Application to help physiotherapists in the evaluation of pelvic dysfunctions after cervical cancer

Abstract Introduction Cervical cancer is caused by a persistent infection with some types of human papillomavirus (HPV), and its treatment entails chemotherapy, radiotherapy and surgery. This may cause different kinds of dysfunction in the pelvic floor. Hence, physiotherapy plays an important role in the evaluation and treatment of urogynecological dysfunctions occasioned by the oncological treatment. Objective To develop a digital technology in application format to help physiotherapists in the assessment of pelvic dysfunctions after cervical cancer. Methods A digital technology in application format was developed after approval from the Ethics in Research Committee of the Tropical Medical Center. The instrument was developed by a physiotherapist with expertise and experience in the area. The researchers held meetings to finalize the creation of the checklist, and the application was programmed using the Android Studio Environment. In the end, the application was evaluated by two physiotherapist experts in the field. Results The application created displays five sections addressing the symptoms of urinary dysfunction, sexual function, anal function, pain and alterations such as: lymphedema, vaginal stenosis and vaginal fibrosis. Conclusion The use of the application may help physiotherapists in the assessment of pelvic dysfunctions after cervical cancer.


Introduction
Cervical cancer (CC) is caused by persistent infection by some types of human papillomavirus (HPV). 1 Genital infection by this virus is frequent, but most of the time the disease does not develop; still, cellular alterations may occur in some cases and progress to cancer.1,2 OA pap smear verifies the cellular alterations caused by HPV, which, if diagnosed early, there is a high cure rate.1,2 In Brazil, except for non-melanoma skin tumors, CC is the third most common type of cancer among women.
According to the 2022 estimate, 16,710 new cases were calculated, which is considered a risk of 15.38 cases per 100,000 women.3 Regarding the treatment of CC, this may involve surgery, radiotherapy and chemotherapy, according to the stage of the disease.These therapies can cause damage to vascularization and pelvic innervation, to the functionality of the pelvic floor muscles, resulting in dysfunctions of the urogynecological system such as urinary incontinence, fecal incontinence, sexual dysfunction and vaginal stenosis, which impair the quality of life of women after completing cancer treatment.4 Physiotherapy plays an important role in the conservative treatment of urogynecological disorders.5-7 Among the resources used by physiotherapy are guidance on pelvic anatomy and on disorders caused by cancer treatment, vaginal desensitization, perineal massage, use of vaginal dilators, electrostimulation and others.[5][6][7] The benefits range from gain in perineal sensation, marked improvement in urinary loss, reduction of nocturia, and increased strength and endurance of the pelvic floor muscles, as well as improved sexual function and quality of life.5-7 In this context, it is worth mentioning that technologies have been helping health area professionals, mainly through the use of a mobile application that can contribute to the diagnosis, clinical decisions and therapeutic approach.8 Thus, instruments that help physiotherapists in the evaluation and treatment of these patients are of great importance in the field of oncology, since few studies are carried out with this specific population.
Thus, the importance of physiotherapy in helping women after CC treatment is evident, so it is important to create instruments that help professionals in this process.Accordingly, the aim of this study was to develop a screening checklist for urogynecological physiotherapy after treatment for CC in the form of a mobile application, with the purpose of guaranteeing patients (who have an indication and real need) adequate physiotherapy assistance, since cancer cannot be treated underestimating the impacts of the disease and its treatment on urological, proctological and sexual functions.

Methods
This was an applied research study with an exploratory  yes (presence of dysfunction) or no (absence of dysfunction).Therefore, the application will be able to

Results
Regarding the professionals' answers about the application, the following points were observed: "I see that the application brings practicality to the evaluation and is an alternative to reach the therapeutic purpose by physiotherapists.However, I advise modifying it in some way so that the answer alternatives are shown and do not appear only after clicking on the question, to give agility to use and, in addition, generate an interface (in PDF, for example) with the patient's responses so that it can be used to guide the treatment depending on the complaints collected in the application" (Physiotherapist 1)."The application is very practical and easy.I believe that initially I need to show directions and explanations about how the application works.Questions related to CheckListScreening    In this way, the instrument contemplates several dysfunctions that may be present in women after CC treatment, emphasizing that with advances in early detection and oncological treatment, there has been a significant increase in patient survival.Thus, this advance must be accompanied by therapeutic developments that improve the quality of life of patients, addressing changes caused by treatment.oncology area, specifically focused on CC, the creation of this application will help in the evaluation of patients and advise on choosing the type of treatment.9,10 The application addresses the most obvious post-

Conclusion
The use of the application can help physiotherapists in the evaluation of patients after treatment for CC, and also includes the main dysfunctions that can be addressed during an evaluation of patients in the area of women's health.This type of monitoring through a checklist in the form of an application proves to be a promising resource in the care of cancer patients.
The instrument was developed by physiotherapists with expertise and experience in the area, based on bibliographical references in the area of women's health and oncology.The researchers held meetings to finalize the checklist creation process, and the application was programmed in an Android Studio environment.In the end, the application was evaluated by two physiotherapist specialists in the area.The programmed application was divided into five sections:1 -symptoms of urinary dysfunction; 2 -sexual function; 3 -anal function; 4 -pain; 5 -body structure according to physiotherapeutic assessment.The application was evaluated by two specialists in the field, who were instructed to explore the application and report their opinion, as well as proposing changes and suggestions in a qualitative way.The instrument created was called CheckIn and comprises five sections and 31 questions (Figures1 -4).Section 1 (symptoms of urinary dysfunction) is subdivided into obstructive, irritative and stress urinary incontinence symptoms (Figure2).Section 2 (sexual function) addresses questions related to sexual interest, sexual pleasure, vaginal stenosis and vaginal lubrication (Figure3).Section 3 (anal function) refers to fecal and anal incontinence (Figure3), and section 4 (pain) is related to the pelvic, vaginal, anal and surgical region and to dyspareunia (Figure3).Finally, section 5, which evaluates body structure according to physiotherapeutic assessment, inquires about the presence of vaginal stenosis (vaginal canal length less than 8 cm), lowerlimb lymphedema (lower-limb perimetry with difference between limbs greater than 2 cm) and presence of fibrosis in the vaginal canal.The questions in sections 1 to 4 should be marked according to the patients' responses, answered using a Likert 1-5 scale, where 1 (never) means absence of symptoms and 5 (always) means very severe symptoms.The final outcome can be classified as: no symptoms (response 1 on the Likert scale), mild symptom (response 2), moderate (response 3), severe (response 4) or very severe (response 5).Section 5, on the other hand, requires physiotherapeutic evaluation through lower limb perimetry, palpation of the vaginal canal and measurement of the vaginal canal, and must be answered by means of a dichotomous answer:

Figure 1 -
Figure 1 -Home screen of the developed app.

FISIOTERAPIA 4 Figure 2 -
Figure 2 -Section 1 of the developed app: Symptoms of urinary dysfunction.
In the study by Rebegea et al., 17 the incidence of lymphedema in post-CC patients was 15%.Bona et al.18 concluded from their study that the frequency of lymphedema after CC treatment is variable and that it is mainly associated with the extent of lymphadenectomy, number of lymph nodes removed and adjuvant radiotherapy.The assessment of lymphedema addressed in the instrument is the perimetry of the lower limbs, which determines the difference between limbs, with results greater than two centimeters indicating the presence of lymphedema.19

3 , 15
Therefore, the evaluation of pelvic floor dysfunctions is a necessary tool in patients who have completed such treatment, as it allows the identification of patients who show some alteration and an indication for appropriate physical therapy.It is worth noting that pelvic floor dysfunctions have physical, economic, psychological, emotional and social consequences.20 Accordingly, treatment through physiotherapy is important, as studies show positive results in the treatment, follow-up and guidance provided by physiotherapists in the field of oncology and women's health.21 Impacto do tratamento do câncer de colo uterino no assoalho pélvico.FEMINA.2011;39(7):403-9.Full text link 12. Noronha AF, Figueiredo EM, Franco TMRF, Cândido EB, Silva-Filho AL.Treatments for invasive carcinoma of the cervix: what are their impacts on the pelvic floor functions?Int Braz J Urol. 2013;39(1):46-54.DOI 13.Vidal MLB, Santana CJM, Paula CL, Carvalho MCMP.Disfunção sexual relacionada à radioterapia na pelve feminina: diagnóstico de enfermagem.Rev Bras Cancerol.2013;59(1):17-24.Full text link 14.Shankar A, Patil J, Luther A, Mandrelle K, Chakraborty A, Dubey A, Saini D, et al.Sexual dysfunction in carcinoma cervix: assessment in post treated cases by LENTSOMA scale.Asian Pac J Cancer Prev.2020;21(2):349-54.DOI 15.Ramalho NM, Pinheiro CC, Paula CL, Carneiro VCG, Lima JTO.
14 According to Ramalho et al., 15 sexual dysfunction is prevalent among gynecological cancer survivors, negatively impacting quality of life.Sexual function is directly associated with the quality of life in patients treated for CC and involves physical Cruz BS et al. 17.Rebegea LF, Stoleriu G, Manolache N, Serban C, Craescu M, Lupu MN, et al.Associated risk factors of lower limb lymphedema after treatment of cervical and endometrial cancer.Exp Ther Med.2020;20(6):181.DOI