Incontinencia urinaria de esforço em mulheres no menacme : tratamento com exercicios do assoalho pelvico associados ao biofeedback eletromiografico

Com o objetivo de avaliar o tratamento da incontinencia urinaria de esforco 
feminina com exercicios do assoalho pelvico associados ao biofeedback 
eletromiografico, realizou-se um ensaio clinico nao controlado de 26 mulheres 
no menacme. Elas foram acompanhadas no periodo de outubro de 2003 a 
junho de 2004, na Secao de Fisioterapia do Centro de Atencao Integral a Saude 
da Mulher (CAISM) da Universidade Estadual de Campinas (Unicamp). Todas as 
mulheres foram clinicamente avaliadas e submetidas a um estudo urodinâmico 
para preencher os criterios de inclusao e exclusao. Antes do inicio e ao final do 
tratamento, as participantes preencheram um diario miccional durante uma 
semana, foram submetidas ao teste do absorvente (pad test) de uma hora e a 
avaliacao da forca muscular do assoalho pelvico pelo toque vaginal e pelo 
perineometro. Em seguida, foram submetidas a avaliacao eletromiografica de 
superficie (sEMG) do assoalho pelvico. Alem disso, elas responderam a um 
questionario de qualidade de vida e outro para elaboracao de um indice de 
perda urinaria. As mulheres foram tratadas individualmente, duas vezes por 
semana, totalizando 12 sessoes de fisioterapia. O protocolo de exercicios consistia 
inicialmente em quatro sequencias de 20 contracoes (fasicas e tonicas) com um acrescimo gradativo nas primeiras quatro sessoes, ate atingir o total de 200 
contracoes, mantidas ate o final do tratamento. Os exercicios foram realizados em 
decubito dorsal, nas posicoes sentada e ortostatica. Os resultados mostraram 
uma reducao significativa na frequencia de perdas urinarias, na nocturia e no 
numero de absorventes utilizados. A cura objetiva foi encontrada em 20 (76,9%) 
mulheres. Houve um aumento significativo na forca de contracao do assoalho 
pelvico. Em relacao a eletromiografia de superficie do assoalho pelvico, as 
amplitudes das contracoes fasica e tonicas de 10 e 20 segundos aumentaram 
significativamente ao longo do tratamento, principalmente na primeira metade. 
O indice de perda urinaria diminuiu significativamente e observou-se melhora 
da qualidade de vida em praticamente todos os parâmetros avaliados. A maioria 
das mulheres referiu melhora importante dos sintomas urinarios, sentindo-se 
curadas ou quase curadas, logo apos o termino do tratamento. Concluiu-se que 
os exercicios do assoalho pelvico associados ao biofeedback eletromiografico 
podem ser uma alternativa eficaz no tratamento conservador da incontinencia 
urinaria de esforco de mulheres no menacme 
Abstract


Summary
The aim of this study was to evaluate the treatment of stress urinary incontinence by pelvic floor muscle exercise associated to electromyography biofeedback. This is an uncontrolled clinical trial of 26 pre-menopausal women, Most of women self reported being cured or almost cured immediately after the treatment. In conclusion, the pelvic floor muscle exercise associated to electromyography biofeedback might be an effective alternative as a conservative treatment of stress urinary incontinence in pre-menopausal women.  BURGIO et al., 1991;PEYRAT et al., 2002;SIRACUSANO et al., 2003).

Introduction
Approximately 50% of the incontinent women had stress urinary incontinence (SUI) and most of them are aged between 25 and 49 years [1]. Many of these women have an active professional and/or social life and are likely to be seriously bothered by the symptoms. It's a socially embarrassing condition, causing withdrawal from physical activity, affecting sexual life and reducing quality of life [2].
Surgery has been widely accepted as the treatment of choice for SUI. However, recently an increasing interest for conservative management has been developed [3,4,5,6].
Besides behavioral methods has been recommended as the first option for SUI in many cases. The initial treatment should be the least invasive with fewest potential side effects [7].
The aim of conservative rehabilitation therapy is a stabilization of the urethra by increasing the pelvic floor muscle strength. Conservative modalities include pelvic floor muscle exercise (PFME), vaginal cones, electrical stimulation and biofeedback. Because of their lower cost and lack of side effects, biofeedback and PFME are usually preferred [5,8,9].
Many women are not aware of how to contract their pelvic floor muscles. Biofeedback promotes correct contraction control and visualization of muscle activity. Therefore, training with biofeedback enhances pelvic floor muscle strength and collaborates to achieve good results when comparing with exercise alone [3,8,10,11].
The aim of this study was to evaluate the treatment of SUI in pre-menopausal women with PFME electromyography (sEMG) assisted biofeedback. Participants were treated individually twice a week during 40 minutes for 12 sessions.
All subjects performed pelvic floor muscle exercises in supine, sitting and standing positions, beginning with four sets of 20 contractions (10 phasic for 3 seconds and 10 sustained for 10 seconds) and increased by 10 contractions per set over 4 weeks until a total of 200 exercises [3]. Biofeedback treatment was accomplished through the use of Myotrac 3G (Thought Technology, Montreal, Canada).
A seven-day voiding diary was completed before the first session and before the 12 th session. To objectively evaluate the results, a standardized one-hour pad test was performed before and after treatment. Objective cure was defined as 2 g or less of leakage after treatment [12]. Pelvic floor muscle strength was assessed by vaginal palpation and perineometry (vaginal squeeze pressure). Vaginal palpation was evaluated by two-finger Publicação 33 palpation to grade the contractions into 0 (none); 1 (weak, <1 sec); 2 (moderate, 1-5 sec) and 3 (strong, > 5 seconds) [13]. Perineometry was accessed using an air-filled silicone sensor connected to a portable pressure transducer perineometer (Peritron 9300V TM Cardio-Desing Pty. Ltd, Baulkham Hills, Australia) [14]. All women were encouraged to contract the pelvic floor muscles during 5 seconds. Maximum contraction pressure and average contraction pressure were recorded.
All participants underwent surface eletromyographic (sEMG) evaluation of pelvic floor muscle activity. A vaginal sEMG sensor consisting of bipolar longitudinal electrode plates was connected to the biofeedback equipment and muscle electrical activity was recorded in microvolts (mµ). An adapted sEMG assessment consisted of initial rest period of 60 seconds, followed by a phasic contraction, a tonic contraction of 10 seconds and a tonic contraction of 20 seconds [15]. Phasic and tonics contractions values sEMG were obtained from the difference between the final contraction amplitude and the amplitude of rest. This sEMG assessment was performed before starting the treatment, at the 6 th session and at the 12 th session.
Leakage index, an instrument designed to evaluated women's perceptional stress incontinence is a 5-point scale (1=never, 5=always) containing 13 types of physical activities known to trigger urinary leakage [16]. This index was applied before and after treatment. The king's Health Questionnaire (khq) was also applied for the assessment of quality of life [17]. After treatment, all participants still answered a subjective improvement grade: cured, almost cured, improved, unchanged and worse [4].
Absolute frequencies were used for the categorical variables and Wilcoxon test was applied for non-parametric data. A P-value < 0.05 was defined as significant. Data were entered into excel and analyzed by the statistical analyzing system (SAS) version 8.2.

Results
The Based on the seven-day diary the voiding frequency did not change. Urinary losses frequency, nocturia and the number of pads decreased significantly at the end of the treatment (table 1).
After completing the treatment, 8 (61,5%) women did not use any pads, compared to 13 (50%) before treatment. Twenty-two (84.6%) women showed a reduction of 50% or more in urine losses frequency. Ten (38,5%) of these women reported complete remission of the symptom. The remaining four participants have had an improvement of less than 50% of urinary losses frequency.

Publicação 35
Objective cure (≤ 2 grams) was found in 20 (76.9%) women and six women (23.1%) still had mild leakage on pad test. Based on the amount of leakage in grams, 18 women improved at least 75%, four between 50%-74% and four improved less than 50% of the urine leakage.
There was a significant improvement in pelvic floor muscle strength evaluated by vaginal palpation and by perineometry. Results showed an increase of 15 and 12 cmh 2 o in the maximum and in the average pressure contractions, respectively (table 2).
According to the grade of pelvic floor muscle strength, 20 (76.9%) women showed grade 0 or 1 (absent/weak) before treatment. After the treatment, almost all of women (92.3%) showed grade 2 or 3 (moderate/strong), demonstrating an evolution/improvement in at least one grade after PFME sEMG-assisted biofeedback.
There was a significant increase in the sEMG amplitudes of all contractions throughout the treatment (p<0.0001). In the middle of treatment (after six sessions) the difference in phasic and tonic 10 and 20 seconds was significantly higher in comparison with initial (p<0.0001). However, these values still increased until the end of treatment, except to the tonic contraction of 20 seconds, which remained quite similar from to the 6 th to 12 th session (0.0653) (figure 1). Figure 2 shows the leakage index values before and after treatment. The corresponding means were 3.52 (± 0.83) and 1.66 (± 0.63), respectively. The difference was statistically significant (p<0.001).
Publicação 36 The quality of life (QOL) by King's Health Questionnaire (KHQ) showed a significant improvement in all score domains with the exception of the personal relationships domain. The results of the score domains are detailed in table 3.

Discussion
This study showed that PFME sEMG-assisted biofeedback is efficient in relieving the symptoms of SUI in pre-menopausal women. These results are in agreement to others authors about the effect of pfme with biofeedback [8,11,18,19,20,21]. Most of these studies, however, have included women not regarding their age and/or their hormonal status.
Our study included only pre-menopausal women because they might obtain additional benefits from initial conservative therapies for SUI. Although stress incontinence is common in postmenopausal patient it does frequently occur in women of reproductive age who may wish to retain their reproductive potential. and fascia to open and close urethra and bladder neck. This is a fundamental biomechanical concept that strengthening a muscle will also strengthen its insertion point [6].
In addition, we observed that the highest increase in sEMG amplitude values was found between the initial and after the 6 th session (i.e., in the middle of treatment). Berghmans et al. [10] comparing PFME with or without biofeedback showed that a significant improvement was also reached after six sessions in the biofeedback group. At the final of 12 sessions, however, the difference between groups was not significant. Based on these results we can hypothesize that biofeedback is essential on the beginning of treatment for a faster improvement.
A criticism to PFME has being that its long-term duration could influence the compliance to this therapy for SUI. Some women may find the exercise hard to conduct at a regular basis [28]. We have had no dropouts and this could probably have occurred due to the relative low number of sessions in our study protocol. However, Glavind et al. [19] concluded that long-term effect with biofeedback was better than PFME alone because of the higher patient motivation for training. We believe that the motivation is not only related with the frequency of sessions but with believe, interest and ability of both the instructor and the patient.
Quality of life has become an important outcome measure in clinical trials of treatment for incontinence. All participants in the present study were in pre-menopausal period and an important consideration for some authors is that younger women revealing more impairment on quality of life than older women [2]. These women are socially, economic and sexual active, what probably contributes to negative effects on quality of life face to stress urinary incontinence. We observed a significant improve in the quality of life after treatment especially those related to the limitations (role, physical and social) and to severity measures.
In conclusion, PFME sEMG-assited biofeedback has shown to be effective for SUI in pre-menopausal women. Despite of this therapy is taking time and costs consuming, this approach is an option and can be a promising alternative as a conservative treatment for SUI for appropriate medical indication, as well as in pre-menopausal women.