Radical Prostatectomy:
Duloxetine - medication that increases the tone of the IUS
Yu K, Bu F, Jian T, Liu Z, Hu R, Chen S, Lu J. Urinary incontinence rehabilitation of after radical prostatectomy: a systematic review and network meta-analysis. Front Oncol. 2024 Mar 22;13:1307434. doi: 10.3389/fonc.2023.1307434. PMID: 38584666; PMCID: PMC10996052.
"Modern studies have documented that pelvic floor muscle training after radical prostate cancer surgery can improve incontinence"
"During the course of treatment, biofeedback with professional therapist-guided treatment may have significant therapeutic effects in the short term after surgery, but, in the long term, the combination of multiple treatments (pelvic floor muscle training+ routine care + biofeedback + professional therapist-guided treatment + electrical nerve stimulation therapy) may address cases of urinary incontinence that remain unrecovered long after surgery."
Leao Ribeiro I, Lorca LA, Peviani Messa S, Berríos Contreras L, Valdivia Valdés FJ, Roteli Oyarzún VD, Rojas Soto CA. Efectividad del entrenamiento muscular pélvico temprano en la fuerza de suelo pélvico, síntomas de incontinencia urinaria, función sexual y calidad de vida en pacientes posprostatectomía radical: revisión sistemática de ensayos clínicos aleatorizados [Effectiveness of early pelvic muscle training on pelvic floor strength, urinary incontinence symptoms, sexual function, and quality of life in post-radical prostatectomy patients: Systematic review of randomized clinical trials]. Rehabilitacion (Madr). 2024 Apr-Jun;58(2):100828. Spanish. doi: 10.1016/j.rh.2023.100828. Epub 2023 Dec 22. PMID: 38141425.
"This study aimed to evaluate the effectiveness of early pelvic muscle training in reducing urinary incontinence symptoms, improving quality of life, sexual function, and increasing pelvic floor strength in post-radical prostatectomy patients . . . The intervention significantly reduced urinary incontinence symptoms compared to a control group (SMD=-2.80, 95% CI=-5.21 to -0.39, P=.02), with significant heterogeneity (I2=83%; P=<.0001) and moderate evidence."
Canning A, Raison N, Aydin A, Cheikh Youssef S, Khan S, Dasgupta P, Ahmed K. A systematic review of treatment options for post-prostatectomy incontinence. World J Urol. 2022 Nov;40(11):2617-2626. doi: 10.1007/s00345-022-04146-5. Epub 2022 Sep 15. PMID: 36107210; PMCID: PMC9617828.
"Post-operatively, the European Association of Urology (EAU) and American Urological Association (AUA) guidelines both recommend Pelvic Floor Muscle Therapy (PFMT) as the first-line for post-prostatectomy incontinence (PPI) with a view of surgical treatments if PFMT fails."
"Four studies (Rajkowska-Labon [21], Gomes [16], Goode [17] and Manassero [19]) with 487 patients showed significant improvements to continence in groups that underwent some form of PFMT."
"Whole-Body vibration Tantawy [13] showed effective results in decreasing mean 24 h pad test weights by 23.1 g more in the group that received whole body vibration (P<0.001). It is believed to function by strengthening muscles involved in continence [32]."
Steenstrup B, Cartier M, Nouhaud FX, Kerdelhue G, Gilliaux M. A systematic review of supervised comprehensive functional physiotherapy after radical prostatectomy. Prog Urol. 2022 Jul;32(7):525-539. doi: 10.1016/j.purol.2022.04.008. Epub 2022 Jun 5. PMID: 35676190.
":Radical prostatectomy (RP) can generate multidimensional physiological changes, like decrease in physical and emotional functioning, as well as Health Related Quality of Life (HRQoL). However, only pelvic floor muscle training (PFMT) is commonly recommended as conservative treatment after RP. More comprehensive interventions than only PFMT, such as physiotherapy promoting general coordination, flexibility, strength, endurance, fitness and functional capacity may seem more relevant and patient-centered.
Aim of the review: Our aim was to evaluate whether a more Comprehensive Functional Physical Therapy (CFPT) than PFMT alone, focused on lower limb and lumbo-pelvic exercises, would improve physical capacities and functions (including urinary continence (UI)), emotional functions and HRQoL in patients after RP."
"Current literature indicates that CFPT was shown to be safe, non-invasive, and particularly effective in terms of UI recovery. CFPT could result in more positive outcomes, including physical capacities, physical and emotional functioning and HRQoL, than PFMT alone."
Prostate Surgery
Zhang Y, Hou S, Qi Z, Wu S, Zhu K, Wang W. Non-pharmacological and nonsurgical interventions in male urinary incontinence: A scoping review. J Clin Nurs. 2023 Sep;32(17-18):6196-6211. doi: 10.1111/jocn.16749. Epub 2023 May 9. PMID: 37161602.
"The findings suggested implementing pelvic floor muscle training alone before or after surgery can both prompt the recovery of continence in men after prostate cancer surgery. "
Male UI
Mazur-Bialy A, Tim S, Kołomańska-Bogucka D, Burzyński B, Jurys T, Pławiak N. Physiotherapy as an Effective Method to Support the Treatment of Male Urinary Incontinence: A Systematic Review. J Clin Med. 2023 Mar 27;12(7):2536. doi: 10.3390/jcm12072536. PMID: 37048619; PMCID: PMC10095040.
"The research showed that the available physiotherapeutic methods for treating men with UI, including those after prostatectomy, involve pelvic floor muscle training (PFMT) alone or in combination with biofeedback (BF) and/or electrostimulation (ES), vibrations, and traditional activity. In conclusion, PFMT is the gold standard of UI therapy, but it may be complemented by other techniques to provide a personalized treatment plan for patients."
Needling with Estim:
Bilgiç FŞ, Gençtürk N, Arikan B. The effect of electroacupuncture applied to women with stress urinary incontinence on urinary incontinence severity and symptoms: Systematic review and meta-analysis of randomized controlled trials. Actas Urol Esp (Engl Ed). 2024 Mar 29:S2173-5786(24)00027-1. English, Spanish. doi: 10.1016/j.acuroe.2024.03.002. Epub ahead of print. PMID: 38556127.
Effect of Electroacupuncture Added to Pelvic Floor Muscle Training in Women with Stress Urinary Incontinence: A Randomized Clinical Trial
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Kangmin Tanga, Tongsheng Sub, Lixin Fuc, Zhaoming Chend, Guiming Liue, Wenguang Houf, Shuren Mingf, Qinqin Songb, Shanshan Fengc, Xiaoman Liud, Ruiping Wangf, Baoyan Liug, Yuelai Chenh
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SUI:
Rodríguez-Longobardo C, López-Torres O, Guadalupe-Grau A, Gómez-Ruano MÁ. Pelvic Floor Muscle Training Interventions in Female Athletes: A Systematic Review and Meta-analysis. Sports Health. 2023 Sep 9:19417381231195305. doi: 10.1177/19417381231195305. Epub ahead of print. PMID: 37688407.
"PFMT is shown to be effective in increasing PFM strength and reducing urine leakage in female athletes, being a powerful tool to prevent and treat pelvic floor dysfunction in this population."
Mantilla Toloza SC, Villareal Cogollo AF, Peña García KM. Pelvic floor training to prevent stress urinary incontinence: A systematic review. Actas Urol Esp (Engl Ed). 2024 Mar 29:S2173-5786(24)00023-4. English, Spanish. doi: 10.1016/j.acuroe.2024.01.007. Epub ahead of print. PMID: 38556125.
"Stress urinary incontinence (SUI) is a common disorder in women that has a negative impact on quality of life. Pregnancy and childbirth are considered important risk factors that directly affect the pelvic floor during pregnancy and labour, increasing the risk of pelvic floor dysfunction, with prevalence rates of SUI in the postpartum period ranging from 30 to 47% during the first 12 months."
"The application of PFMT in an early stage of pregnancy has positive effects on the continence capacity after delivery."
Woodley SJ, Lawrenson P, Boyle R, Cody JD, Mørkved S, Kernohan A, Hay-Smith EJC. Pelvic floor muscle training for preventing and treating urinary and faecal incontinence in antenatal and postnatal women. Cochrane Database Syst Rev. 2020 May 6;5(5):CD007471. doi: 10.1002/14651858.CD007471.pub4. PMID: 32378735; PMCID: PMC7203602.
"This review provides evidence that early, structured PFMT in early pregnancy for continent women may prevent the onset of UI in late pregnancy and postpartum."
Zhang D, Bo K, Montejo R, Sánchez-Polán M, Silva-José C, Palacio M, Barakat R. Influence of pelvic floor muscle training alone or as part of a general physical activity program during pregnancy on urinary incontinence, episiotomy and third- or fourth-degree perineal tear: Systematic review and meta-analysis of randomized clinical trials. Acta Obstet Gynecol Scand. 2023 Dec 23. doi: 10.1111/aogs.14744. Epub ahead of print. PMID: 38140841.
"PFMT during pregnancy proves to be an effective preventive intervention for reducing the risk of urinary incontinence and the occurrence of third- or fourth-degree perineal tears. These findings highlight the importance of incorporating PFMT into antenatal care and training programs to improve maternal well-being and overall childbirth outcomes."
Wang Y, Zhang S, Peng P, He W, Zhang H, Xu H, Liu H. The effect of myofascial therapy on postpartum rectus abdominis separation, low back and leg pain, pelvic floor dysfunction: A systematic review and meta-analysis. Medicine (Baltimore). 2023 Nov 3;102(44):e35761. doi: 10.1097/MD.0000000000035761. PMID: 37932976; PMCID: PMC10627697.
"The results suggested that myofascial therapy could effectively reduce rectus abdominis separation, relieve pelvic floor muscle dysfunction, enhance lumbar function, relieve pain, and improve the ability of daily living activities. All the data demonstrated that myofascial therapy had a good therapeutic effect on postpartum dysfunction."
Introduction
A number of postpartum disorders, such as rectus abdominis separation, abdominal circumference enlargement, pelvic leaning forward, lumbago, sacroiliac joint disorders, sacral pain, pelvic floor muscles weakness, urinary incontinence, pelvic organ prolapse, etc, are brought on by pregnancy, childbirth, and lack of rest after delivery. These conditions cannot be recovered naturally after delivery. Over time, women's physical and mental health suffers due to impacts on significant muscle weakness, pain, which severely limited daily life abilities.
The main causes of these injuries are disturbance of the myofascial system caused by weight and hormonal changes. During pregnancy, the center of the body leans forward to balance the increase in the weight of the abdomen, coupling with the pelvis leaning forward, the pubococcygeal bone leaning backward, and the center of gravity of the body moving backward. This causes an excessive increase in the curvature of the lumbar spine, as well as an increase in the physiological curvature of the cervical and thoracic vertebrae. The body also produces forward tension as a result of increasing mammary gland bulk, shoulder blades and glenohumeral joints migrate inward toward the chest, and kyphosis or other aberrant postures develop. Further lordosis occurs in the lower abdomen as a result of the spine adjusting to reduce pressure on the lower abdomen.[1,2] Long-term bad posture exacerbates biomechanical problems, including skeletal displacement to accommodate for upright walking, continual tension in the cervical, thoracic, lumbar, and abdominal muscles, and a restricted range of motion in the flexion, extension, and lateral flexion of the thoracolumbar region. On the other hand, during pregnancy, the increased progesterone destroyed the pelvic floor's collagen fibers, resulting in decreased muscle strength for loss of protection of pelvic floor muscles and pelvic floor muscles elongated excessively.[3] During pregnancy, the secretion of relaxin is also increased to aid in labor. Relaxin can weaken the pelvic floor support tissue by degrading collagen,[1] which causes laxity in the ligaments surrounding the pubic symphysis and the sacroiliac joint, increases the spacing between the pubic symphysis. Laxity in the lumbar and abdominal muscles worsens pelvic pressure and puts additional strain on the pelvic floor muscles.[4] Birth injuries, disturbance of core stabilizing mechanisms, insufficient abdominal pressure, and scarring are all possible during labor in both vaginal and cesarean deliveries.[5] If there is insufficient rest after childbirth and excessive physical activity earlier, the body's structure and function will be further harmed, leading to postpartum strain. The myofascial system may become over drafted as a result of these injuries. Therefore, myofascial system abnormalities can occur before, during, or after pregnancy. It will eventually cause rectus abdominis separation, dysfunction of the pelvic floor muscles, injuries to the lumbosacral and sacroiliac joints and ligaments, and injuries to the abdominal, lumbosacral, and sacroiliac muscles. Once injury occurs during the postpartum period, it is challenging on self-healing.
Myofascial chain is a tensile, integrated structure that includes ligaments, myofascial membrane, and is supported by bone. Through the chain network, each component works together to ensure the stability of the body's structure and functionality. As an uninterrupted connective tissue, fascia has the characteristics of continuity, integrity, conduction and so on, and has the function of affecting the whole body. There is synergy between muscles and fascia to form larger interconnected anatomical chains.[6] According to the myofascial chain theory, the myofascial membrane serves as the body's conduction and support system for tension, and the functional state of the local myofascial membrane directly affects the overall myofascial chain.[7] Therefore, once the local function is abnormal, the function of the corresponding remote part will be affected along the direction of stress conduction. In order to maintain overall balance, the other tissues of the body compensate for the tension deficit in the damaged tissue, further exacerbating the dysfunction of the entire fascial chain. It will help in the treatment of dysfunction by releasing or activating local fascia, inactivating myofascial pain triggers to relieve fatigue and pain in the body, and remodeling myofascial tension. Currently, the commonly used fascia therapy methods include myofascial manipulation,[8] myofascial pain point therapy,[9] extracorporeal shock wave therapy,[10] massage manipulation,[11] acupoint application,[11] myofascial CC point,[12] visceral myofascial manipulation,[13] acupuncture,[14] shockwave therapy,[15] etc.
At present, some studies have shown that myofascial therapy was effective in musculoskeletal diseases, but there was still a lack of effective on the effect of common problems in postpartum women. The purpose of this study was to integrate the results of relevant studies and conduct a meta-analysis to clarify the influence of myofascial therapy on postpartum rectus separation, lumbago and pelvic floor muscle dysfunction, so as to provide a basis for clinical treatment."
Conclusion
In summary, myofascial therapy could reduce abdominal circumference, relieve the pain of lumbar and pelvic floor muscle fascia, improve the contractile strength of pelvic floor muscle, improve the ability of daily living activities, and play a positive role in improving postpartum health, maintaining husband and wife life, and improving the relationship between husband and wife. It is worth applying in clinic."
Curillo-Aguirre CA, Gea-Izquierdo E. Effectiveness of Pelvic Floor Muscle Training on Quality of Life in Women with Urinary Incontinence: A Systematic Review and Meta-Analysis. Medicina (Kaunas). 2023 May 23;59(6):1004. doi: 10.3390/medicina59061004. PMID: 37374208; PMCID: PMC10301414.
"UI affects both sexes. However, women are more affected than men [2]. The prevalence of UI worldwide is estimated to be around 17% to 30% in women older than 20 years and 38% to 50% in women older than 60 years [3,4]."
"Defining the underlying cause of UI is essential to guide an appropriate treatment. Multiple techniques are available for the treatment of UI, and these should be adjusted based on the patient rather than the type of incontinence."
"The conservative approach is considered the first choice of treatment due to its accessibility, cost-effectiveness, and limited risks and side effects compared to more invasive treatments. Conservative management consists of lifestyle changes and exercises that strengthen the PFM. The most effective treatment is the PFMT paired with lifestyle changes such as adequate fluid intake, scheduled urination, decreased carbonated and caffeinated beverage intake, smoking cessation, moderate physical activity, avoiding tight clothing, and weight loss if necessary [20]."
"A systematic review found that, in SUI, 58.8% of patients achieved a significant improvement after 12 months of supervised PFMT, reached a 17% improvement after 12 months in UUI, and, in MUI, 28% of patients had improved symptoms and QoL after 6 months [23]."
"In this systematic review and meta-analysis, ten studies were used; they showed the data of 1648 women from nine different countries from 2018 to 2022. We found that the incidence of UI has been increasing over the years and that there has also been a statistically significant increase in the QoL when pelvic floor muscle exercises have been used to treat UI women."
"Considering the various protocols and training regimens aimed at strengthening the pelvic floor muscles, we identified that, for the most part, a 12-week regimen is an adequate therapy duration."
" The NICE guidelines for UI recommend supervised pelvic floor muscle training for at least 3 months (12 weeks)."
sexual function "In a meta-analysis, Hadizadeh-Talasaz et al. [45] sought to identify the effect of pelvic floor exercise on female sexual function and quality of life in the postpartum period, where they found that pelvic floor muscle training in primi- or multi-parous women can boost sexual function and quality of life in postpartum women."
"Based on the obtained data, we can be certain that PFMT can improve the symptoms of SUI and other types of UI and reduce the number of involuntary leakages and symptoms in UI-specific symptom questionnaires. In addition, the review findings suggest that PFMT could be included in first-line conservative treatment programs for women with UI."
Huang H, Han X, Liu Q, Xue J, Yu Z, Miao S. Associations between metabolic syndrome and female stress urinary incontinence: a meta-analysis. Int Urogynecol J. 2022 Aug;33(8):2073-2079. doi: 10.1007/s00192-021-05025-0. Epub 2022 Feb 5. PMID: 35122481.
"Metabolic syndrome is associated with SUI in women and increases its risk."
Incontinence
Todhunter-Brown A, Hazelton C, Campbell P, Elders A, Hagen S, McClurg D. Conservative interventions for treating urinary incontinence in women: an Overview of Cochrane systematic reviews. Cochrane Database Syst Rev. 2022 Sep 2;9(9):CD012337. doi: 10.1002/14651858.CD012337.pub2. PMID: 36053030; PMCID: PMC9437962.
"PFMT with more individual health professional supervision was more effective than less contact/supervision and more-intensive PFMT was more beneficial than less-intensive PFMT."
"There is high certainty that PFMT is more beneficial than control for all types of UI for outcomes of cure or improvement and quality of life. We are moderately certain that, if PFMT is more intense, more frequent, with individual supervision, with/without combined with behavioural interventions with/without an adherence strategy, effectiveness is improved."
Core Stabilization and UI
Yu CY, Yu TY, Chen YW, Lin LF, Peng CW, Chen HC. Core Stabilization Exercise in Prenatal and Postnatal Women With Urinary Incontinence: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Am J Phys Med Rehabil. 2023 Nov 1;102(11):990-999. doi: 10.1097/PHM.0000000000002260. Epub 2023 Apr 16. PMID: 37104619.
"Core stabilization exercises are safe and beneficial for alleviating urinary symptoms, improving quality of life, strengthening pelvic floor muscles, and improving transverse muscle function in prenatal and postnatal women with urinary incontinence."
Overactive Bladder
Funada S, Yoshioka T, Luo Y, Sato A, Akamatsu S, Watanabe N. Bladder training for treating overactive bladder in adults. Cochrane Database Syst Rev. 2023 Oct 9;10(10):CD013571. doi: 10.1002/14651858.CD013571.pub2. PMID: 37811598; PMCID: PMC10561149.
"bladder training may cure or improve OAB compared to no treatment. Bladder training may be more effective to cure or improve OAB than anticholinergics, and there may be fewer adverse events."
Zhang Q, Zhang Z, He X, Liu Z, Shen L, Long C, Wei G, Liu X, Guo C. Vitamin D levels and the risk of overactive bladder: a systematic review and meta-analysis. Nutr Rev. 2024 Jan 10;82(2):166-175. doi: 10.1093/nutrit/nuad049. PMID: 37195440.
"Vitamin D deficiency increases the risk of overactive bladder and urinary incontinence, and vitamin D supplementation reduces the risk of urinary incontinence. The development of new strategies to prevent or alleviate bladder symptoms is crucial. Vitamin D supplementation may be gaining recognition as an effective strategy for prevention or alleviation of bladder symptoms such as overactive bladder and incontinence."
Park J, Lee H, Kim Y, Norton C, Woodward S, Lee S. Effectiveness of Fluid and Caffeine Modifications on Symptoms in Adults With Overactive Bladder: A Systematic Review. Int Neurourol J. 2023 Mar;27(1):23-35. doi: 10.5213/inj.2346014.007. Epub 2023 Mar 31. PMID: 37015722; PMCID: PMC10073005.
"Although there were limited studies, our review provides scientific evidence that fluid and caffeine intake modification effectively manages OAB symptoms."
Tibial nerve Stimulation
Alomari MS, Abdulhamid AS, Ghaddaf AA, Alshareef KM, Haneef AK, AlQuhaibi MS, Banjar RA. Non-inferior and more feasible transcutaneous tibial nerve stimulation in treating overactive bladder: A systematic review and meta-analysis. Int J Urol. 2022 Oct;29(10):1170-1180. doi: 10.1111/iju.14961. Epub 2022 Jun 16. PMID: 35711082.
"The current meta-analysis reveals that there is no statistically significant difference between TTNS versus PTNS or anticholinergic drugs for the nonsurgical management of OAB patients."
Zomkowski K, Kammers I, Back BBH, Moreira GM, Sonza A, Sacomori C, Sperandio FF. The effectiveness of different electrical nerve stimulation protocols for treating adults with non-neurogenic overactive bladder: a systematic review and meta-analysis. Int Urogynecol J. 2022 May;33(5):1045-1058. doi: 10.1007/s00192-022-05088-7. Epub 2022 Feb 4. PMID: 35119495.
"Nine randomized controlled trials were included. Tibial neurostimulation showed better results than sacral neurostimulation for urge incontinence (mean difference = 1.25 episodes, 95% CI, 0.12-2.38, n = 73). On the pooled analysis, the different neurostimulation protocols-intravaginal, percutaneous tibial, and transcutaneous tibial nerve stimulation-demonstrated similar results for urinary frequency, nocturia, and urgency as well as quality of life. In general, effect sizes from meta-analyses were low to moderate. The best reported parameters for percutaneous tibial nerve stimulation were 20-Hz frequency and 200-μs width, once a week."
Supervised versus unsupervised PFM training
Kharaji G, ShahAli S, Ebrahimi-Takamjani I, Sarrafzadeh J, Sanaei F, Shanbehzadeh S. Supervised versus unsupervised pelvic floor muscle training in the treatment of women with urinary incontinence - a systematic review and meta-analysis. Int Urogynecol J. 2023 Jul;34(7):1339-1349. doi: 10.1007/s00192-023-05489-2. Epub 2023 Feb 22. PMID: 36811635; PMCID: PMC9944784.
"However, supervised and unsupervised PFMT with thorough education and regular reassessment showed better results than those for unsupervised PFMT without educating patients about correct PFM contractions."
Perineal Massage:
Milka W, Paradowska W, Kołomańska-Bogucka D, Mazur-Bialy AI. Antenatal perineal massage - risk of perineal injuries, pain, urinary incontinence and dyspereunia - a systematic review. J Gynecol Obstet Hum Reprod. 2023 Oct;52(8):102627. doi: 10.1016/j.jogoh.2023.102627. Epub 2023 Jul 4. PMID: 37414371.
"APM can protects the perineum from injuries during labor. It also reduces risk of fecal and gas incontinence in postpartum period."
"APM relaxes the pelvic floor muscles (PFM) and improves blood flow. So as the APM can prepare tissues to labor, women who did it during pregnancy may have less perineal injuries, e.g. episiotomies [25]. It also reduces persistent perineal pain [25], leads to shortening second phase of labor, improve tissue regenerationand parameters of the newborn on APGAR scale [26]. If long-term consequences of delivery are considered, APM can minimize postpartum complications such as anal incontinence and can help in better wound healing also [26]."
Pushing Technique for DeliveryShinozaki K, Suto M, Ota E, Eto H, Horiuchi S. Postpartum urinary incontinence and birth outcomes as a result of the pushing technique: a systematic review and meta-analysis. Int Urogynecol J. 2022 Jun;33(6):1435-1449. doi: 10.1007/s00192-021-05058-5. Epub 2022 Feb 1. PMID: 35103823; PMCID: PMC9206626.
Prenatal/Postpartum
Hroncová Michaela. Pelvic pain in women after childbirth and physiotherapy. Ceska Gynekol. 2023;88(3):214-220. English. doi: 10.48095/cccg2023214. PMID: 37344188.
"Based on the analysis of the above studies, it can be concluded that a comprehensive physiotherapy designed for postpartum women that includes manual techniques, behavioral techniques, relaxation of hypo-tonic and shortened muscles and strengthening of hypotonic muscles can positively affect a wide range of pain and associated dysfunctions of the pelvic floor and trunk muscles."
Menopause
Christmas MM, Iyer S, Daisy C, Maristany S, Letko J, Hickey M. Menopause hormone therapy and urinary symptoms: a systematic review. Menopause. 2023 Jun 1;30(6):672-685. doi: 10.1097/GME.0000000000002187. Epub 2023 May 16. PMID: 37192832.
"Vaginal estrogen improves urinary symptoms and decreases the risk of recurrent UTI in postmenopausal women."
López-Pérez MP, Afanador-Restrepo DF, Rivas-Campo Y, Hita-Contreras F, Carcelén-Fraile MDC, Castellote-Caballero Y, Rodríguez-López C, Aibar-Almazán A. Pelvic Floor Muscle Exercises as a Treatment for Urinary Incontinence in Postmenopausal Women: A Systematic Review of Randomized Controlled Trials. Healthcare (Basel). 2023 Jan 11;11(2):216. doi: 10.3390/healthcare11020216. PMID: 36673584; PMCID: PMC9859482.
"PFM exercise is a highly recommended intervention to treat urinary incontinence in postmenopausal women."
Pessaries
Dabic S, Sze C, Sansone S, Chughtai B. Rare complications of pessary use: A systematic review of case reports. BJUI Compass. 2022 Jul 5;3(6):415-423. doi: 10.1002/bco2.174. PMID: 36267197; PMCID: PMC9579882.
"Pessaries are a reasonable and durable treatment for POP with exceedingly rare reports of severe adverse complications."
Klein J, Stoddard M, Rardin C, Menefee S, Sedrakyan A, Sansone S, Chughtai B. The Role of Pessaries in the Treatment of Women With Stress Urinary Incontinence: A Systematic Review and Meta-Analysis. Female Pelvic Med Reconstr Surg. 2022 Jun 1;28(6):e171-e178. doi: 10.1097/SPV.0000000000001180. Epub 2022 Apr 5. PMID: 35420550.
"Based on both subjective and objective measures, pessaries are an effective conservative treatment option for SUI."
Manzini C, Morsinkhof LM, van der Vaart CH, Withagen MIJ, Grob ATM. Parameters associated with unsuccessful pessary fitting for pelvic organ prolapse up to three months follow-up: a systematic review and meta-analysis. Int Urogynecol J. 2022 Jul;33(7):1719-1763. doi: 10.1007/s00192-021-05015-2. Epub 2022 Jan 17. PMID: 35037973; PMCID: PMC9270314.
"Twenty-four studies were included in the meta-analysis. Parameters associated with unsuccessful pessary fitting were: age (OR 0.70, 95% CI 0.56-0.86); BMI (OR 1.35, 95% CI 1.08-1.70); menopause (OR 0.65 95% CI 0.47-0.88); de novo stress urinary incontinence (OR 5.59, 95% CI 2.24-13.99); prior surgery, i.e. hysterectomy (OR 1.88, 95% CI 1.48-2.40), POP surgery (OR 2.13, 95% CI 1.34-3.38), pelvic surgery (OR 1.81, 05% CI 1.01-3.26) and incontinence surgery (OR 1.87, 95% CI 1.08-3.25); Colorectal-Anal Distress Inventory-8 scores (OR 1.92, 95% CI 1.22-3.02); solitary predominant posterior compartment POP (OR 1.59, 95% CI 1.08-2.35); total vaginal length (OR 0.56, 95% CI 0.32-0.97); wide introitus (OR 4.85, 95% CI 1.60-14.68); levator ani avulsion (OR 2.47, 95% CI 1.35-4.53) and hiatal area on maximum Valsalva (OR 1.89, 95% CI 1.27-2.80)."
SUI and female athletes
Fukuda FS, Arbieto ERM, Da Roza T, Luz SCTD. Pelvic Floor Muscle Training In Women Practicing High-impact Sports: A Systematic Review. Int J Sports Med. 2023 Jun;44(6):397-405. doi: 10.1055/a-1939-4798. Epub 2022 Sep 8. PMID: 36075371.
"Three RCTs and two non-RCTs (104 participants) were analyzed. PFMT provided a significant improvement in UI symptoms with a reduction in the frequency (n=3) and the amount of UI (n=5)."
Dominguez-Antuña E, Diz JC, Suárez-Iglesias D, Ayán C. Prevalence of urinary incontinence in female CrossFit athletes: a systematic review with meta-analysis. Int Urogynecol J. 2023 Mar;34(3):621-634. doi: 10.1007/s00192-022-05244-z. Epub 2022 May 30. PMID: 35635565; PMCID: PMC9150382.
"A total of 4,823 women aged 18 to 71 were included, 91.0% participated in CrossFit, and 1,637 presented UI, which indicates a prevalence of 44.5%. Also, 55.3% and 40.7% presented mild or moderate UI respectively. Stress UI was the most common type reported (81.2%)."
Álvarez-García C, Doğanay M. The prevalence of urinary incontinence in female CrossFit practitioners: A systematic review and meta-analysis. Arch Esp Urol. 2022 Jan;75(1):48-59. English, Spanish. PMID: 35173077.
"A total of 282 records were identified, ofwhich 13 were included in the qualitative and quantitativesynthesises. The prevalence of urinary incontinenceamong female CrossFit practitioners was 32.1%(95% CI = 22.2-43.8%, n = 2187) and of stress urinaryincontinence was 35.8% (95% CI = 19.4-56.4%, n =1323). The prevalence of urinary incontinence was higher among women over 35 years old, with previouspregnancies and vaginal deliveries (P = 0.004). TheCrossFit exercises associated with higher stress urinaryincontinence were rope jumping, double under,weightlifting, and box jumps. Some preventive strategieswere pelvic floor training, using pads, emptyingthe bladder before workouts, and wearing dark pants."
Multiple Sclerosis
Vecchio M, Chiaramonte R, DI Benedetto P. Management of bladder dysfunction in multiple sclerosis: a systematic review and meta-analysis of studies regarding bladder rehabilitation. Eur J Phys Rehabil Med. 2022 Jun;58(3):387-396. doi: 10.23736/S1973-9087.22.07217-3. Epub 2022 Feb 1. PMID: 35102733; PMCID: PMC9980558.
Yavas I, Emuk Y, Kahraman T. Pelvic floor muscle training on urinary incontinence and sexual function in people with multiple sclerosis: A systematic review. Mult Scler Relat Disord. 2022 Feb;58:103538. doi: 10.1016/j.msard.2022.103538. Epub 2022 Jan 18. PMID: 35066277.
"Current evidence suggests that pelvic floor muscle training seems to be an effective treatment modality for improving health-related quality of life and reducing the severity of urinary incontinence and overactive bladder symptoms in people with multiple sclerosis. It also can reduce leakage episodes, pad usage, anxiety, and depression and improve sexual function"
Dysmenorrhea
Lin KC, Huang KJ, Lin MN, Wang CY, Tsai TY. Vitamin D Supplementation for Patients with Dysmenorrhoea: A Meta-Analysis with Trial Sequential Analysis of Randomised Controlled Trials. Nutrients. 2024 Apr 8;16(7):1089. doi: 10.3390/nu16071089. PMID: 38613122; PMCID: PMC11013696.
"vitamin D supplement reduced primary dysmenorrhoea pain but not secondary dysmenorrhoea pain."
Šabec L, Golob I, Kozinc Ž. The effects of taping in the management of primary dysmenorrhoea: A systematic review with meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2024 May;296:148-157. doi: 10.1016/j.ejogrb.2024.02.056. Epub 2024 Mar 1. PMID: 38442532.
" The results indicate that both kinesiotaping (SMD = -1.22; 95 % CI: -2.15, -0.29; p = 0.01) and other tapes (SMD = -1.61, 95 % CI: -2.15, -0.65; p = 0.001) significantly reduces pain intensity in women with PD. However, the certainty of evidence was very low according to GRADE criteria."
Donayeva A, Amanzholkyzy A, Abdelazim I, Saparbayev S, Nurgaliyeva R, Kaldybayeva A, Zhexenova A, Gubasheva G, Ayaganov D, Samaha I. The effects of vitamin D and calcium on primary dysmenorrhea: a systematic review. J Med Life. 2023 Nov;16(11):1597-1605. doi: 10.25122/jml-2023-0248. PMID: 38406773; PMCID: PMC10893561.
"Abnormal low Vit. D levels increased the severity of primary dysmenorrhea through increased prostaglandins and decreased calcium absorption. Vitamin D and calcium supplements could reduce the severity of primary dysmenorrhea and the need for analgesics."
González-Mena Á, Leirós-Rodríguez R, Hernandez-Lucas P. Treatment of Women With Primary Dysmenorrhea With Manual Therapy and Electrotherapy Techniques: A Systematic Review and Meta-Analysis. Phys Ther. 2024 May 1;104(5):pzae019. doi: 10.1093/ptj/pzae019. PMID: 38366860.
"Manual therapy techniques and electrotherapy methods reduce the pain intensity of women with primary dysmenorrhea. Quality of life and degree of anxiety improved significantly with manual therapy interventions. Transcutaneous electrical nerve stimulation combined with thermotherapy and effleurage massage are the interventions with which positive effects were achieved with fewer sessions."
Babazadeh-Zavieh SS, Bashardoust Tajali S, Haeri SMJ, Shamsi A. Effects of Transcutaneous Electrical Nerve Stimulation on Chronic Pelvic Pain in Women: A Systematic Review and Meta-Analysis. Complement Med Res. 2023;30(2):161-173. English. doi: 10.1159/000528133. Epub 2022 Nov 21. PMID: 36412569.
"TENS application can mildly improve the level of pain in patients with CPP caused by primary dysmenorrhea. Although no distinct agreement was observed among the effective parameters, the high-frequency mode with maximum tolerated intensity was more effective compared to the low-frequency mode."
Deodato M, Grosso G, Drago A, Martini M, Dudine E, Murena L, Buoite Stella A. Efficacy of manual therapy and pelvic floor exercises for pain reduction in primary dysmenorrhea: A prospective observational study. J Bodyw Mov Ther. 2023 Oct;36:185-191. doi: 10.1016/j.jbmt.2023.07.002. Epub 2023 Jul 13. PMID: 37949558.
Vulvodynia
Calafiore D, Marotta N, Curci C, Agostini F, De Socio RI, Inzitari MT, Ferraro F, Bernetti A, Ammendolia A, de Sire A. Efficacy of Rehabilitative Techniques on Pain Relief in Patients with Vulvodynia: A Systematic Review and Meta-Analysis. Phys Ther. 2024 Apr 2:pzae054. doi: 10.1093/ptj/pzae054. Epub ahead of print. PMID: 38564267.
Nascimento RP, Falsetta ML, Maurer T, Sarmento ACA, Gonçalves AK. Efficacy of Physiotherapy for Treating Vulvodynia: A Systematic Review. J Low Genit Tract Dis. 2024 Jan 1;28(1):54-63. doi: 10.1097/LGT.0000000000000787. Epub 2023 Nov 7. PMID: 37934153.
"The studied interventions (electromyography biofeedback, transcutaneous electrical nerve stimulation, shockwave, physiotherapy, and pelvic floor exercise) seem to improve pain, sexual function, and quality of life."
Sexual Function
Jorge CH, Bø K, Chiazuto Catai C, Oliveira Brito LG, Driusso P, Kolberg Tennfjord M. Pelvic floor muscle training as treatment for female sexual dysfunction: a systematic review and meta-analysis. Am J Obstet Gynecol. 2024 Jan 6:S0002-9378(24)00006-1. doi: 10.1016/j.ajog.2024.01.001. Epub ahead of print. PMID: 38191016.
"This systematic review and meta-analysis showed that pelvic floor muscle training improved female Female Sexual Function Index total score and several subscales; however, the certainty of the evidence is low."
Dyspareunia
Fernández-Pérez P, Leirós-Rodríguez R, Marqués-Sánchez MP, Martínez-Fernández MC, de Carvalho FO, Maciel LYS. Effectiveness of physical therapy interventions in women with dyspareunia: a systematic review and meta-analysis. BMC Womens Health. 2023 Jul 24;23(1):387. doi: 10.1186/s12905-023-02532-8. PMID: 37482613; PMCID: PMC10364425.
"Physiotherapy techniques are effective and procedures have been identified with reliable results in improving pain and quality of life in patients with dyspareunia. One of the most important aspects is the strengthening of the perineal musculature and the application of Transcutaneous Electrical Nerve Stimulation. Furthermore, manual trigger point release therapy and Thiele massage, optimize and guarantee the reduction of pain intensity."
Endometriosis
Abril-Coello R, Correyero-León M, Ceballos-Laita L, Jiménez-Barrio S. Benefits of physical therapy in improving quality of life and pain associated with endometriosis: A systematic review and meta-analysis. Int J Gynaecol Obstet. 2023 Jul;162(1):233-243. doi: 10.1002/ijgo.14645. Epub 2023 Jan 17. PMID: 36571475.
"Non-pharmacologic conservative therapies are a therapeutic option for women with endometriosis for improving pain intensity and physical function."
Gynecological Cancer
Pizetta LM, Reis ADC, Méxas MP, Guimarães VA, de Paula CL. Management Strategies for Sexuality Complaints after Gynecologic Cancer: A Systematic Review. Rev Bras Ginecol Obstet. 2022 Oct;44(10):962-971. doi: 10.1055/s-0042-1756312. Epub 2022 Sep 29. PMID: 36174653; PMCID: PMC9708405.
The main complaints identified in the scientific literature were low libido and lack of interest in sexual activity, vaginal dryness, pain during sexual intercourse, and stenosis. Different care strategies may be adopted, such as follow-up with a multidisciplinary health team and sexual health rehabilitation programs, which could minimize these symptoms and ensure the quality of life of patients.
Colorectal Cancer
Haas S, Mikkelsen AH, Kronborg CJS, Oggesen BT, Møller PF, Fassov J, Frederiksen NA, Krogsgaard M, Graugaard-Jensen C, Ventzel L, Christensen P, Emmertsen KJ. Management of treatment-related sequelae following colorectal cancer. Colorectal Dis. 2023 Mar;25(3):458-488. doi: 10.1111/codi.16299. Epub 2022 Nov 19. PMID: 35969031.
Low Back Pain
Kazeminia M, Rajati F, Rajati M. The effect of pelvic floor muscle-strengthening exercises on low back pain: a systematic review and meta-analysis on randomized clinical trials. Neurol Sci. 2023 Mar;44(3):859-872. doi: 10.1007/s10072-022-06430-z. Epub 2022 Oct 7. PMID: 36205811.
"Conclusion: Based on the results of the present meta-analysis, pelvic floor muscle-strengthening exercises significantly reduce the low back pain intensity. Therefore, these exercises can be regarded as a part of a low back pain management plan."
CPGs
4. Prior to radical prostatectomy, patients may be offered pelvic floor muscle exercises or pelvic floor muscle training. (Conditional Recommendation; Evidence Level: Grade C)
Post-Prostate Treatment
6. In patients who have undergone radical prostatectomy, clinicians should offer pelvic floor muscle exercises or pelvic floor muscle training in the immediate post-operative period. (Moderate Recommendation; Evidence Level: Grade B)
16. In patients seeking treatment for incontinence after radical prostatectomy, pelvic floor muscle exercises or pelvic floor muscle training should be offered. (Moderate Recommendation; Evidence Level: Grade B)
access Journal of Urology AUA Guideline Article 23 Apr 2024
The AUA/SUFU Guideline on the Diagnosis and Treatment of Idiopathic Overactive Bladder
STATEMENT ELEVEN: Clinicians should offer bladder training to all patients with OAB (Strong Recommendation; Evidence Level: Grade A)
STATEMENT TWELVE: Clinicians should offer behavioral therapies to all patients with OAB. (Clinical Principle)
Behavioral therapies for OAB, such as fluid management, caffeine reduction, physical activity/exercise, dietary modifications, and mindfulness offer patients with OAB some efficacy, excellent safety, and few if any adverse effects. However, the success of these measures is highly dependent on patient acceptance, adherence, and compliance. While the research on the effectiveness of behavioral therapies is highly variable, bladder training has been extensively studied and is recommended based on strong evidence.4
STATEMENT THIRTEEN: Clinicians may offer select non-invasive therapies to all patients with OAB. (Clinical Principle)
Non-invasive therapies, such as pelvic floor muscle therapy (PFMT), transcutaneous tibial nerve stimulation, transvaginal electrical stimulation, and yoga are conservative therapies for OAB that are provided by a healthcare professional and require participation by the patient. While safety profiles are excellent across modalities, with few adverse effects and a high risk-benefit ratio, all non-invasive therapies do not have equivalent efficacy and the evidence base is highly variable. Most non-invasive therapies require long-term patient compliance to maintain a durable effect and patients should be counselled as such before embarking on a course of a potentially lifelong therapy.
STATEMENT FOURTEEN: In patients with OAB whose symptoms do not adequately respond to monotherapy, clinicians may combine one or more of the following: behavioral therapy, non-invasive therapy, pharmacotherapy, and/or minimally invasive therapies. (Expert Opinion)
Historically, treatment of OAB has followed a stepwise progression of therapies from least invasive to most invasive based on patient response. However, clinicians may use a layering or combination approach of two or more therapies simultaneously. Behavioral therapies have been added to other non-invasive,5 minimally invasive,6 and pharmacological therapy7 with potentially additive favorable effects. When combining therapies, the practitioner should carefully monitor improvement of OAB symptoms, and if no improvement is noted, then one or both therapies should be discontinued and other treatments pursued. When combining greater than two therapies, the practitioner should proceed in a stepwise fashion, not instituting multiple additions simultaneously thereby allowing the practitioner to determine the individual impact of each therapy on symptoms.
STATEMENT FIFTEEN: Clinicians should counsel patients that there is currently insufficient evidence to support the use of nutraceuticals, vitamins, supplements, or herbal remedies in the treatment of patients with OAB. (Expert Opinion)
There are not adequately powered RCTs demonstrating efficacy for any of these agents and therefore are not recommended at this time.
Surgical Treatment of Female Stress Urinary Incontinence (SUI): AUA/SUFU Guideline
Guideline statement 8:
"Pelvic floor muscle training and incontinence pessaries are appropriate for patients interested in pursuing therapy that is less invasive than surgical intervention."
Guideline statement 11:
"Patients may opt for the use of conservative measures to treat stress or stress-predominant urinary incontinence. These may include use of urethral plugs, continence pessaries or vaginal inserts. In addition, there are exercises that may aid patients with stress incontinence or stress-predominant mixed incontinence. These may include pelvic floor muscle exercises (PFME) with or without biofeedback. The Panel believes these are low-risk options to consider in the treatment of patients. The literature supports the use of this modality as conservative therapy for women with SUI and UUI. The addition of dynamic lumbopelvic stabilization (DLS) in short pelvic floor muscle and lumbar muscle resistance training has been shown to add to the efficacy of PFME alone in a recent small RCT.27 In this study, at longer follow-up (90 days), patients in the PFME and DLS group had improved day and night urine loss and lower severity of urine loss as well as improved QOL than the group with just PFME alone (p<0.05). This difference was not seen at the immediate completion of training, but effect size increased with time."
Female UI prevalence
Patel UJ, Godecker AL, Giles DL, Brown HW. Updated Prevalence of Urinary Incontinence in Women: 2015-2018 National Population-Based Survey Data. Female Pelvic Med Reconstr Surg. 2022 Apr 1;28(4):181-187. doi: 10.1097/SPV.0000000000001127. Epub 2022 Jan 12. PMID: 35030139.
Results: Complete data were available for 5,006 women. In weighted analyses, 61.8% had UI, corresponding to 78,297,094 adult U.S. women, with 32.4% of all women reporting symptoms at least monthly. Of those with UI, 37.5% had stress urinary incontinence, 22.0% had urgency urinary incontinence, 31.3% had mixed symptoms, and 9.2% had unspecified incontinence. The prevalence of moderate or more severe UI by Sandvik Severity Index was 22.1%, corresponding to 28,454,778 adult U.S. women. In multivariate models, increasing age, body mass index ≥25, prior vaginal birth, anxiety, depression, functional dependence, and non-Hispanic White ethnicity and race were associated with any and moderate UI. Urinary incontinence was not associated with diabetes, education level, prior hysterectomy, smoking status, physical activity level, or current pregnancy status.
Conclusions: More than 60% of community-dwelling adult women in the United States experience any UI and an increase from prior estimates (38%-49%) using NHANES data from 1999 to 2004; more than 20% experience moderate or more severe UI. Increases in UI prevalence may be related to population aging and increasing obesity prevalence. Age greater than 70 years, body mass index >40, and vaginal birth had the strongest association with UI in multivariate modeling.
