Is PREHAB in Pelvic Floor Surgery Needed? A Topical Review
Abstract
:1. Introduction
2. Discussion
2.1. Perioperative Physiotherapy in Female Pelvic Floor Surgery
2.1.1. Perioperative Intervention in Pelvic Organ Prolapse and/or Stress Urinary Incontinence Surgery
2.1.2. Perioperative Intervention in Pelvic Organ Prolapse
2.1.3. Perioperative Intervention in Mixed Urinary Incontinence
2.2. Prehab in Male Pelvic Floor Surgery
2.3. Preoperative Muscle Function and Surgical Outcomes
2.4. Could Surgery Improve PFM Function?
3. Conclusions
Author Contributions
Funding
Conflicts of Interest
References
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Author | Type of Study | Population | Condition Studied | Intervention | Intervention Delivery | Outcome Measures | Results |
---|---|---|---|---|---|---|---|
Jarvis et al., 2005 [6] | RCT | 60 females (30 in the PFM training group; 30 in the control group) | UI and/or POP | - Individual PFM training, 4 sets per day - “The Knack” - Education (voiding, defecation techniques) | Perioperatively, continued 12 weeks after surgery | Assessment 12 weeks after surgery | |
Paper towel test | No statistically significant differences between the groups p = 0.150, 95% CI: 11.4, 72.3 | ||||||
Standardized urinary symptom-specific health and quality of life questionnaire | Intergroup mean difference of 3.8 favoring the PFM training treatment group, p = 0.017, 95% CI: 0.7, 6.9. | ||||||
48 h urinary frequency/volume diary | Mean difference in diurnal frequency between the groups in favor of the PFM training group, p = 0.024 (PFM training group mean reduction 1.5, control group mean reduction 0.4). | ||||||
Manometry | Significantly different mean maximum squeeze in the PFM group in comparison to the control group p = 0.022, 95% CI: 9.92, 0.81. Improvement in the mean maximum squeeze of 2.7 cm H2O in the PFM training group, reduction in the mean maximum squeeze of 1.8 cm H2O in the control group | ||||||
Zhang et al., 2016 [9] | Systematic review | 5 studies 591 females (292 in the PFM training group; 299 in the control group) | POP (one trial included patients scheduled for POP and/or UI surgery) | In 2 studies, women received individual PFM training and lifestyle advice in combination with different adjunct therapies (biofeedback, electrical stimulation, vaginal balls) In the other 3 studies, women received individual PFM training and lifestyle advice only In PFM training, the number of contraction repetitions varied between 8 and 12 and the exercise frequency varied between 3 and 4 times per day | Perioperatively, the number of treatment sessions varied from 3 to 8 during the follow-up period | Primary outcomes: assessment 3–24 months after surgery Primary: Prolapse symptoms Prolapse-specific quality of life Secondary: Degree of prolapse Pelvic floor muscle function Urinary outcomes Measures of quality of life Bowel outcomes Activity scales PFM training adherence Adverse events | No improvement in primary or secondary outcomes between women in the PFM training group and control group |
Sung et al., 2019 [10] | RCT | 480 females (242 in the PFM training group; 238 in the control group) | Stress and urgency UI | - Education on pelvic floor anatomy, bladder function and voiding habits - PFM training (individual, progressive, administered daily) - Bladder training- Strategies to control stress and urgency symptoms | One preoperative (2–4 weeks before) and 5 postoperative sessions through 6 months | Primary: Urogenital Distress Inventory (UDI) change (from baseline) in symptoms at 12 months | Statistically significant improvement in the PFM training group vs. the control (sling-only) group (−13.4 points, 95% CI: −25.9 to −1.0, p = 0.04;); however, it did not meet the prespecified threshold for clinical importance. |
Secondary: Subscale scores between groups at 12 months. | |||||||
UDI-stress | Statistically significant improvement in the PFM training group vs. the control (sling-only) group. The model-estimated between-group difference (−6.1 points; 95% CI: −12.1 to −0.2; p = 0.04) did not meet the prespecified threshold for clinical importance. | ||||||
UDI-irritative | No statistically significant difference in the PFM training group vs. the control (sling-only) group. The model-estimated between-group difference: −5.5 points; 95% CI: −11.5 to 0.6; p = 0.08 | ||||||
Other: 3-day bladder diary | Significantly greater mean reduction in urgency incontinence episodes (−1.1 vs. −0.4 daily episodes; adjusted difference, −0.7; 95% CI: −1.2 to −0.1; p = 0.02) and total incontinence (−2.4 vs. −1.4; daily episodes difference, −1.0; 95% CI: −1.7 to −0.2; p = 0.009) in the PFM training group vs. the control (sling-only) group | ||||||
Incontinence Impact Questionnaire | Significantly greater improvements in the PFM training group vs. the control (sling-only) group, reached the prespecified threshold for clinical importance. Difference in difference, −29.7; 95% CI: −51.9 to −7.4, p = 0.009 | ||||||
Patient Global Impression of Improvement | No statistically significant difference | ||||||
Overactive Bladder Treatment | No statistically significant difference | ||||||
Satisfaction Questionnaire | No statistically significant difference | ||||||
Symptom and Health-Related Quality of Life (questionnaires administered at 3, 6 and 12 months after surgery) | No statistically significant difference |
Author | Type of Study | Population | Condition Studied | Intervention | Intervention Delivery | Outcome Measures | Results |
---|---|---|---|---|---|---|---|
Ocampo-Trujillo et al., 2014 [11] | Randomized prospective intervention study | 16 males (8 in the PFM training group; 8 in the control group) | Patients undergoing radical prostatectomy | Intensive PFM training including: - Voluntary and selective contractions and relaxations of the levator ani muscles - Addition of audible and visual biofeedback | 3 times a day for 4 weeks, 30 days prior to surgery | Measures were taken at the beginning of the intervention and 8 weeks after surgery | |
The pressure assessment of the levator ani contraction by surface electromyography | Greater degree of change in the average pressure of the levator ani muscle contraction (F = 9.188; p = 0.010) in the PFM training group vs. the control group. | ||||||
Continence assessed by a 24 h pad test | 75% of the patients who underwent muscle training did not require guards, compared with 50% in the control group (p > 0.05). Similar observations in the use of 1–2 guards (35.7% vs. 12.5%; p > 0.05). | ||||||
Prostate Cancer Index health questionnaire (UCLA-PCI) | After the training program, the PFM training group scored higher in the physical 52.1 ± 3.6 vs. 48.7 ± 3.6) and mental (48.3 ± 5.1 vs. 49.4 ± 4.6) items of the UCLA-PCI questionnaire vs. the control group. However, these differences were not statistically significant | ||||||
Muscle morphometry | The participants from the PFM training group had higher values in the cross-sectional area of the external sphincter muscle fibers of the urethra compared to the control group (1313 ± 1075 μm2 vs. 1056 ± 844 μm2, F = 5.458, p = 0.03). There were no changes in other morphometric characteristics, minor diameter (μm2) or percentage of central nuclei | ||||||
Manley et al., 2016 [12] | Pilot study | 98 males | Patients undergoing robot-assisted radical prostatectomy | - Individual PFM training including strength, reflex action, coordination and endurance exercises - Education about anatomy | The initial physiotherapy consultation of a 2 h duration PFM training implemented before and after surgery, practiced daily. Consultation and training implemented preoperatively, not stated when exactly | Perineal pelvic floor muscle assessment anteriorly Digital rectal exam to evaluate the external anal sphincter and puborectalis Real-time transabdominal ultrasound assessment for assessment of PFM strength rated as absent, weak, moderate or strong Assessments repeated postoperatively with the exception of the rectal exam due to possible pain | Absence of the control group limits the conclusions of the beneficial effects of PFM training prior to surgery |
Chang et al., 2016 [13] | Systematic review and meta-analysis | 11 studies in a systematic review, 7 studies in meta-analysis | Patients undergoing radical prostatectomy | Different PFM training protocols, with or without biofeedback | In the majority of studies, the first session was 2–4 weeks prior to the surgery. Two studies had their first session 1 day before surgery. Some of the studies did not clearly state the beginning of preoperative PFM training. Duration of PFM exercises varied from 20 min to 1 h in length, frequency from twice a week to weekly | Continence rates (different definitions across the studies) | Significantly lower rates of postoperative incontinence at 3 months postsurgery in the PFM training group compared with the control group, with an OR of being incontinent of 0.64 (p = 0.005). There was no significant difference in postoperative incontinence rates at 1 month (OR: 0.68; p = 0.07) or 6 months (OR: 0.60; p = 0.12) |
Quality of life (American Urological Association Symptom Index, King’s Health Questionnaire (KHQ), University of California Los Angeles Prostate Cancer Index (UCLA-PCI), International Consultation on Incontinence Questionnaire (ICIQ), International Prostate Symptom Score (IPSS)) | Seven studies measured quality of life. Four studies showed statistically significant improvements in the PFM training group at 3 months postsurgery | ||||||
Goonewardene et al., 2018 [14] | Narrative review | 9 studies | Patients undergoing robotic radical prostatectomy | Different PFM training protocols, with or without biofeedback | Different PFM training delivery | Continence rates, incidence, duration and severity | Statistically significant improvements in the PFM training groups regardless of the PFM training regimen |
Tienforti et al., 2012 [15] | A prospective, single-center RCT | 34 males (17 in the PFM training group; 17 in the control group) | Patients undergoing standard open retropubic radical prostatectomy | - Supervised training session with biofeedback - Oral and written instructions on pelvic floor muscle contractions. Three sets of 10 min each (5 s contractions then 5 s relaxations) - Education about anatomy and physiology of the lower urinary tract | The day before surgery and immediately after catheter removal, repeated daily Exercise frequency was recorded in a training diary | Outcome assessment performed monthly for the PFM training group and at 1, 3 and 6 months after catheter removal for the control group | |
Primary: Self-reported recovery of continence 6 months after catheter removal (continence defined by the International Consultation on Incontinence Questionnaire on Urinary Incontinence (ICIQ-UI) as a score of zero) | The difference between groups was statistically significant at each reported follow-up time favoring the PFM training group | ||||||
Secondary: Number of incontinence episodes per week | The number of incontinence episodes per week was significantly lower for patients in the PFM training group at both the 3 (3.84 vs. 14, p = 0.01) and 6-month follow-ups (2.72 vs. 13.06, p = 0.005) | ||||||
Number of pads used per week | The number of pads per week was significantly lower for patients in the PFM training group at boththe 3 (1.50 vs. 6.25, p = 0.005) and 6-month follow-ups (1.31 vs. 4.625, p = 0.03) | ||||||
Overactive bladder symptoms, measured by the International Consultation on Incontinence Questionnaire Overactive Bladder Module (ICIQ-OAB) | ICIQ-OAB scores showed significant differences in favor of the PFM training group at the 3- (10.12 vs. 13.19, p = 0.04) and 6-month follow-ups (9.06 vs. 12.62, p = 0.01) | ||||||
Urinary function measured by the University of California Los Angeles Prostate Cancer Index (UCLA-PCI) | UCLA-PCI scores showed significant differences in favor of the PFM training group at the 3- (403.81 vs. 272.44, p = 0.006) and 6-month follow-ups (422.50 vs. 274.25, p = 0.003) | ||||||
Impact of incontinence on quality of life measured by the International Prostate Symptom Score (IPSS-QoL) | Patients in the PFM training group reported lower IPSS-QoL scores (better quality of life) than those in the control group at all follow-up times but the difference was not statistically significant | ||||||
Dijkstra-Eshuis et al., 2015 [16] | RCT | 248 males (124 in each group) | Patients undergoing laparoscopic radical prostatectomy | 30 min sessions of PFM training with biofeedback (maximal voluntary contractions, endurance, relaxation and coordination with abdominal breathing) - Education about toilet behavior | Once weekly, four weeks prior to surgery | Assessments at 6 weeks, 3 months, 6 months, 9 months and 1 year postoperatively King’s Health Questionnaire (KHQ) International Prostate Symptom Score (IPSS) 24 h bladder diary 24 h pad test | There were no significant differences between the PFM training group and the control group in terms of the incidence of urinary incontinence and quality of life measured by KHQ and IPSS 6 weeks, 3, 6 and 9 months and 1 year postoperatively (p > 0.05) |
Geraerts et al., 2013 [17] | 180 males (91 in the PFM training group; 89 in the control group) | Patients undergoing open radical prostatectomy and robot-assisted laparoscopic radical prostatectomy | - Individual PFM training program (exercises of the pelvic floor manually controlled by the therapist and electromyography biofeedback once a week). Additionally, patients performed a home program of 60 contractions per day - Education on contracting the pelvic floor muscles while coughing and sitting down or getting up from a chair | 3 weeks before surgery and continued after surgery. Supervised 30 min sessions once a week and daily home exercises The control group started PFM training after catheter removal | Assessment before surgery and 1, 3, 6 and 12 months after surgery | ||
Primary: Time to continence (24 h pad test) | Time to continence comparable between PFM training and control groups during the first year after surgery (p = 0.878). Compared with controls, patients in the PFM training group had comparable cumulative incidence rates for continence and average amount of urine loss at all time points | ||||||
Secondary: The point prevalence of urinary continence (0 or 1 g on the 1 h pad test and the Visual Analogue Scale (VAS)) | Comparable for both groups at 1, 3, 6 and 12 months after surgery | ||||||
International Prostate Symptom Score (IPSS) | Did not differ between the groups at any time point. | ||||||
King’s Health Questionnaire (KHQ) | Only one aspect of the KHQ, incontinence impact, was in favor of the PFM training group at 3 (p = 0.008) and 6 months after surgery (p = 0.024) | ||||||
Wang et al., 2014 [18] | Meta-analysis | 5 studies | Patients undergoing radical prostatectomy | Of the five, two trials implemented PFM training with biofeedback, three trials used physiotherapist-supervised PFM training | PFM training started 2–4 weeks before surgery | Urinary continence at different time points (1, 3, 6 and 12 months after surgery) | PFM training before surgery did not improve the reestablishment of urinary continence after radical prostatectomy |
Time to continence | Narrative analysis: no significant difference between groups in included studies | ||||||
Quality of life | Narrative analysis: inconsistent results about differences in quality of life between the groups in included studies | ||||||
Laurienzo et al., 2013 [19] | RCT | 49 males (3 randomized groups: 15 in the control group, 17 in the exercise group and 17 in the electrical stimulation group) | Patients undergoing radical retropubic prostatectomy | The electrical stimulation group: 10 physiotherapy sessions before surgery, using electrical stimulation and rectal pelvic exercises (5 types) The exercise group: 10 physiotherapy sessions before surgery, only the pelvic exercises. The exercises were the same as in the electrical stimulation group | Variable frequency (respecting scheduled surgery) | Assessment 1, 3 and 6 months after the surgical procedure | |
1 h pad test | No significant difference between the 3 groups at 1, 3 and 6 months of follow-up (p > 0.05). Based on the odds ratios between groups, there was no significant difference (p > 0.05), with a 95% confidence interval. | ||||||
International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) | No significant difference in ICIQ-UI SF score between the 3 groups at 1, 3 and 6 months of follow-up (p > 0.05) | ||||||
Short Form Health Survey (SF-36) | No differences between groups on the various domains of the SF-36 (p > 0.05) |
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Szymański, J.K.; Starzec-Proserpio, M.; Słabuszewska-Jóźwiak, A.; Jakiel, G. Is PREHAB in Pelvic Floor Surgery Needed? A Topical Review. Medicina 2020, 56, 593. https://doi.org/10.3390/medicina56110593
Szymański JK, Starzec-Proserpio M, Słabuszewska-Jóźwiak A, Jakiel G. Is PREHAB in Pelvic Floor Surgery Needed? A Topical Review. Medicina. 2020; 56(11):593. https://doi.org/10.3390/medicina56110593
Chicago/Turabian StyleSzymański, Jacek K., Małgorzata Starzec-Proserpio, Aneta Słabuszewska-Jóźwiak, and Grzegorz Jakiel. 2020. "Is PREHAB in Pelvic Floor Surgery Needed? A Topical Review" Medicina 56, no. 11: 593. https://doi.org/10.3390/medicina56110593