Análise dos recursos para reabilitação da musculatura do assoalho pélvico em mulheres com prolapso e incontinência urinária

Esta revision tiene como objetivo analizar los recursos y su eficacia en la rehabilitacion del suelo pelvico en el tratamiento de los prolapsos genitales y la incontinencia urinaria. Las busquedas fueron realizadas en las bases de datos Medline/Pubmed, LILACS/SciELO y Cochrane. Fueron encontrados 886 articulos, de los cuales fueron utilizados 34 estudios clinicos relevantes y que respondian las preguntas construidas por los autores. Los estudios analizados mostraron que el entrenamiento del suelo pelvico puede ser usado en el tratamiento de los prolapsos, sin embargo, son necesarios mas estudios randomizados para sustentar esta evidencia. Para la incontinencia urinaria la rehabilitacion del suelo pelvico es eficiente y debe ser el tratamiento de primera opcion.


INTRODUCTION
Urinary incontinence (UI) and pelvic organ prolapse (POP) are pelvic floor (PF) disorders that may occur alone or in association, and are caused by dysfunctions in ligaments, fascia and pelvic floor muscles (PFM) 1 .
UI is a very prevalent symptom in the general population.Studies show increasing rates during the young adult age and prevalence from 30 to 50% in patients older than 60 years old 2 .The POP is also relatively common, and it may affect about 40% of the women, especially those with more advanced age, as well as multiparous and white women 3 .The demand for health services specialized in PF dysfunctions should grow significantly in the next decades, since the relative proportion of elderly increases and, consequently, also does the incidence of these dysfunctions 4 .
PF dysfunctions are not conditions that threaten life, but they cause important morbidity.They can intensively affect the quality of life (QOL) of patients, leading to physical, social, occupational and sexual limitations 5 .
Pelvic floor muscle exercises (PFME) were established by Arnold Kegel, in 1948 6 .Since the pathogenesis of the dysfunctions begins with the loss of PF muscle support, training these muscles has proven to be effective 7 .Individual instruction and making sure that the patient is properly contracting the muscles are essential before the beginning of the treatment, since around 30% of the women are not able to contract the PFM at the first evaluation 8 .
With the progress in research concerning the physiology of the lower urinary tract and with the improvement of diagnostic techniques, physical therapy has achieved an important role in the rehabilitation of patients.Its objectives include increasing the resistance of PFM, preventing the evolution of POP, reducing the frequency or severity of urinary symptoms and preventing or slowing down the need for surgery 9 .The approach is minimally invasive and practically has no adverse effects.Success depends on the motivation and effort both from the patient and the involved multidisciplinary team 10 .
This review article aimed to analyze the resources and their efficacy in the rehabilitation of the PV in the treatment of POP and UI, which can assist doctors in the indication of rehabilitation and physical therapists to guide the treatment.

METHODOLOGY
Each item in this article was built according to seven clinically relevant questions created by the authors: is PF training efficient in the treatment of POP?Does physical therapy, which is used as an adjuvant method, help the treatment of the prolapse?Is PF training in UI more efficient when conducted individually or in groups?Is PF training in UI more efficient when supervised or unsupervised?Which training parameters should be used in PF rehabilitation?How are the PFM rehabilitation and the Paula Method results performed?Which other resources are used by physical therapy to rehabilitate the PFM?
The searches were conducted in MEDLINE/ PubMed, LILACS/SciELO and the Cochrane Library, with the following descriptors, in Portuguese and English: rehabilitation, pelvic diaphragm, prolapsed and urinary incontinence, from 1997 to 2012.The search resulted in 886 articles, out of which were used 34 relevant clinical studies that answered to the questions made by the authors.Recent articles and those with higher level of evidence were prioritized, since they expose applications that are more coherent with the current practice.
In order to facilitate clinical applicability, the results are followed by a level of evidence (LE) graded from 1 to 5 and a degree of recommendation (DR) ranging from A to D, as described in Table 1.This classification was previously used by the Brazilian Committee of Endometriosis studies 11 .

RESULTS AND DISCUSSION
The list of all the articles used, level of evidence and degree of recommendation are presented in Table 2.

Is the pelvic floor training efficient in the treatment of POP?
Slieker-ten-Hove et al. 7 analyzed the relationship between the muscular function of PF and POP and observed there are no significant differences in muscle strength and resistance during voluntary muscle contraction between the stages of POP.However, with cough, the involuntary contraction that results in the stabilization of the PF was significantly weaker in women with stage I and II POP than in women without POP.This study shows that women with POP present with less resistant PA muscles and less motor control 7 (NE 4 GR C).Braekken et al. 12 investigated the efficacy of PFME to revert POP and its symptoms.Women with stage I, II and III prolapsed were divided into experimental and control groups.Both groups were enlightened as to changes of lifestyle and learned to perform the PF contraction.The experimental group also performed PFME composed of individual physical therapy sessions and exercises at home.Compared to control, the PFME group obtained bladder (3.0 mm) and rectum (5.5 mm) elevation and reduction of weight symptoms and vaginal vault.The conclusion was that PFME can be used as a treatment for POP 12 (LE 1; DR A).
In another study, functional and morphologic changes in PFME were assessed with ultrasound.The conclusion was that the supervised PFME increased muscle volume, reduced the hiatus in the levator ani muscle and elevated the resting position of the rectum and bladder 13 (LE 1; DR 1).
A pilot randomized study investigated the efficacy of PFME for the treatment of stage II POP.After 14 weeks, the intervention group showed significant improvement in relation to control group and also the decrease of symptoms.Besides, it presented with increased strength and muscular resistance and better electromyography parameters than the control group 14 (LE 2; DR B).
A Cochrane review published in 2011 concluded that there is currently evidence that the PFME has a positive effect on the symptoms and the severity of the prolapse.The performance of six months of treatment supervised by a physical therapist showed benefits in anatomical terms and improvement of symptoms.However, scientific evidence is still required in relation to the efficacy and the cost-benefit of PFME for the symptomatic prolapsed in the medium and long term 15 (LE 1; DR A).

Does physical therapy, which is used as an adjuvant method, help the treatment of the prolapse?
The idea to indicate adjuvant physical therapy is based on the fact that surgeries for prolapse or UI do not heal the pelvic muscle dysfunction that may have caused the disorder.Besides, conservative treatment could reduce residual symptoms or the ones that would appear after surgery.
Frawley et al. 16 performed a randomized study comparing patients who did PFME before and after surgery to correct prolapse or hysterectomy and women who only underwent surgery.No differences were found between groups as to bladder and prolapse symptoms assessed by questionnaires of QOL 16 (EL 1; DR A).
Lakeman et al. 17 , in a review study, assessed if PFME in the pre-surgical period of POP improves the symptoms after surgery, also preventing recurrence.They concluded that PFME can reduce PF symptoms and improve QOL after surgery for POP, even though evidence is insufficient for its frequent indication in clinical practice 17 (LE 1; DR A).Jarvis et al. 18 also concluded that the performance of physical therapy before and after gynecological surgery is limited, and there is the need to conduct more randomized studies 18 (LE 1; DR A).

Is the pelvic floor training in urinary incontinence more efficient when conducted individually or in groups?
The individual exercise aims to a rehabilitation that specifically depends on the muscular condition of each patient.For the individual rehabilitation, the perfect method of evaluation has proven to be reliable and replicable.This method assesses strength and resistance, allowing a more specific conduct 19 .With the individual training, the length of each session and the time of treatment are smaller.However, in the group treatment there is the reinforcement of motivation among the participants 20 (LE 3; DR B).
Oliveira Camargo et al. 21compared these two treatment techniques in women with stress UI and observed that, after 12 weeks, both groups obtained significant reductions of UI and improved QOL, without significant differences 21 (LE 1; DR A).
Is the pelvic floor training in urinary incontinence more efficient when supervised or unsupervised?Zanetti et al. 22 assessed the effect of PF exercise in women with stress UI in two groups, with and without supervision, for three consecutive months.They observed that the supervised group presented statistically better results in the volume of urinary loss and in QOL than the control group.In the subjective evaluation, only 23.8% of the patients in the control group were satisfied with the treatment, while in the supervised group, 66.8% of them were satisfied 22 (LE 1; DR A).However, another study observed that after the treatment with PFME there were no differences between the two groups, and the conclusion was that the supervised PFME is not efficient to treat for stress UI if the patient in the control group is trained correctly to perform PF contraction.According to the authors, this detailed instruction before the randomization made a difference in the final result between the two groups 10 (LE 1; DR A).
According to a Cochrane review, the effect of the treatment seems to be greater on women with stress UI who participate in a supervised PFME program for at least three months 23 (LE 1; DR A) and PFME should be included as a first line conservative treatment for stress, urge and mixed UI 23,24 (LE 1; DR A).
Tsai e Liu 25 analyzed if professional follow-up and digital palpation as part of the PFME (experimental group), with 99 women, is more efficient for stress UI than PFME performed by means of instructions in a book (control group).The conclusion was that the experimental group obtained significant decrease in the pad test (p<0.001) in comparison to the control group (p=0.514), and that the PFME performed correctly is more efficient even for patients with mild symptoms of stress UI 25 (LE 3; DR B).

Which training parameters should be used in the pelvic floor rehabilitation?
There is no consensus in data from literature about the number of repetitions, time of contractions or frequency and length of PF treatment with PFME 21 (LE 1; DR A).The number of contractions reported in the studies ranges from 8 to 12, 3 times a day, to 20 contractions, 4 times a day, and the length of contraction ranges from 4 to 40 seconds 23 (LE 1; DR A).This happens because of the anatomic and functional differences of each women 22 , besides the fact that 30% of women are unable to properly contract the PF muscles 6 .That is why it is important that an expert professional be present to conduct the PFME 22 (LE 3; DR B).The postures and the length of the treatment with PFME also range and include sitting down, kneeling, standing up, and may last from one week to six months.The three-month length was the most frequently used 24 (LE 1; DR A).
How are the pelvic floor muscle rehabilitation and the Paula Method results performed?
Another conservative treatment, considered as alternative, called the Paula Method (because of its creator, Paula Garbourg), is based on the theory that all sphincters of the body work together and may affect each other.According to this theory, if there is weakness in the levator ani, resulting in stress UI, this muscle dysfunction can be improved by circular muscle training, such as the eyes, nose and mouth 26,27 (LE 1; DR A / LE 4; DR C).
Liebergall-Wischnitzer et al. 26 performed circular exercises (Paula Method) or PFME to treat women with stress UI.It was observed that both methods are efficient and suggest the superiority of the Paula Method in relation to healing rates 26 (LE 1; DR A).
On the other hand, some authors recommend that the contraction of the circular muscle is a way to help the patients who cannot isolate or contract the PFM, and not a way to strengthen them specifically 28 .Resende et al. 27 observed there was no differences in the electrical activity of PFM during the contraction of the circular muscles, isolated or associated with the PFM contraction 27 (LE 4; DR C).More studies comparing PFME and the Paula Method are required, with similar quantities of exercises, repetitions and periods of treatment.
Which other resources are used by physical therapy to rehabilitate the pelvic floor muscles?
The biofeedback uses a device to show the biological signals during the voluntary contraction of PFM, and presents this information back to the women in auditory and/or visual form, thus enabling the awareness and the proper contraction of PFM.A systematic review concluded that the biofeedback associated with PFME provided greater benefits than the isolated PFME in women with UI 29 (LE 1; DR A).
The electrotherapy to reeducate the PFM is a result of the passive contraction of levator ani muscles 24 (LE 1; DR A).The electrical stimulation is believed to increase the intraurethral pressure by means of a direct action of the efferent nerves to the periurethral muscles, to increase the blood flow to the PFM, to reestablish the neuromuscular connections and to improve the muscle fiber function 30

(LE 3; DR B).
Vaginal cones also represent a way to identify and train the PFM.A systematic review reported there is limited evidence proving that vaginal cones are better than no active treatment for UI, and that they may be as effective as PFME and electrical stimulation.This review concluded that the cones should be offered as a treatment option, since the women who will not accept its use will know there are other available treatments 31 (LE 1; DR A).
Santos et al. 32 performed a clinical randomized study to compare the effects of electrical stimulation and vaginal cones in women with stress UI, and the conclusion was that both treatments were effective 32 (LE 1; DR A).
Bø, Talseth e Holme 33 performed a randomized study comparing PFME, electrical stimulation and vaginal cones in women with stress UI.The control group was composed of women who had not undergone any treatment.The conclusion was that PFME was more efficient to treat for stress UI 33 (LE 1; DR A).However, in another study with the same objectives, there was significant improvement of UI in the groups that used PFME, electrical stimulation and vaginal cones in comparison to the control group 34 (LE 1; DR A).This difference in results can be due to the way both studies performed the intervention.In the study by Castro et al. 34 , a physical therapist supervised the treatment at home while in the study by Bø, Talseth and Holme 33 , participants were treated at home.These data reinforce the importance of having a specialized professional for the treatment of PFM dysfunctions 33,34 (LE 1; DR A/LE 1; DR A).

CONCLUSION
Even though there are other methods of treatment, the PFME should still be the first conservative treatment choice for women with UI and POP, since it is a safe, efficient and low-cost method.PFME should be offered with specialized supervision and last at least for three months.Biofeedback, electrical stimulation and vaginal cones should be offered to the patients who cannot properly contract the PFM.

Table 1 .
Level of evidence and degree of recommendation

Table 2 .
List of articles, level of evidence and degree of recommendation 13P: pelvic organ prolapse; PF: pelvic floor; PFME: pelvic floor muscle exercise; QOL: quality of life; PFM: pelvic floor muscles.132010After supervised PFME, there were functional and morphological changes of the PF, such as the increased muscle volume 1 A Stupp et al. 14 2011 PFME group presented decreased POP symptoms, increased PF strength and resistance, better than control 2 B Hagen e Stark 15 2011 PFME has a positive effect on the symptoms and severity of the prolapse 1 A Frawley et al. 16 2010 There was no difference in the group that performed PFME before and after surgery in relation to vesical and prolapse symptoms 1 A Lakeman et al. 17 2012 They concluded that PFME before POP surgery can reduce the PV symptoms and improve QOL after the POP surgery 34 2008 There was significant improvement of UI in the groups that underwent PFME, electrical stimulation and vaginal cones in relation to the control group 1 A