**1. Introduction**

58 Urinary Incontinence

Zorn, B.H.; Montgomery, H.; Pieper, K.; Gray, M. & Steers, W.D. (1999). Urinary

This chapter addresses the effects of training of the pelvic floor muscles using an electromyographic biofeedback equipment as a tool for treatment in women with stress urinary incontinence.

The Stress Urinary Incontinence (SUI) is defined by the International Continence Society (ICS) as involuntary loss of urine during physical effort with sneezing and coughing, and it is considered a consequence of the weakness of the pelvic floor1,2. It is the most common type of urinary incontinence and its prevalence can vary from 12% to 56% depending on the population studied and the diagnostic criterion adopted3,4. In Brazil the prevalence of complaints of stress urinary incontinence is around 35% 2.

Approximately 1/3 of women of the research presented mixed complaints, i.e., urinary loss during stress associated with irritative symptoms, such as increased urinary frequency, urinary urgency, nocturia, urgency incontinence and/or enuresis3.

Nowadays there are several risk factors for the onset of sui, and we can realize that the literature often relates it to obesity, menopause, smoking, parity, types of delivery and exercise. The white ethnicity is also related to risk factors; In an American study, when the authors compared white to black people, it appears an higher incidence for the first group (white one), varying from 23 to 32% and a lower incidence to the second group, with na average from 16 to 18% 5, 6,7.

It is known that SUI compromises the quality of life (QOL) of women of different ages5,6. However, many women with UI believe that sporadic involuntary urinary loss is a normal part of the aging process and, also because they find it embarrassing, they do not refer to its impact on their daily activities or report these symptoms to their doctors8.

<sup>\*</sup> Corresponding Author

Effects of Pelvic Floor Muscle Training with

specialist in diagnostic imaging.

that domain17.

Biofeedback in Women with Stress Urinary Incontinence 61

endocavitary probe with a frequency of 6.5 MHz and the thickness of the levator ani muscle was measured by the transabdominal technique using a 3.5 MHz transducer. This test was conducted while the bladder contained a maximum of 50 ml of urine15 and by the same

After referral, the patients were assessed by the same specialized physical therapist before and after the study. PFM strength was done by digital vaginal palpation using the Ortiz16 scale to assess PF muscle strength. PFM EMG motor activity was measured with PHENIX equipment (Vivaltis, Paris, France), model USB-4 through a 5-cm long and 5.5-cm wide vaginal probe, dampened with KY Johnson gel. The probe was introduced 3 cm inside of the vagina's introitus. The PFM electric signal was registered in microvolts (µv) by two 1-cm

The electrical signal of the PFM was registered in microvolts (µv), with the use of an individual intravaginal probe with the patient lying in supine position, flexed legs and feet supported by a stretcher after instruction the patient was asked to perform 3 maximal PFM contractions. The highest registration of the contraction was selected as starting point for the treatment that was registered by and transmitted to the computer through a visual signal.

The King´s Health Questionnaire (KHQ) assesses both the presence of urinary incontinence and its relative impact. It consists of 30 questions distributed across nine domains: general health, impact on life, role limitations, physical limitations, social limitations, personal relationships, emotions, sleep/energy and severity (coping) measures17. There is also a scale of symptoms: increased urinary frequency, nocturia, urgency, bladder overactivity, SUI, nocturnal enuresis, incontinence during sexual intercourse, urinary infections and bladder pain. Each domain receives a individual score; therefore, there is not an overall score. Scores vary from zero to 100 and the higher the score, the worse the quality of life associated with

Before they started treatment, Gbio patients received information on the function of pelvic floor muscles and were informed of the importance of continuing their exercises and functional training, so, adaptation into daily life activities. In addition to the EMG BFassisted exercises, patients were advised to do the same exercises at home to strengthen the PFM through slow and rapid contractions, being told to do three series of 10 contractions in the supine, sitting and orthostatic positions three times a day with a duration of 5-10 seconds, the contraction per subject was verified through an initial assessment of each individual18. They were also encouraged to undergo functional PFM training, i.e. to contract

The same EMG BF that was used to test the electromyographic activity of the PFM was also used to train the Gbio. The EMG BF was connected to a computer, equipped with specific software. Two pre-established programs with alternate contraction and relaxation periods were used: a twenty-minute program (85 rapid contractions and 34 slow contractions including) and a ten-minute program (including 54 rapid contractions and 24 slow contractions) 19. The women watched the contractions on the computer screen receiving visual feedback. Recent literature reviews show there is no a consensus regarding what kind of training program would be the most effective 20,21. This study's protocol was based on the review of Hay-Smith et. al, in which the maximum number of daily contractions requested

this muscle group during stress activities and increased intra-abdominal pressure.

rings located in the probe, captured and viewed by patients on the computer screen.

The King´s Health Questionnaire (KHQ) was also applied.

from patients was estimated at between 36 and 200 21,22.

In the literature, there are some questionnaires to assess quality of life of women with SUI, but the King's Health (KHQ) is the most commonly used in Brazil, which is validated in Portuguese and evaluates the presence of UI symptoms AND ITS relative impact, leading to more consistent results9.

Many factors are involved in the SUI physiopathology, especially the rotational descent of the urethra, a functionally shorturethra, pudendal nerve lesions, fascia laceration, pelvic floor muscle (PFM) ruptures, intrinsic urethral mechanism deficiency and bladder neck hypermobility10.

PFM functional detoriation, or weakness is an important factor causing SUI11. Physical therapy is considered a first line option for the rehabilitation of the pelvic floor muscles. Regarding to the conservative treatment, Kinesiotherapy is considered as level 1 evidence of its beneficial effects in SUI women (ICI 2009), but when we talk about operative interventions, Slings are the level 1 evidence. The most commonly used treatment modalities are pelvic floor muscle training (PFMT) to strengthen the PFM, vaginal electrostimulation, biofeedback (BF), vaginal cones and behavioral therapy, including information, education, awareness and advice12.

Electromyographic biofeedback (EMG BF) can be used to measure, assess and treat PFM dysfunctions and is one of the potential treatment modalities used for the rehabilitation of pelvic floor muscles10, once in its clinical use allows the patient to obtain informations about the physiological process of contraction, which used to be unknown in most of the cases. it facilitates the motor control of the pelvic floor muscles, favoring the re- education through a visual or hearing feedback generated by electromyography 13.
