -2.6 to -0.2) in the change of the ICIQ-UI-SF score in favour of the PFMT group. The PFMT group completed a mean of 70% (SD: 23) of the prescribed protocol. 64% in the PFMT group versus 8% in the control group reported improved symptoms of SUI (p<0.001, relative risk: 7.96, 95% CI, 2.03 to 31.19). There were no group differences in the change of PFM strength or AI/POP symptoms. CONCLUSION: A 16-week home-training programme of the PFM led to improvements in SUI in female functional fitness exercisers. However, PFM strength and AI and POP symptoms did not improve significantly in the PFMT group compared with the control group.

Entrenamiento muscular del suelo pélvico en el tratamiento del prolapso de órganos pélvicos: un metaanálisis de ensayos controlados aleatorizados / Pelvic floor muscle training in the treatment of pelvic organ prolapse: A meta-analysis of randomized controlled trials

ANTECEDENTES: El objetivo fue evaluar el efecto general del entrenamiento muscular del suelo pélvico (EMSP) en pacientes con prolapso de órganos pélvicos (POP) con base en una selección de ensayos controlados aleatorizados (ECA). MÉTODOS: Se realizaron búsquedas en bases de datos, como PubMed, Cochrane y Embase, para identificar ECA elegibles en función de las palabras indexadas, actualizadas en diciembre del 2018. También buscamos en publicaciones relacionadas con el presente estudio. Los resultados principales se analizaron usando odds ratio (OR) y la diferencia media (DM), con un intervalo de confianza del 95% (IC del 95%). RESULTADOS: En este metaanálisis se incluyeron 15 ECA, con un total de 1.309 pacientes en el grupo de EMSP y un total de 1.275 pacientes en el grupo de control. Los resultados generales no mostraron diferencias significativas entre los 2grupos en la incidencia del aumento de 2 grados POP-Q (RR: 0,55, IC del 95%: 0,19-1,63), aumento de 1 grado POP-Q (RR: 1,04, IC del 95%: 0,69-1,57), ausencia de cambio de grado POP-Q (RR: 0,94, IC del 95%: 0,81-1,09), reducción de 2 grados POP-Q (RR: 1,72, IC del 95%: 0,79-3,76), ausencia de cambio en los síntomas reportada por las propias pacientes (RR: 0,70, IC del 95%: 0,45-1,09) y cambio a peor en los síntomas reportado por las propias pacientes (RR: 0,67, IC del 95%: 0,22-2,03). Además, la incidencia de la reducción de 1 grado POP-Q fue significativamente mayor en el grupo de EMSP que en el grupo de control (RR: 1,80, IC del 95%: 1,20-2,69) y el EMSP cambió significativamente los síntomas informados por las pacientes produciendo mejores resultados en comparación con el grupo de control (RR: 2,90, IC del 95%: 1,72-4,89). Sin embargo, después de la terapia, los resultados del grupo de EMSP disminuyeron frente al grupo de control en las siguientes pruebas: POP-SS (SMD: -0,24, IC del 95%: -0,71-0,22), POPDI-6 (SMD: -0,14, IC del 95%: -0,43-0,15), CRADI-8 (SMD: -0,03, IC del 95%: -0,16-0,11) y UDI-6 (SMD: -0,17, IC del 95%: -0,43-0,10), pero sin significación estadística. CONCLUSIÓN: El EMSP tuvo un mejor efecto en la reducción de 1 grado de POP-Q, con mejores resultados en los síntomas reportados por los pacientes, disminuyendo el puntaje POP-SS, POPDI-6, CRADI-8 y UDI-6 en las mujeres con POP versus el grupo de control. Sin embargo, se necesitan más ECA multicéntricos de alta calidad con un tamaño de muestra mayor para confirmar las presentes conclusiones

BACKGROUND: We aimed to assess the overall effect of pelvic muscle training (PFMT) on patients with pelvic organ prolapse (POP) based on eligible randomized controlled trials (RCT). METHODS: We searched the following databases, such as PubMed, Cochrane, and Embase, to identify eligible RCT based on the index words updated to December 2018. We also searched the publications related to the present study. Odds rations (OR), and mean difference (MD) along with 95% confidence interval (95% CI) were used to analyze the main outcomes. RESULTS: In this meta-analysis, 15 RCTs were included with a total of 1309 patients in the PFMT group and a total of 1275 patients in the control group. The overall results showed no significant difference in the incidence of add 2 POP-Q stages (RR: 0.55, 95%CI: 0.19-1.63), add 1 POP-Q stages (RR: 1.04, 95%CI: 0.69-1.57), no POP-Q stages change (RR: 0.94, 95%CI: 0.81-1.09), reduce 2 POP-Q stages (RR: 1.72, 95%CI: 0.79-3.76), self-reported same symptom change (RR: 0.70, 95%CI: 0.45-1.09), and self-reported worse symptom change (RR: 0.67, 95%CI: 0.22-2.03) between the 2groups. Besides, the incidence of reduce 1 POP-Q stages was significantly higher in the PFMT group than that of the control group (RR: 1.80, 95%CI: 1.20-2.69), and the PFMT significantly changed the self-reported symptoms with better outcomes when compared with the control group (RR: 2.90, 95%CI: 1.72-4.89). However, after the therapy, the PFMT group decreased the POP-SS (SMD: -0.24, 95%CI: -0.71-0.22), POPDI-6 (SMD: -0.14, 95%CI: -0.43-0.15), CRADI-8 (SMD: -0.03, 95%CI: -0.16-0.11), and UDI-6 (SMD: -0.17, 95%CI: -0.43-0.10) versus the control group, but without statistical significance. CONCLUSION: PMFT showed better effect in reducing 1 POP-Q stages, changing the self-reported symptoms with better outcomes, decreasing the score of POP-SS, POPDI-6, CRADI-8, and UDI-6 in women with POP versus the control group. However, more high-quality multicenter RCTs with a larger sample size are needed to confirm the present conclusions

Survey of Postoperative Activity Guidelines After Minimally Invasive Gynecologic and Pelvic Reconstructive Surgery.

OBJECTIVES: Most surgeons recommend restriction of activities after minimally invasive gynecologic and pelvic reconstructive surgery. The goal of this study was to identify and assess the postoperative guidelines gynecologists and urogynecologists provide their patients. METHODS: This was a cross-sectional study of physicians at a national gynecology conference in March 2018. Respondents were asked to answer questions about the typical postoperative recommendations they provide patients after gynecologic surgery as well as their postoperative prescribing habits. RESULTS: There were 418 attendees, and 135 (32%) eligible physicians completed the survey. Of respondents, 87% were specialists in female pelvic medicine and reconstructive surgery. Most respondents (61%) were in academic practice. Most respondents (82%-86%) recommended specific postoperative lifting restrictions, and 49% to 52% recommended limiting lifting to a maximum of 10 lb after surgery with some variation depending on the surgical procedure performed. Many respondents (42%-56% depending on the surgical procedure) recommended that patients wait at least 2 weeks before returning to sedentary work. Male respondents and those who were in practice for more than 10 years recommended that patients return to work sooner compared with those who were in practice less than 10 years. Male respondents prescribed fewer opioids to patients after vaginal hysterectomy (P = 0.04) and vaginal prolapse repair (P = 0.03) compared with female respondents. CONCLUSIONS: After minimally invasive gynecologic or pelvic reconstructive surgery, providers recommend a wide range of postoperative restrictions and prescribe significantly different quantities of opioids during the postoperative period. This study highlights some of the recommendations with the greatest variability.

Perioperative pelvic floor muscle training did not improve outcomes in women undergoing pelvic organ prolapse surgery: a randomised trial.

QUESTION: In women undergoing surgery for pelvic organ prolapse (POP), what is the average effect of the addition of perioperative pelvic floor muscle training on pelvic organ prolapse symptoms, pelvic floor muscle strength, quality of life, sexual function and perceived improvement after surgery? DESIGN: Randomised controlled trial with concealed allocation, blinded assessors, and intention-to-treat analysis. PARTICIPANTS: Ninety-six women with an indication for POP surgery. INTERVENTION: The experimental group received a 9-week pelvic floor muscle training protocol with four sessions before the surgery and seven sessions after the surgery. The control group received surgery only. OUTCOME MEASURES: Symptoms were assessed using the Pelvic Floor Distress Inventory (PFDI-20), which is scored from 0 'unaffected' to 300 'worst affected'. Secondary outcomes were assessed using vaginal manometry, validated questionnaires and Patient Global Impression of Improvement, which is scored from 1 'very much better' to 7 'very much worse'. All participants were evaluated 15 days before surgery, and at Days 40 and 90 after surgery. RESULTS: There was no substantial difference in POP symptoms between the experimental and control groups at Day 40 (31 (SD 24) versus 38 (SD 42), adjusted mean difference -6, 95% CI -25 to 13) or Day 90 (27 (SD 27) versus 33 (SD 33), adjusted mean difference -4, 95% CI -23 to 14). The experimental group perceived marginally greater global improvement than the control group; mean difference -0.4 (95% CI -0.8 to -0.1) at Day 90. However, the estimated effect of additional perioperative pelvic floor muscle training was estimated to be not beneficial enough to be considered worthwhile for any other secondary outcomes. CONCLUSION: In women undergoing POP surgery, additional perioperative pelvic floor muscle training had negligibly small effects on POP symptoms, pelvic floor muscle strength, quality of life or sexual function. TRIAL REGISTRATION: ReBEC, RBR-29kgz5.

Can we evaluate the levator ani after Kegel exercise in women with pelvic organ prolapse by transperineal elastography? A preliminary study.

OBJECTIVES: The aim of this study was to evaluate the stiffness variation of the levator ani in patients with stage I/II pelvic organ prolapse (POP) before and after Kegel exercises by transperineal elastography. METHODS: A total of 20 patients who were diagnosed with staged I/II POP underwent conventional transperineal ultrasound and elastography. For each patient, the levator ani was located and evaluated in the state of Valsalva. After Kegel exercises for 12 weeks, transperineal ultrasound and elastography were repeated. The elasticity images were assessed using a four-point scale scoring system. RESULTS: Of the 20 cases, four had an elastography score of 1, 14 had a score of 2, two had a score of 3, and no cases had a score of 4 in the levator ani before Kegel exercises. After Kegel exercises, one had an elastography score of 1, two had a score of 2, 15 had a score of 3, and two cases had a score of 4. The mean elastography score was statistically significantly higher for the levator ani after Kegel exercises (2.90 ± 0.48) than for the baseline score (1.90 ± 0.29) (p = 0.025). CONCLUSIONS: Transperineal elastography was an effective and useful tool in the evaluation of the levator ani in patients with POP-Q stage I/II before and after Kegel exercises.

Perioperative Behavioral Therapy and Pelvic Muscle Strengthening Do Not Enhance Quality of Life After Pelvic Surgery: Secondary Report of a Randomized Controlled Trial.

BACKGROUND: There is significant need for trials evaluating the long-term effectiveness of a rigorous program of perioperative behavioral therapy with pelvic floor muscle training (BPMT) in women undergoing transvaginal reconstructive surgery for prolapse. OBJECTIVE: The purpose of this study was to evaluate the effect of perioperative BPMT on health-related quality of life (HRQOL) and sexual function following vaginal surgery for pelvic organ prolapse (POP) and stress urinary incontinence (SUI). DESIGN: This study is a secondary report of a 2 × 2 factorial randomized controlled trial. SETTING: This study was a multicenter trial. PARTICIPANTS: Participants were adult women with stage 2-4 POP and SUI. INTERVENTION: Perioperative BPMT versus usual care and sacrospinous ligament fixation (SSLF) versus uterosacral ligament suspension (ULS) were provided. MEASUREMENTS: Participants undergoing transvaginal surgery (SSLF or ULS for POP and a midurethral sling for SUI) received usual care or five perioperative BPMT visits. The primary outcome was change in body image and in Pelvic Floor Impact Questionnaire (PFIQ) short-form subscale, 36-item Short-Form Health Survey (SF-36), Pelvic Organ Prolapse-Urinary Incontinence Sexual Questionnaire short form (PISQ-12), Patient Global Impression of Improvement (PGII), and Brink scores. RESULTS: The 374 participants were randomized to BPMT (n = 186) and usual care (n = 188). Outcomes were available for 137 (74%) of BPMT participants and 146 (78%) of the usual care participants at 24 months. There were no statistically significant differences between groups in PFIQ, SF-36, PGII, PISQ-12, or body image scale measures. LIMITATIONS: The clinicians providing BPMT had variable expertise. Findings might not apply to vaginal prolapse procedures without slings or abdominal apical prolapse procedures. CONCLUSIONS: Perioperative BPMT performed as an adjunct to vaginal surgery for POP and SUI provided no additional improvement in QOL or sexual function compared with usual care.

Bilateral plication of the puborectal muscles: A new surgical concept for treating vulvar widening.

OBJECTIVES: This study describe a new myorraphy technique by bilateral plication of the puborectalis bundles (PRP) of the levator ani muscle to treat vulvovaginal widening. The aim of this work was to report our preliminary experience in terms of morbidity and results (anatomical and functional) in the short and medium term. MATERIALS AND METHODS: This single centre retrospective study concerned 69 women who underwent PRP between January 2011 and December 2014. The main criterion for judging success was the GH before and after surgery (Genital Hiatus in the POP-Q classification: Pelvic Organ Prolapse Quantification System). The secondary criteria were the quality of sexual intercourse and the morbidity. RESULTS: The average GH post-surgery was 31, 35 and 35mm at 6 weeks, 6 and 12 months respectively compared to 65±5mm preoperatively (P<0.00001). Among the 27 patients who were sexually active prior to surgery, 18.52% deemed the quality of sexual intercourse satisfactory. After surgery, more than 88% of the patients observed an improvement (P<0.00001). After the surgery the reported rate of minor complications was under 3%. CONCLUSION: This preliminary study of PRP confirms the feasibility of the procedure, its low morbidity and the stability of the anatomical outcomes at 12 months.

Is Pelvic-Floor Muscle Training a Physical Therapy or a Behavioral Therapy? A Call to Name and Report the Physical, Cognitive, and Behavioral Elements.

This perspective article explores whether pelvic-floor muscle training (PFMT) for the management of female urinary incontinence and prolapse is a physical therapy or a behavioral therapy. The primary aim is to demonstrate that it is both. A secondary aim is to show that the plethora of terms used for PFMT is potentially confusing and that current terminology inadequately represents the full intent, content, and delivery of this complex intervention. While physical therapists may be familiar with exercise terms, the details are often incompletely reported; furthermore, physical therapists are less familiar with the terminology used in accurately representing cognitive and behavioral therapy interventions, which results in these elements being even less well reported. Thus, an additional aim is to provide greater clarity in the terminology used in the reporting of PFMT interventions, specifically, descriptions of the exercise and behavioral elements. First, PFMT is described as a physical therapy and as an exercise therapy informed predominantly by the discipline of physical therapy. However, effective implementation requires use of the cognitive and behavioral perspectives of the discipline of psychology. Second, the theoretical underpinning of the psychology-informed elements of PFMT is summarized. Third, to address some identified limitations and confusion in current terminology and reporting, recommendations for ways in which physical therapists can incorporate the psychology-informed elements of PFMT alongside the more familiar exercise therapy-informed elements are made. Fourth, an example of how both elements can be described and reported in a PFMT intervention is provided. In summary, this perspective explores the underlying concepts of PFMT to demonstrate that it is both a physical intervention and a behavioral intervention and that it can and should be described as such, and an example of the integration of these elements into clinical practice is provided.

Activity Restriction Recommendations and Outcomes After Reconstructive Pelvic Surgery: A Randomized Controlled Trial.

OBJECTIVE: To assess the relationship between prescribed postoperative activity recommendations (liberal compared with restricted) after reconstructive prolapse surgery and patient satisfaction and pelvic floor symptoms. METHODS: In our multicenter, randomized, double-blind clinical trial, women undergoing reconstructive prolapse surgery were randomized to liberal compared with restricted postoperative activity recommendations. Liberal recommendations instructed women to resume postoperative activity at the woman's own pace with no restrictions on lifting or high-impact activities. Conversely, restricted recommendations instructed women to avoid heavy lifting or strenuous exercise for 3 months. The primary outcome, patient satisfaction, was assessed on a 5-point Likert scale at 3 months postoperatively with the question, "How satisfied are you with the result of your prolapse surgery?" Secondary outcomes included anatomic outcomes and pelvic floor symptoms. RESULTS: From September 2014 to December 2015, 130 women were screened and 108 were randomized. Ultimately, 95 were allocated to study intervention (n=45 liberal, n=50 restricted) and completed the primary outcome. Baseline characteristics (including pelvic organ prolapse quantification stage and demographics) and surgical intervention did not differ between groups. Most women underwent a minimally invasive sacrocolpopexy (58) followed by vaginal suspension (27) or vaginal closure procedures (nine). Rates of satisfaction were similarly high in the liberal and restricted recommendations groups (98% compared with 94%, odds ratio 0.36 [0.036-3.55], P=.619). Anatomic outcomes did not differ between groups; however, fewer pelvic floor symptoms were reported in the liberal group. CONCLUSION: Satisfaction was equally high 3 months after prolapse surgery in women who were instructed to liberally resume activities compared with those instructed to restrict postoperative activities. Women who liberally resumed their activities reported fewer prolapse and urinary symptoms and had similar short-term anatomic outcomes suggesting that allowing women to resume their normal activities postoperatively may result in improved pelvic floor outcomes. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT02138487.

Pelvic floor muscle training for secondary prevention of pelvic organ prolapse (PREVPROL): a multicentre randomised controlled trial.

BACKGROUND: Pelvic floor muscle training can reduce prolapse severity and symptoms in women seeking treatment. We aimed to assess whether this intervention could also be effective in secondary prevention of prolapse and the need for future treatment. METHODS: We did this multicentre, parallel-group, randomised controlled trial at three centres in New Zealand and the UK. Women from a longitudinal study of pelvic floor function after childbirth were potentially eligible for inclusion. Women of any age who had stage 1-3 prolapse, but had not sought treatment, were randomly assigned (1:1), via remote computer allocation, to receive either one-to-one pelvic floor muscle training (five physiotherapy appointments over 16 weeks, and annual review) plus Pilates-based pelvic floor muscle training classes and a DVD for home use (intervention group), or a prolapse lifestyle advice leaflet (control group). Randomisation was minimised by centre, parity (three or less vs more than three deliveries), prolapse stage (above the hymen vs at or beyond the hymen), and delivery method (any vaginal vs all caesarean sections). Women and intervention physiotherapists could not be masked to group allocation, but allocation was masked from data entry researchers and from the trial statistician until after database lock. The primary outcome was self-reported prolapse symptoms (Pelvic Organ Prolapse Symptom Score [POP-SS]) at 2 years. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01171846. FINDINGS: Between Dec 21, 2008, and Feb 24, 2010, in New Zealand, and Oct 27, 2010, and Sept 5, 2011, in the UK, we randomly assigned 414 women to the intervention group (n=207) or the control group (n=207). One participant in each group was excluded after randomisation, leaving 412 women for analysis. At baseline, 399 (97%) women had prolapse above or at the level of the hymen. The mean POP-SS score at 2 years was 3·2 (SD 3·4) in the intervention group versus 4·2 (SD 4·4) in the control group (adjusted mean difference -1·01, 95% CI -1·70 to -0·33; p=0·004). The mean symptom score stayed similar across time points in the control group, but decreased in the intervention group. Three adverse events were reported, all of which were in the intervention group (one women had a fall, one woman had a pain in her tail bone, and one woman had chest pain and shortness of breath). INTERPRETATION: Our study shows that pelvic floor muscle training leads to a small, but probably important, reduction in prolapse symptoms. This finding will be important for women and caregivers considering preventive strategies. FUNDING: Wellbeing of Women charity, the New Zealand Continence Association, and the Dean's Bequest Fund of Dunedin School of Medicine.

The Evaluation of Baseline Physical Function and Cognition in Women Undergoing Pelvic Floor Surgery.

OBJECTIVES: Physical and cognitive function impairments are associated with increased perioperative morbidity; however, limited data exist regarding these parameters in women planning pelvic floor surgery. Thus, our goal was to assess baseline physical function and cognition in patients scheduled for pelvic reconstructive surgery and to evaluate factors associated with preoperative upper and lower body function. METHODS: In a prospective study, we evaluated sociodemographics, body mass index, the Functional Comorbidity Index (FCI), Katz Activities of Daily Living (ADL), and Instrumental ADL (IADL). Physical function was evaluated with Timed Up and Go (TUG) test and dynamometers to assess handgrip and pinch strength. The Mini-Mental State Examination (MMSE) was used to evaluate cognitive impairment. RESULTS: Among 142 women in our study population, mean age was 58.4 ± 13.9 years, comorbidities were low (mean FCI, 3.7 ± 2.7) and independence level was high (mean ADL, 5.7 ± 0.5; mean IADL, 7.8 ± 0.8). Mean TUG test was 11.6 ± 4.5 seconds, reflecting mildly impaired mobility. Maximum handgrip and pinch strength were 51.7 ± 16.6 lb and 12.7 ± 3.6 lb, respectively, which represent normal/above average scores. Age (P = 0.007), body mass index (P = 0.003), IADL (P = 0.003), and MMSE (P = 0.003) were significantly associated with TUG test scores in a multivariate linear regression analysis that adjusted for FCI. The mean MMSE mean score was 29.2 ± 0.9; only 3.5% had mild cognitive impairment and 0.7% had moderate-severe impairment. CONCLUSIONS: Women undergoing elective pelvic reconstructive surgery had good physical and cognitive function. The simple TUG test was the most likely tool to identify patients with poorer physical function.

Can pelvic floor muscle training improve sexual function in women with pelvic organ prolapse? A randomized controlled trial.

INTRODUCTION: Pelvic floor muscle training (PFMT) has level 1 evidence of reducing the size and symptoms associated with pelvic organ prolapse (POP). There is scant knowledge, however, regarding whether PFMT has an effect on sexual function. AIM: The aim of the trial was to evaluate the effect of PFMT on sexual function in women with POP. METHODS: In this randomized controlled trial, 50 women were randomized to an intervention group (6 months of PFMT and lifestyle advice) and 59 women were randomized to a control group (lifestyle advice only). MAIN OUTCOME MEASURES: Participants completed a validated POP-specific questionnaire to describe frequency and bother of prolapse, bladder, bowel, and sexual symptoms and answered a semi-structured interview. RESULTS: No significant change in number of women being sexually active was reported. There were no significant differences between groups regarding change in satisfaction with frequency of intercourse. Interview data revealed that 19 (39%) of women in the PFMT group experienced improved sexual function vs. two (5%) in the control group (P<0.01). Specific improvements reported by some of the women were increased control, strength and awareness of the pelvic floor, improved self-confidence, sensation of a "tighter" vagina, improved libido and orgasms, resolution of pain with intercourse, and heightened sexual gratification for partners. Women who described improved sexual function demonstrated the greatest increases in pelvic floor muscle (PFM) strength (mean 16 ± 10 cmH2 0) and endurance (mean 150 ± 140 cmH2 0s) (P<0.01). CONCLUSION: PFMT can improve sexual function in some women. Women reporting improvement in sexual function demonstrated the greatest increase in PFM strength and endurance.

Effect of pelvic floor muscle training compared with watchful waiting in older women with symptomatic mild pelvic organ prolapse: randomised controlled trial in primary care.

OBJECTIVE: To compare the effects of pelvic floor muscle training and watchful waiting on pelvic floor symptoms in a primary care population of women aged 55 years and over with symptomatic mild pelvic organ prolapse. DESIGN: Randomised controlled trial. SETTING: Dutch primary care. PARTICIPANTS: Women aged 55 years or over with symptomatic mild prolapse (leading edge above the hymen) were identified by screening. Exclusion criteria were current prolapse treatment or treatment in the previous year, malignancy of pelvic organs, current treatment for another gynaecological disorder, severe/terminal illness, impaired mobility, cognitive impairment, and insufficient command of the Dutch language. INTERVENTIONS: Pelvic floor muscle training versus watchful waiting. MAIN OUTCOME MEASURES: The primary outcome was change in bladder, bowel, and pelvic floor symptoms measured with the Pelvic Floor Distress Inventory-20 (PFDI-20), three months after the start of treatment. Secondary outcomes were changes in condition specific and general quality of life, sexual function, degree of prolapse, pelvic floor muscle function, and patients' perceived change in symptoms. RESULTS: Of the 287 women who were randomised to pelvic floor muscle training (n=145) or watchful waiting (n=142), 250 (87%) completed follow-up. Participants in the intervention group improved by (on average) 9.1 (95% confidence interval 2.8 to 15.4) points more on the PFDI-20 than did participants in the watchful waiting group (P=0.005). Of women in the pelvic floor muscle training group, 57% (82/145) reported an improvement in overall symptoms from the start of the study compared with 13% (18/142) in the watchful waiting group (P<0.001). Other secondary outcomes showed no significant difference between the groups. CONCLUSIONS: Although pelvic floor muscle training led to a significantly greater improvement in PFDI-20 score, the difference between the groups was below the presumed level of clinical relevance (15 points). Nevertheless, 57% of the participants in the intervention group reported an improvement of overall symptoms. More studies are needed to identify factors related to success of pelvic floor muscle training and to investigate long term effects.Trial registration Dutch Trial Register (www.trialregister.nl) identifier: NTR2047.

Pelvic floor physical therapy: impact on quality of life 6 months after vaginal reconstructive surgery.

OBJECTIVES: Pelvic floor physical therapy (PFPT) is often used as a treatment of pelvic floor disorders and may improve function after pelvic reconstructive surgery. However, the long-term impact of this modality is not understood. METHODS: This randomized controlled trial compared PFPT to the standard care in women undergoing vaginal reconstruction. The intervention group received PFPT biweekly until 12 weeks postoperatively, in conjunction with a physician assessment. Control subjects underwent a physician assessment alone at all postoperative intervals. The final follow-up was at 24 weeks. Physical examinations (pelvic organ prolapse quantification assessment), intravaginal electromyography, voiding diaries, and validated questionnaires were completed by all subjects. The primary outcome was change in the World Health Organization Quality of Life-BREF. RESULTS: Forty-nine women completed the study, 24 in the PFPT group and 25 in the control group. Although electromyography measures showed better muscular function in PFPT subjects after 12 weeks, at 6 months after surgery, this was no longer noted. However, quality of life parameters improved for the entire sample at 24 weeks, with no difference between groups. Positive change from 12 to 24 weeks was also documented in scores on the Pelvic Floor Distress Inventory-20 (P = 0.04) and Pelvic Floor Impact Questionnaire-7 (P = 0.018), corresponding with continued improvement in bladder symptoms. Finally, Prolapse and Incontinence Sexual Questionnaire-12 and Female Sexual Function Index scores improved between 12 and 24 weeks, suggesting better sexual function overall with time elapsed from surgery. CONCLUSIONS: Quality of life improves in all subjects after vaginal reconstructive surgery, with ongoing benefit between 3 and 6 months. Nevertheless, standardized PFPT was not associated with differences at 24 weeks in this cohort of women.

Vaginal versus robotic hysterectomy and concomitant pelvic support surgery: a comparison of postoperative vaginal length and sexual function.

STUDY OBJECTIVE: To compare the change from pre- to postoperative total vaginal length (TVL) in women who underwent either a total vaginal hysterectomy (TVH) with uterosacral ligament suspension (USLS) or a robotic hysterectomy (RH) with colpopexy (SCP). Secondary objectives included comparing sexual function, pelvic floor function, and prolapse recurrence between routes of surgery. DESIGN: This was a retrospective cohort study (Canadian Task Force classification II-2). SETTING: This was conducted at 1 tertiary academic medical center over a 2-year period. PATIENTS: Women who underwent either TVH/USLS or RH/SCP. INTERVENTIONS: Baseline and postoperative POP-Q Pelvic Organ Prolapse Quantification exams were recorded as well as postoperative validated questionnaires. Twenty-nine subjects were needed in each group to detect a 1.5-cm difference in TVL. MEASUREMENTS AND MAIN RESULTS: There were 38 TVH/USLS and 46 RH/SCP participants. RHs were either total (28/46 [61%]) or supracervical (18/46 [39%]). The mean postoperative follow-up was 9.5 ± 3.1 months. For the primary outcome, women in the TVH/USLS group had a decrease in TVL, whereas women in the RH/SCP group had an increase in TVL (-0.6 ± 1.0 cm vs 0.5 ± 0.8 cm, p < .001). Among sexually active women (55/84, 65.5%), there was no difference in postoperative sexual function between groups based on Pelvic Organ Prolapse/Urinary incontinence Sexual Function Questionnaire short form scores, with good sexual function in both groups (32.6 ± 6.2 TVH/USLS vs 35.1 ± 7.3 RH/SCP, p = .22). Although both groups showed good postoperative apical support, the TVH/USLS group had a slightly lower mean C point compared with the RH/SCP group (-6.8 ± 1.2 vs -7.7 ± 1.8, p = .02). Both groups showed good postoperative pelvic floor function, with no difference in mean postoperative Pelvic Organ Prolapse Distress Inventory scores (42.2 ± 45.4 vs 52.7 ± 46.6, p = .44). Recurrent prolapse (defined as any prolapse at or beyond the hymen) was not different between groups (13.2% for TVH/USLS vs 6.5% for RH/SCP, p = .46). CONCLUSION: Vaginal length decreased after vaginal hysterectomy with pelvic support surgery compared with RH with pelvic support surgery, with no differences in postoperative sexual function or pelvic floor function between groups.

Long-term outcomes of perineal rehabilitation.

AIM: Pelvic floor muscle training (PFMT) is classified with a level 1 evidence and a grade A recommendation, but long term effects have not been studied thoroughly. This study aims at assessing the long-term effectiveness of perineal rehabilitation on patients with mild prolapse and pure stress urinary incontinence (IUS) symptoms. METHODS: Retrospective observational study on 49 patients examined at the beginning of the observation and 60 months after receiving biofeedback assisted PFMT. We created two groups. Group A: 27 women with mild symptoms of prolapse and pure mild IUS; Group B: 22 symptomatic patients postsurgery. We considered as therapeutic success a 50% general reduction of the symptoms experienced by the patients in terms of reduction of leakage episodes, number of pads used, strength and endurance of the pubococcygeus muscle and initial prolapse signs/symptoms. RESULTS: Group A (follow-up 60 months): Reduction of prolapse symptoms: cured/much improved: 65% (17 patients); worsened: 22.4% (6 patients); unchanged: 18.5% (5 patients); reduction of urinary symptoms: cured/much improved: 59.3% (16 patients); surgery: 40.7% (11 patients); group B (follow-up 60 months); cured: 55.5% (12 patients); much improved: 44% (10 patients). CONCLUSION: In conclusion, as for the treatment of menopausal patients with symptoms of mild disorders of the urinary/genital system, excellent results were reported in women underwent rehabilitation, as a first approach or after failed TVT-O.

Impact of physical therapy on quality of life and function after vaginal reconstructive surgery.

OBJECTIVES: Although pelvic floor physical therapy (PFPT) can be beneficial for complaints after vaginal reconstructive surgery, it is not routinely offered to all patients. We sought to evaluate the role of perioperative PFPT in improving quality of life and function after prolapse repairs. METHODS: This randomized controlled trial compared PFPT to standard care after vaginal reconstructive surgery. The intervention group received PFPT 2 weeks preoperatively and 2, 4, 6, 8, and 12 weeks postoperatively, as well as a physician assessment. Control subjects underwent a physician's assessment alone at the same time points postoperatively. Both groups completed pelvic organ prolapse quantification examinations, intravaginal electromyography (EMG), voiding diaries, and validated questionnaires at baseline and 12 weeks. The primary outcome was change in the World Health Organization Quality of Life-BREF scale after surgery. RESULTS: Forty-nine women completed the study: 24 women in the PFPT group and 25 women in the control group. At 12 weeks, condition-specific questionnaires improved for the entire sample, confirming effectiveness of surgery. Nevertheless, no significant differences were noted between the groups despite therapy with PFPT. However, intravaginal EMG measures were notably affected by the intervention. The PFPT group showed significantly lower averages across all measurements of rest, indicating positive impact on muscle function. Pearson correlations revealed associations with better scores on the World Health Organization Quality of Life-BREF physical domain and greater EMG relaxation, supporting effects from PFPT on quality of life. CONCLUSIONS: Pelvic symptoms improved in all subjects after vaginal reconstructive surgery. Whereas PFPT did not result in detectable subjective differences in this short-term study, superior muscular function suggested benefit from the intervention.

Análise dos recursos para reabilitação da musculatura do assoalho pélvico em mulheres com prolapso e incontinência urinária / Analysis of the resources for rehabilitation of pelvic floor muscles in women with prolapse and urinary incontinence / Análisis de los recursos para rehabilitación de la musculatura del suelo pélvico en mujeres con prolapso e incontinencia urinaria

Esta revisão teve como objetivo analisar os recursos e sua eficácia na reabilitação do assoalho pélvico no tratamento dos prolapsos genitais e incontinência urinária. As buscas foram realizadas nas bases de dados MEDLINE/PubMed, LILACS/SciELO e Biblioteca Cochrane. Foram encontrados 886 artigos, dos quais foram utilizados 34 estudos clínicos relevantes que respondiam às perguntas construídas pelos autores. Os estudos analisados mostraram que o treinamento do assoalho pélvico pode ser usado no tratamento dos prolapsos, porém são necessários mais estudos randomizados para sustentar essa evidência. Para a incontinência urinária a reabilitação do assoalho pélvico é eficiente e deve ser o tratamento de primeira escolha.

This review aimed to assess the capabilities and effectiveness of pelvic floor rehabilitation in the treatment of genital prolapse and urinary incontinence. The research was conducted in MEDLINE/PubMed, LILACS/SciELO and Cochrane Library. There were found 886 articles, of which were used 34 relevant clinical trials that answered the questions constructed by the authors. The studies analyzed showed that pelvic floor training can be used in prolapse treatment, but further randomized studies are necessary to support this evidence. For urinary incontinence pelvic floor, rehabilitation is effective and should be the treatment of first choice.

Esta revisión tiene como objetivo analizar los recursos y su eficacia en la rehabilitación del suelo pélvico en el tratamiento de los prolapsos genitales y la incontinencia urinaria. Las búsquedas fueron realizadas en las bases de datos Medline/Pubmed, LILACS/SciELO y Cochrane. Fueron encontrados 886 artículos, de los cuales fueron utilizados 34 estudios clínicos relevantes y que respondían las preguntas construidas por los autores. Los estudios analizados mostraron que el entrenamiento del suelo pélvico puede ser usado en el tratamiento de los prolapsos, sin embargo, son necesarios más estudios randomizados para sustentar esta evidencia. Para la incontinencia urinaria la rehabilitación del suelo pélvico es eficiente y debe ser el tratamiento de primera opción.