Impact of pelvic floor muscle training on the quality of life in women with urinary incontinence

Abstracts

OBJETIVO: Avaliar o impacto do treinamento dos músculos do assoalho pélvico (TMAP) na qualidade de vida (QV) em mulheres com incontinência urinária de esforço (IUE). MÉTODOS: Ensaio clínico prospectivo com 36 mulheres com diagnóstico médico de IUE conrmado no estudo urodinâmico. Não foram incluídas mulheres com doenças neuromusculares, com uso de reposição hormonal e com prolapso grau III e IV. O protocolo de exercícios para os músculos do assoalho pélvico foi constituído de contrações lentas (bras tônicas), seguidas de contrações rápidas (bras fásicas), realizadas nas posições de decúbito dorsal, sentada e ortostática, três vezes na semana, por um período de três meses. Avaliou-se o impacto do TMAP na QV por meio do King's Health Questionnaire (KHQ), diário miccional e palpação digital para avaliar a função dos músculos do assoalho pélvico, durante a avaliação inicial e após os três meses de tratamento. O resultado foi descrito em médias e desvios-padrões. Utilizou-se o teste de Wilcoxon para comparação dos escores referentes ao KHQ para amostras pareadas, e adotou-se como nível de signicância o valor de 0,05. RESULTADOS: Observou-se diminuição signicativa das médias dos escores dos domínios avaliados pelos KHQ. Esses domínios consistem na percepção da saúde, impacto da incontinência, limitações das atividades diárias, limitações físicas, limitações sociais, relações pessoais, emoções, sono/disposição e também medidas de gravidade. Em concordância com esses resultados, foram observados diminuição signicativa na frequência urinária noturna e na perda urinária, bem como aumento signicativo na força e endurance muscular. CONCLUSÃO: O treinamento muscular do assoalho pélvico proporcionou melhora signicativa na QV de mulheres com IUE.

Modalidades de fisioterapia; qualidade de vida; incontinência urinária por estresse; soalho pélvico

ORIGINAL ARTICLE

Impact of pelvic floor muscle training on the quality of life in women with urinary incontinence

Fátima Faní Fitz^I; Thaís Fonseca Costa^I; Deborah Mari Yamamoto^I; Ana Paula Magalhães Resende^II; Liliana Stupp^II; Marair Gracio Ferreira Sartori^III; Manoel João Batista Castello Girão^IV; Rodrigo Aquino Castro^V

^IMSc Students in Gynecology; Physical Therapists at the Urogynecology and Vaginal Surgery Outpatient Clinic, Department of Gynecology, Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil

^IIPhD in Gynecology; Physical Therapists of the Urogynecology and Vaginal Surgery Outpatient Clinic, Departament of Gynecology, EPM-UNIFESP, São Paulo, SP, Brazil

^IIIPhD in Gynecology; Associate Professor, Department of Gynecology, EPM-UNIFESP, São Paulo, SP, Brazil

^IVPhD in Gynecology, Full Professor, Department of Gynecology, EPM-UNIFESP, São Paulo, SP, Brazil

^VPhD in Gynecology; Adjunct Professor, Department of Gynecology, EPM-UNIFESP, São Paulo, SP, Brazil

^{Correspondence to}

SUMMARY

OBJECTIVE: To evaluate the impact of pelvic floor muscle (PFM) training on the quality of life (QOL) in women with stress urinary incontinence (SUI).

METHODS: Prospective clinical trial with 36 women with a diagnosis of SUI confirmed by urodynamic study. Women with neuromuscular diseases, using hormone replacement therapy, and with prolapse stage III and IV were not included. The exercise protocol for the PFM consisted of slow contractions (tonic fibers), followed by rapid contractions (phasic fibers) practiced in the supine, sitting, and standing positions, three times a week for a period of three months. We evaluated the impact of PFM on QOL using the King's Health Questionnaire (KHQ), a voiding diary, and digital palpation to assess the function of the PFMs during the initial evaluation and after three months of treatment. The result was described as means and standard deviations. We used the Wilcoxon test for comparison of the KHQ scores for paired samples, and the significance level was set at 0.05.

RESULTS: There was a significant decrease in the mean scores of the domains assessed by the KHQ regarding the perception of health, impact of the incontinence, limitations of daily activities, physical limitations, social limitations, personal relationships, emotions, sleep/disposition, and measures of severity. In agreement with these results, significant decrease in nocturnal urinary frequency and urinary incontinence, as well as significant increase in muscle strength and endurance were observed.

CONCLUSION: PFM training resulted in significant improvement in the QOL of women with SUI.

Keywords: Physical therapy modalities; quality of life; stress urinary incontinence; pelvic floor.

INTRODUCTION

Stress urinary incontinence (SUI) is defined by the International Continence Society (ICS) as the complaint of involuntary loss of urine during exertion, exercise, when sneezing or coughing¹. The risk factors are related to the number of pregnancies, parity, high body mass index (BMI), chronic constipation, postmenopausal status, and chronic cough^2-7. The prevalence of symptoms is 80% in women between 25 and 60 years of age⁸.

Although urinary incontinence (UI) does not represent a direct risk for the affected individuals, there is a consensus on the fact that UI can negatively affect quality of life (QOL) in many aspects, such as the psychological, physical, social, personal, and sexual⁹.

In general, women with UI report physical limitations (playing sports, carrying objects), and changes in social, occupational and domestic activities, which negatively influence the emotional and sexual aspects of life. Moreover, it can cause social and hygienic discomfort, due to the fear of loss of urine, the smell of urine, the need for wearing sanitary pads, and more frequent changes of clothing^10,11. Family members and caregivers also experience a negative impact on their QOL, especially regarding the psychological aspects¹².

The assessment of QOL has been shown to be a predictor of treatment-seeking for UI¹³. Among the treatments, the conservative option must be mentioned, which aims to increase the support of the lower urinary tract through increased strength of the pelvic floor muscles (PFMs) and promote urethral closure by involuntary contraction of periurethral muscles. The ICS considers the perineal exercises as the gold standard in SUI, and its efficacy has been demonstrated by randomized controlled trials^1,14-17.

Several questionnaires have been developed and tested to measure the impact of UI on the QOL. Among the dimensions studied, the impact on daily life, personal relationships, the psychological and emotional aspects, and the social and physical limitations are important factors measured by these instruments¹⁸.

Recent publications have shown improvement in the QOL of women undergoing conservative treatment, who were evaluated through the King's Health Questionnaire (KHQ)^19,20. Therefore, assessment of QOL in women who undergo interventions for the treatment of UI becomes mandatory, as the UI has an impact not only on the QOL of individuals who have it, but also affects the QOL of family members and caregivers. One of the goals of physiotherapy is to investigate and intervene in the impact of incontinence on quality of life of affected women. This study aimed to evaluate the impact of pelvic floor muscle training (PFMT) on the QOL of women with SUI.

METHODS

This is a prospective clinical trial of the before-and-after type, carried out from April 2009 to May 2010. It was conducted at the Outpatient Clinic of Urogynecology and Vaginal Surgery, of the Universidade Federal de São Paulo (UNIFESP/EPM). The Ethics Committee in Research of UNIFESP approved the study - protocol #1966/09. All participants signed an informed consent, drafted in accordance with the National Health Council Resolution number 196/96.

The inclusion criterion for the participant women was a history of SUI without sphincter deficiency during the urodynamic study. Exclusion criteria were neuromuscular diseases, prolapse grade III and IV according to the classification of ICS¹, and use of hormone replacement therapy. At the initial approach, we collected socio-demographic (age) and clinical (body mass index, duration of urinary loss) data as well as obstetric history (parity, vaginal delivery).

Before and after the treatment, the KHQ on quality of life, which has been validated in Brazil, was applied²¹. This is a questionnaire with 30 questions distributed in nine domains: the patients report perception of health, impact of incontinence, task performance limitations, physical limitations, social limitations, personal relationships, emotions, sleep/disposition, and measures of severity. Numerical values are assigned to all answers, added, and evaluated by domain. The KHQ is scored in each of its domains and, therefore, there is no overall score. Scores range from zero to 100, and the higher the score, the worse the quality of life related to that domain. The questionnaire was originally standardized to be selfadministered, but it was applied during an interview, and questions were read by the examiner as written.

PFM function was measured by palpation with two fingers. The muscle function was assessed by recording the following variables: power (P), classified by the Oxford scale; and muscular endurance (E), given by the maintenance of muscle contraction in seconds. This evaluation was adapted from the PERFECT method described by Laycock et al.²², widely used in the literature.

Prior to assessment, the patient received instructions regarding the location and function of the PFMs and how to contract them properly: as strongly as possible and eliminating the contraction of the gluteal, abdominal, and adductor muscles as much as possible. The evaluation procedures were explained in detail.

For physical therapy evaluation, patients were instructed to empty the bladder and then were placed in lithotomy position. The resting time was three times greater than the contraction time, and subsequently patients were asked to maintain the contraction for as long as possible.

Urinary loss was measured by the simplified voiding diary, in which the patient wrote down, for a period of seven days, the diurnal and nocturnal urinary frequency and number of urinary leakage events.

The training protocol for the pelvic floor muscles used was described previously by Bo et al.²³. However, in this study, the patients performed the exercises individually. All patients underwent training sessions with a physical therapist specialized in urogynecology. The protocol consisted of exercises to strengthen the pelvic floor muscles, in which women were encouraged to perform three sets of 10 slow contractions (tonic fibers), maintaining each contraction for 6-8 seconds, followed by a resting period equal to the time of contraction maintenance; then, 3-4 fast contractions (phasic fibers), in the supine, sitting and standing positions, for at least three times a week. The treatment was performed for a period of three months.

Data were expressed as means and standard deviations. The scores of the domains of QOL assessment were compared using the Wilcoxon test for paired samples, with a significance level of 0.05.

RESULTS

Initially, 40 women were included in the study. Of these, two patients could not come to the clinic due to work schedule conflicts, and two had to care for sick relatives. A total of 36 women completed the pelvic floor muscle training during the period of April 2009 to May 2010. The mean age of patients was 55.2 (± 9.1) years, duration of symptoms was 7.0 (± 6.6) years, and body mass index was 28.9 (± 5.2) (kg/m²).

Regarding the obstetric history, three women were nulliparous, 24 had between one and three pregnancies, nine had four or more pregnancies, with an average of 3.1 (± 2.1) pregnancies. As for the type of delivery, 22 women had one to three vaginal deliveries, and seven women had four or more vaginal deliveries, with an average of 2.5 (± 2.2) deliveries.

There was a significant decrease in mean scores in all domains assessed by the KHQ (Table 1). In accordance with the results of the QOL assessment, decreased urinary loss and nocturnal urinary frequency were observed by patients, both symptoms assessed by the daily voiding diary (Table 2). A significant increase in muscle strength and endurance was also observed (Table 3).

DISCUSSION

The effects of the PFMT have been widely described in literature in more than 50 randomized clinical trials. It is considered the gold standard for the treatment of SUI, with level of evidence A²⁴. Additionally, this treatment also results in the improvement of patient's perception of the disease, and in the decrease in the impact on their QOL. When measured with precision and reliability, the assessment about the severity and impact of the disease is an important parameter for the assessment and treatment of affected patients. Although subjective, these data are significantly relevant, as they indirectly reflect the quality of care provided.

In this study, the measurement of pelvic floor muscle function was performed by palpation with two fingers, a validated and widely used technique in the literature^22,25,26. Prior to treatment, a mean score at the Oxford scale of 2.0 (± 0.9), which is considered weak muscle function, was observed. Moen et al.²⁷ suggest that, for the pelvic floor muscle function to be adequate, the value assessed by the Oxford scale must be > 3. In this study, after three months of treatment, a mean of 3.5 (± 1.0) was observed, which is considered effective. Muscular endurance progressed positively from 3.0 (± 1.7) to 6.6 (± 2.4) seconds. The improvement can be attributed to the quality of the instituted protocol, which recommended a maintenance time of 6 to 8 seconds²⁷.

The improved pelvic floor muscle function and QOL were associated with improvement in urinary incontinence. In this study, a decrease in urinary loss events from 1.3 (± 1.3) to 0.5 (± 0.7) was observed. In a recent publication, the voiding diary was considered an important tool for the objective measurement of urinary loss, with good correlation with the patients' reports on their symptoms²⁸.

Similarly to this study, Rett et al.^{2 9} recruited 26 women with SUI, with a mean age of 42 years (± 5.5), and used PFMT associated with biofeedback. After the treatment, improvement was observed in eight of the nine domains assessed by the KHQ. Only the domain regarding personal relationships was not different after the treatment. However, the authors suggest that this domain may be related to aspects of family and sex life, and among the women studied, many of them may not have reported to the family about the problem of urinary loss, or were not sexually active²⁹.

In another recent study by Fozzati et al.²⁵, 26 women with a mean age of 50 years were selected and treated using the global postural reeducation (GPR) technique. After the treatment, the authors observed an improvement in the areas of general health perception, incontinence impact, and SUI symptoms (p < 0.05). Three and six months after the end of treatment, these results persisted. For the authors, the benefits of improved QOL in the short- and mid-term may be related to modifications in the body schema, and improvement in body selfknowledge, which reduces structural overload; these factors can result in pelvic floor protection²⁵.

Literature demonstrates that PFMT, when performed regularly, can improve pelvic floor muscle function²⁴. Due to this factor, it is believed that the improved functionality can be directly associated with a decrease in the number of urinary leakage events, and consequently improve QOL for these women.

It is worth emphasizing the importance of using a properly translated questionnaire that has been adapted to Brazilian Portuguese, with high reliability and validity, which may be included in any Brazilian study on urinary incontinence and in clinical practice²¹.

One of the limitations of this study was the lack of detail in the frequency of exercises through the use of a daily record. Additionally, it lacked a comparison between the data from the present study and a control group. Finally, suggestions for further studies including the reevaluation of patients after a period of time to verify the maintenance of the results should be considered for researchers in this field.

CONCLUSION

Based on the results of the study, pelvic floor muscle training resulted in significant improvement in the QOL of women with SUI.

REFERENCES

2. Brown J, Grady D, Ouslander JG, Herzog AR, Varner RE, Posner SF. Prevalence of urinary incontinence and associated risk factors in postmenopausal women. Obstet Gynecol. 1999;94:66-70.

3. Moller LA, Lose G, Jorgensen T. Risk factors for lower urinary tract symptoms in women 40 to 60 years of age. Obstet Gynecol. 2000;96:446-51.

4. Buchsbaum GM, Chin M, Glantz C, Guzick D. Prevalence of urinary incontinence and associated risk factors in a cohort of nuns. Obstet Gynecol. 2002;100:226-9.

5. Higa R, Lopes MHBM. Fatores associados com a incontinência urinária na mulher. Rev Bras Enferm. 2005;58:422-8.

6. Viktrup L, Koke S, Burgio KL, Ouslander JG. Stress urinary incontinence in active eldery women. South Med J. 2005;98:79-89.

7. Gomes GV, Da Silva GD. Incontinência urinária de esforço em mulheres pertencentes ao programa de saúde da família de dourados (ms). Rev Assoc Med Bras. 2010;56:649-54.

8. Hannestad YS, Rortveit G, Sandvik H, Hunskaar S. A community-based epidemiological survey of female urinary incontinence: The Norwegian EPICONT Study. J Clin Epidemiol. 2000;53:1150-7.

9. Chiverton PA, Wells TJ, Brink CA, Mayer R. Psychological factors associated with urinary incontinence. Clin Nurse Spec. 1996;10:229-33.

10. Kelleher C. Quality of life and urinary incontinence. Baillieres Best Pract Res Clin Obstet Gynecol. 2000;14:363-79.

11. Saleh N, Bener A, Khenyab N, Al-Mansori Z, Al-Muraikhi A. Prevalence, awareness and determinants of health care-seeking behaviour for urinary incontinence in Qatari women: a neglected problem? Maturitas. 2005;50:58-65.

12. Gotoh M, Matsukawa Y, Yoshikawa Y, Funahashi Y, Kato M, Hattori R. Impact of urinary incontinence on the psychological burden of family caregivers. Neurourol Urodynamics. 2009;28:492-6.

13. Huang AJ, Brown JS, Thom DH, nk HA, Yaffe K. Urinary incontinence in older community dwelling women: the role of cognitive and physical function decline. Obstet Gynecol. 2007;109:909-16.

14. Burns PA, Pranikoff K, Nochajski TH, Hadley EC, Lew KJ, Ory MG. A comparison of effectiveness of biofeedback and pelvic muscle exercise treatment of stress incontinence in older community-dwelling women. J Gerontol. 1993;48:M167-M74.

15. Bø K, Talseth T, Holm I. Single blind, randomized controlled trial of pelvic floor exercises, electrical stimulation, vaginal cones, and no treatment in the management of genuine stress incontinence in women. BMJ. 1999;318:487-93.

16. Goode P, Burgio KL, Locher JL, Roth DL, Umiauf MG, Richter HE et al. Effect of behavioral training with or without pelvic floor electrical stimulation on stress incontinence in women: a randomized controlled trial. JAMA. 2003;290:345-352.

17. Borello-France DF, Zyczynski HM, Downey PA, Rause CR, Wisler JA. Effect of pelvic-floor muscle exercise position on continence and quality-of-life outcomes in women with stress urinary incontinence. Phys Ther. 2006;86:974-86.

18. Kwon BE, Kim GY, Son YJ, Roh YS, You MA. Quality of life of women with urinary incontinence: a systematic literature review. Int Neurourol J. 2010;14:133-8.

19. Balmforth JR, Mantle J, Bidmead J, Cardozo L. A prospective observational trial of pelvic floor muscle training for female stress urinary incontinence. BJU Int. 2006;98:811-7.

20. Wang AC, Wang YY, Chen MC. Single-blind, randomized trial of pelvic floor muscle training, biofeedback-assisted pelvic floor muscle training, and electrical stimulation in the management of overactive bladder. Urology. 2004;63:61-6.

21. Fonseca ESM, Camargo ALM, Castro RA, Sartori MGF, Fonseca MCM, Lima GR et al. Validação do questionário de qualidade de vida (Kings Health Questionaire) em mulheres brasileiras com incontinência urinária. Rev Bras Ginecol Obstet. 2005;27:235-42.

22. Laycock J, Whelan MM, Dumoulin C. Patient assessment. In: Haslam J, Laycock J, editors. Therapeutic management of incontinence and pelvic pain. 2nd ed. London: Springer; 2008. p.57-66.

23. Bo K, Hagen RH, Kvarstein B, Jorgensen J, Larsen S. Pelvic floor muscle exercise for the treatment of female stress urinary incontinence. An exercise physiology perspective. Int Urogynecol J. 1995;6:282-91.

24. Dumoulin C, Hay-Smith JC. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database Syst Rev. 2010;(1):CD005654.

25. Fozzatti MC, Palma P, Herrmann V, Dambros M. Impacto da reeducação postural global no tratamento da incontinência urinaria de esforço feminina. Rev Assoc Med Bras. 2008;54:17-22.

26. Bo K, Sherburn M. Evaluation of female pelvic-floor muscle function and strength. Phys Ther. 2005;85:269-82.

27. Moen MD, Noone MB, Vassalho BJ, Elser DM. Pelvic floor muscle function in women presenting with pelvic floor disorders. Int Urogynecol J. 2009;20:843-846.

28. Bradley CS, Brown JS, Van Den Eeden SK, Schembri M, Ragins A, Thom DH. Urinary incontinence self-report questions: reproducibility and agreement with bladder diary. Int Urogynecol J. 2011;22:1565-71.

29. Rett MT, Simões JA, Herrmann V, Gurgel MSC, Morais SS. Qualidade de vida em mulheres após tratamento da incontinência urinária de esforço com sioterapia. Rev Bras Ginecol Obstet. 2007;29:134-40.

Submitted on: 08/25/2011

Approved on: 12/18/2011

Conflict of interest: None.

Study conducted at the Department of Gynecology, Service of Urogynecology and Vaginal Surgery, Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil

• 2. Brown J, Grady D, Ouslander JG, Herzog AR, Varner RE, Posner SF. Prevalence of urinary incontinence and associated risk factors in postmenopausal women. Obstet Gynecol. 1999;94:66-70.
• 3. Moller LA, Lose G, Jorgensen T. Risk factors for lower urinary tract symptoms in women 40 to 60 years of age. Obstet Gynecol. 2000;96:446-51.
• 4. Buchsbaum GM, Chin M, Glantz C, Guzick D. Prevalence of urinary incontinence and associated risk factors in a cohort of nuns. Obstet Gynecol. 2002;100:226-9.
• 5. Higa R, Lopes MHBM. Fatores associados com a incontinência urinária na mulher. Rev Bras Enferm. 2005;58:422-8.
• 6. Viktrup L, Koke S, Burgio KL, Ouslander JG. Stress urinary incontinence in active eldery women. South Med J. 2005;98:79-89.
• 7. Gomes GV, Da Silva GD. Incontinência urinária de esforço em mulheres pertencentes ao programa de saúde da família de dourados (ms). Rev Assoc Med Bras. 2010;56:649-54.
• 8. Hannestad YS, Rortveit G, Sandvik H, Hunskaar S. A community-based epidemiological survey of female urinary incontinence: The Norwegian EPICONT Study. J Clin Epidemiol. 2000;53:1150-7.
• 9. Chiverton PA, Wells TJ, Brink CA, Mayer R. Psychological factors associated with urinary incontinence. Clin Nurse Spec. 1996;10:229-33.
• 10. Kelleher C. Quality of life and urinary incontinence. Baillieres Best Pract Res Clin Obstet Gynecol. 2000;14:363-79.
• 11. Saleh N, Bener A, Khenyab N, Al-Mansori Z, Al-Muraikhi A. Prevalence, awareness and determinants of health care-seeking behaviour for urinary incontinence in Qatari women: a neglected problem? Maturitas. 2005;50:58-65.
• 12. Gotoh M, Matsukawa Y, Yoshikawa Y, Funahashi Y, Kato M, Hattori R. Impact of urinary incontinence on the psychological burden of family caregivers. Neurourol Urodynamics. 2009;28:492-6.
• 14. Burns PA, Pranikoff K, Nochajski TH, Hadley EC, Lew KJ, Ory MG. A comparison of effectiveness of biofeedback and pelvic muscle exercise treatment of stress incontinence in older community-dwelling women. J Gerontol. 1993;48:M167-M74.
• 15. Bø K, Talseth T, Holm I. Single blind, randomized controlled trial of pelvic floor exercises, electrical stimulation, vaginal cones, and no treatment in the management of genuine stress incontinence in women. BMJ. 1999;318:487-93.
• 16. Goode P, Burgio KL, Locher JL, Roth DL, Umiauf MG, Richter HE et al. Effect of behavioral training with or without pelvic floor electrical stimulation on stress incontinence in women: a randomized controlled trial. JAMA. 2003;290:345-352.
• 17. Borello-France DF, Zyczynski HM, Downey PA, Rause CR, Wisler JA. Effect of pelvic-floor muscle exercise position on continence and quality-of-life outcomes in women with stress urinary incontinence. Phys Ther. 2006;86:974-86.
• 18. Kwon BE, Kim GY, Son YJ, Roh YS, You MA. Quality of life of women with urinary incontinence: a systematic literature review. Int Neurourol J. 2010;14:133-8.
• 19. Balmforth JR, Mantle J, Bidmead J, Cardozo L. A prospective observational trial of pelvic floor muscle training for female stress urinary incontinence. BJU Int. 2006;98:811-7.
• 20. Wang AC, Wang YY, Chen MC. Single-blind, randomized trial of pelvic floor muscle training, biofeedback-assisted pelvic floor muscle training, and electrical stimulation in the management of overactive bladder. Urology. 2004;63:61-6.
• 21. Fonseca ESM, Camargo ALM, Castro RA, Sartori MGF, Fonseca MCM, Lima GR et al. Validação do questionário de qualidade de vida (Kings Health Questionaire) em mulheres brasileiras com incontinência urinária. Rev Bras Ginecol Obstet. 2005;27:235-42.
• 22. Laycock J, Whelan MM, Dumoulin C. Patient assessment. In: Haslam J, Laycock J, editors. Therapeutic management of incontinence and pelvic pain. 2nd ed. London: Springer; 2008. p.57-66.
• 23. Bo K, Hagen RH, Kvarstein B, Jorgensen J, Larsen S. Pelvic floor muscle exercise for the treatment of female stress urinary incontinence. An exercise physiology perspective. Int Urogynecol J. 1995;6:282-91.
• 24. Dumoulin C, Hay-Smith JC. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database Syst Rev. 2010;(1):CD005654.
• 25. Fozzatti MC, Palma P, Herrmann V, Dambros M. Impacto da reeducação postural global no tratamento da incontinência urinaria de esforço feminina. Rev Assoc Med Bras. 2008;54:17-22.
• 26. Bo K, Sherburn M. Evaluation of female pelvic-floor muscle function and strength. Phys Ther. 2005;85:269-82.
• 27. Moen MD, Noone MB, Vassalho BJ, Elser DM. Pelvic floor muscle function in women presenting with pelvic floor disorders. Int Urogynecol J. 2009;20:843-846.
• 28. Bradley CS, Brown JS, Van Den Eeden SK, Schembri M, Ragins A, Thom DH. Urinary incontinence self-report questions: reproducibility and agreement with bladder diary. Int Urogynecol J. 2011;22:1565-71.
• 29. Rett MT, Simões JA, Herrmann V, Gurgel MSC, Morais SS. Qualidade de vida em mulheres após tratamento da incontinência urinária de esforço com sioterapia. Rev Bras Ginecol Obstet. 2007;29:134-40.

Publication Dates

• Publication in this collection
  04 May 2012
• Date of issue
  Apr 2012

History

• Received
  25 Aug 2011
• Accepted
  18 Dec 2011