**5. Discussion**

64 Urinary Incontinence

The assessment of pelvic floor muscular strength showed a statistically significant difference

In Gbio the levator ani muscle thickness (13.27 ±2.12 mm) was statistically significant bigger

Bladder neck mobility was statistically significant less in the Gbio group (9.26 ±3.01 mm)

The intergroup KHQ analysis showed significant differences in 5 domains. In the impact on life domain (p = 0.0305), Gbio (mean = 33.3%) presented lower levels compared to Gc (mean = 50%); in the role limitations domain, there was a significant improvement (p = 0.0099) in Gbio (mean = 0.0%), but not in Gc (mean = 33.3%); in the physical limitations domain, the result was statistically significant (p = 0.0010), since Gbio (mean = 0.0%) showed fewer limitations than Gc (mean 33.33%); in the personal relationships domain (p = 0.0426), the mean for both groups was the same (0.0%), but no Gbio individual had scores higher than 50%; and in the severity (coping) measures, there was also a significant difference (p =

On the other hand, general health, social limitations, emotions and sleep/energy did not

Comparison between groups of KHQ urinary scale symptoms (Table 3) shows that urinary frequency, nocturia and SUI were statistically significantly different after intervention

> **NRA (%)**

Frequency 56 36 0 8 32 24 8 36 0.0337\* Nocturia 52 32 0 16 40 8 8 44 0.0261\* Urgency 36 40 0 24 36 12 4 48 0.0796

incontinence 60 12 0 28 40 12 0 48 0.3141

enuresis 8 4 0 88 4 0 0 96 0.4916

infections 12 0 0 88 16 0 0 84 0.9999 Bladder pain 4 0 0 96 8 4 0 88 0.4916

Table 3. Urinary symptoms in Gc (n=25) and Gbio (n=25) after intervention.

**Gc Gbio Intensity Intensity** 

> **Slight (%)**

28 56 16 0 52 4 0 44 <0.000

20 12 0 68 12 0 0 88 0.1261

**Moderate (%)** 

**Severe (%)** 

**NRA** 

**(%) Value-p** 

1\*

(p = 0.0009): Gbio (mean = 4) was higher than Gc (mean = 3).

0.0021), with a mean of 6.6% in Gbio, versus a mean of 26.7% in Gc.

show a statistically significant difference between groups after treatment.

**Severe (%)** 

compared to Gc (11.66 ±1.65 mm) (p= 0.0044).

than in Gc (17.67 ±4.53 mm) (p = 0.0044\*).

**Symptoms slight**

Urge

Stress urinary incontinence

Nocturnal

Sexual intercourse incontinence

Frequent

\*Chi-square

NRA: omitted response

**(%)** 

**Moderate (%)** 

The results of this study indicate that the training of pelvic floor muscles through EMG BF can lead to changes in the anatomic and functional structures of PF, since there were statistically significant differences in all the assessed characteristics of the incontinent women treated.

When compared to healthy women, decrease of surface electromyographic activity in women with SUI, urgency incontinence and mixed incontinence has been found, which suggests a deterioration of the neuromuscular function in these women24. In this study, we observed that the quantification of muscular activity carried out through the EMG test showed statistically significant increase (p = 0.0068) after treatment in Gbio, which suggests that BF can restore PF neuromuscular function.

In this study, compared to Gc, PFM strength presented a statistically significant change (p = 0.0009) after BF treatment. However, we did not objectively quantify the SUI reduction. In a study of 52 women, aged from 24 to 64 (mean 45.4 years) suffering from SUI, a positive correlation between the increase in PFM maximum strength and the reduction in urine loss during stress was demonstrated 25, and in another study by Rett at al26, who included a sample of 26 women with SUI a significant improvement in pelvic floor muscular strength, from 0 (zero) or 1 (one) to 2 (two) or 3 (three) was seen. Yet, the profile of the patients in both studies was different.

Regarding the thickness of the levator ani muscle, Bernstein27 demonstrated through transabdominal ultrasonography a significant reduction in the thickness of the levator ani muscle in women over 60 compared to that of younger women. According to this author, the levator ani muscle was significantly thicker in healthier women than in those with urinary incontinence and this problem can be eliminated through physical therapy, as corroborated by this study, which showed a statistically significant increase in the thickness of the levator ani muscle in Gbio (p = 0.0044), but not in Gc, which did not have any statistically relevant improvement.

The investigation of the effectiveness of ultrasound in assessing bladder neck descent in the SUI diagnosis still presents contradictory results and unclear responses. Urethral

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hypermobility can occur in patients without UI and the reason to extent urethral hypermobility has been related to (the severity) of UI remains unclear 28,29. However, regardless the cause of SUI, nowadays, there is some consensus also to measure urethral hypermobility30. Recently, ultrasound seems to play an important role in the study of the urethral vesical junction(UVJ) and the proximal urethra (PU), also because it is a simple, low-cost, innocent and easily repeatable technique30,31,32.

In this study, there was a statistically relevant reduction in urethral mobility (p<0.0001) in Gbio after the treatment compared to Gc. These results contradict that of a study with transvaginal electrostimulation in a group of 23 women suffering from SUI who did not show a significant difference in bladder neck mobility before and after treatment (p= 0.30)33. However, our data are in line with the studies of Balmforth et al34, which comprised 97 women (49.5±10.6 years) and demonstrated a positive and significant association of the improved position of the bladder neck and the anatomical and functional improvement of the pelvic floor, accompanied by an improvement in the quality of life as measured by the KHQ.

Regarding the impact on the quality of life of the SUI patients in this study, in the intergroup comparison considering the KHQ domains there was a positive response in the following ones: incontinence impact on life (p = 0.0305), activity of daily life limitations (p = 0.0099), physical limitations (p = 0.0010), personal relationships (p = 0.0426) and severity (coping) measures (p = 0.0021) in Gbio. Similar results were obtained by other studies9,30. It is worth to notice that the impact of these symptoms on the life of each patient is closely related to the individual perception these women have of the severity, type and amount of loss, in addition to each individual's cultural context35.

This study showed that the most prevalent symptoms were SUI, urinary frequency and nocturia, and that, after treatment, the Gbio presented a reduction or elimination of these symptoms compared to the Gc, in line with the findings of the Rett study26, in which a sample of 26 women of reproductive age with SUI showed a significant response to the use of EMG BF, with a decrease of urinary symptoms, especially urinary frequency, nocturia, urinary urgency and urine loss during stress.

We concluded that the EMG BF for the PFM can lead to changes in anatomo-functional changes in the PF assessed in this study, with a positive influence on the quality of life of these women, although we cannot prove there was a reduction in SUI since we did not use a quantitative instrument to measure the decrease of urinary loss. Considering the results, this study was of huge importance regarding the use of ultrasound as an objective instrument on the evaluation of the efficacy of EMG BF on the reduction of urethral mobility, which is one of the important factors that is directly related to SUI.
