The effect of pelvic floor muscle training in urinary incontinent elderly women: a sistematic review

Jácomo, Raquel Henriques; Fitz, Fátima Fani; Alves, Aline Teixeira; Fernandes, Isabella Silveira; Teixeira, Fellipe Amatuzzi; Sousa, João Batista de

doi:10.1590/0103-5150.027.004.AR02

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Review articles • Fisioter. mov. 27 (4) • Oct-Dec 2014 • https://doi.org/10.1590/0103-5150.027.004.AR02 copy

The effect of pelvic floor muscle training in urinary incontinent elderly women: a sistematic review

Efeito do treinamento dos músculos do assoalho pélvico na incontinência urinária de mulheres idosas: revisão sistemática

Authorship SCIMAGO INSTITUTIONS RANKINGS

Introduction

The International Continence Society (ICS) determines that the pelvic floor muscles training (PFMT) is the first-choice treatment of urinary symptoms in women.

Objective

The aim of this study was to systematize randomized controlled clinical trials that address the effects of PFMT in the treatment of urinary symptoms in older women using objective outcome measures.

Method

Systematic review search was performed eletronic the following databases: Medline, Pubmed, Lilacs, PEDro and manual research conducted in the references of the studies. Were considered eligible women aged over 60 years who performed PFMT in isolation, without the involvement of another technique. The PFMT performed in clinic or at home, with or without the supervision of a therapist and with or without the use of biofeedback as an adjunct. Considered as outcome measures urodynamic studies, voiding diary that assesses daytime urinary frequency, nocturnal urinary frequency, urinary incontinence and exchange absorbent, and, finally, the absorbent test that quantifies loss urinary grams. The assessment of methodological quality of the studies was conducted by PEDro scale.

Results

Three studies were reviewed in full. Only one trial was rated high methodological quality. There was significant improvement in urinary symptoms after treatment proposed in the three selected studies.

Conclusion

Considering the studies available so far are weak the evidence for the use of PFMT in the treatment of urinary symptoms in elderly women.

Exercises therapy; Urinary incontinence; Pelvic floor; Aged; Women’s health

Study	Characteristics of the individuals, size of sample	Outcome measures	Design of the study	Results
Sherburn et al, 2011	Age = 71 years (TMAP Group) and 72 years (TB Group) N= 83 Inclusion Criteria = Presence of urinary incontinence of effort as diagnosed by the urodynamic study and mini mental test with a score of > 22 Exclusion Criteria = previous sessions of physiotherapy in the last 6 months. Neurological causes for urinary incontinence; urinary infection or any other urinary difficulty.	Symptom Evaluation = -Pad-test (10 minutes) - Urine Journal (of 7 days) Quality of Life Evaluation = - ICIQ-SF - AQoL- Visual Analogical Scale Follow-up = Not reported	TMAP Group =Educational Component – Patients were oriented to contract the MAP before activities that require strength, they also received orientation regarding normal bladder control and urinary parameters, regarding liquid intake and correct sitting position when using the toilet and the benefits of the exercises.TMAP Exercises – Ambulatory exercises – weekly visits in which they practiced MAP exercises in a group for 45 minutes with the supervision of a therapist: 12 CVM in a sitting position, orthostatic, kneeling and dorsal decubitus. Home exercises – performed 3 (three) times a day in the preferred position with audio feedback. Duration of treatment = 5 monthsTB Group =Educational Component – patient was oriented to contract the MAP before any activities that require strength, received orientation on normal bladder control and urinary parameter and orientation regarding liquid intake and correct sitting position in the toilet as well as the benefits of the exercises, urination delay program, diaper use progression, skin care, bladder deflation dynamic, relaxing and breathing as a means to control the urination allowing its delay.Breathing and Relaxation Exercises – stretching exercises, having consciousness of your breathing and relaxation without having specific exercises for those with MAP. Duration of Treatment = 5 months	The TMAP group showed superior improvement when compared to the training of the bladder Group regarding the reduction of urinary loss in thePad–test with previous contraction of the MAP before the effort exam after 3 months of treatment (p = 0.04) and without previous contraction of the MAP after 5 months of treatment (p = 0.03). Reduction of the number of urinary loss in the urinary journal after one months of training (p = 0.05)
Spruijt et al, 2003	Age= 72 years (EIV Group) and 74 years (TMAP Group) N= 37 Inclusion Criteria = Women over 60 years of age with urinary incontinence of any sort, symptoms of incontinence for over a period of 3 months; a registered urinary loss of over 10cc in the 24 hourpad test. Exclusion Criteria = Infection in the lower urinary tract, urinary dysfunctions caused by fistulas, tumors, pelvic irradiation or neurological conditions; any other treatment in the past 6 months; genital prolapse that goes beyond the vaginal entrance; use of a cardiac pacemaker and mental deficiency	Symptom Evaluation = - 48 hourPad test - Urodynamic Study - Self-evaluation of the gravity of the urinary incontinence by the PRAFAB Scale. MAP Evaluation = - Perineometry of the MPA Follow-up = not performed	TMAP Group= Home exercises without any supervision Protocol written in the German language Duration of Treatment = 8 weeksEIV Group = biphasic current with a duration of de 1ms, frequency of 50Hz (IUE) or 20Hz (IUU), 30 minutes of application with 5 minute intervals after the 15^th minute. 3 times a week in a total of 24 sessions Duration of Treatment = 8 weeks	There was no significant improvement when comparing both groups in relation to thePad-test (p = 0.08), the urodynaimic study (p = 0.85), the quantity of urinary loss (p = 0.32), and the frequency of urinary losses (p = 0.30) evaluated by an item of the PRAFAB; perineometry (0.24), PRAFAB score (p = 0.89). However, there was a 36.4% improvement when comparing the before and after treatment in the TMAP Group and a 29.2% improvement in the EIV treatment.
Aslan et al, 2007	Age = 78 years (TMAP Group) and 79 years (Control Group) N = 50 Inclusion Criteria = Women who have been institutionalized for at least 6 months and had regular complaints of urinary loss Exclusion Criteria = Women who had neurological or chronic diseases that affected their daily life activities (severe paralysis, dementia, arthritis, fractures); mini mental exam <22;Rankin Scale above 3; insufficient alphabetization level and motor abilities to register their data	Evaluation of Symptoms = -Pad-test(1 hour) MAP Evaluations = - Digital Palpitations of the MAP Follow-up = 06 months	TMAP TB Group =Educational Component – patient received explanations about the structure of the inferior urinary tract, about the mechanisms of continence, MAP, about problems related to urination, about how to perform the TB and the TMAP and how to register the data They were taught how to urinate in regular intervals, as well as how to overcome the urgency to urinate by keeping their breathing stable and mentally solve games like puzzles so as to delay their need to urinate.TMAP Exercises - home exercises – patient was oriented to perform the MAP contractions to the maximum extent during their daily life activities Ambulatory visit – 3 to 4 times a week to observe the evolution of the TB and to answer any questions related to the TMAP Duration of treatment = 6 to 8 weeksControl Group = Didn’t receive treatment	There was significant improvement in the group that had an intervention in the urgency (p = 0.02) and urinary frequency. (p = 0.000), nocturia (p = 0.00),pad-test (p = 0.00) after 08 weeks of treatment. The nocturia also showed improvement after 06 months (p = 0.004)

Study	E^a	01	02	03	04	05	06	07	08	09	10	Total
Sherburn et al, 2011	+	+	+	+	-	-	+	?	+	+	+	8
Spruijt et al, 2003	+	+	?	+	-	-	?	+	-	+	+	5
Aslan et al, 2008	+	+	-	+	-	-	-	-	=	+	+	4

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[TFN1] Note: MAP = Pelvic floor muscles; TMAP = Training of the pelvic floor muscles; TB = Bladder training; EIV = Intra-vaginal electro stimulation; IUE = Effort of urinary incontinence; IUU = Urgency urinary incontinence; ICIQ = AQoL Assessment of Quality of Life; ICIQ-UI-SF = Disease specific symptom and bother measure; PRAFAB = Protection, Amount, Frequency, Adjustment, Body image; CVM = Maximum voluntary contraction.