I Department of Gynecology & Obstetrics Medical University of Lodz Tutor: Edyta Wlaźlak MD Aneta Gruchała, Michał Pazdrak, Klaudia Tachasiuk, Kacper Kąkol The usefulness of the introital pelvic floor ultrasound in teaching how to perform the Kegel’s exercises

Three methods of treatment, which are used in urogynaecology: 1.Observation 2.Conservative treatment 3.Surgery Abrams P., Cardozo L., Khoury S. et al. Incontinence 2009

Kegel’s exercises - One of the most common used method of a non-operative treatment - Often recommended by physicians and media for all patients Abrams P., Cardozo L., Khoury S. et al. Incontinence 2009

Kegel's exercises Pelvic floor muscle exercises Used as a conservative treatment in: – Urinary stress incontinence – Overactive bladder – Female genital prolapse Effect of pelvic floor muscle training during pregnancy and after childbirth on prevention and treatment of urinary incontinence: a systematic review Morkved S, Bo K Br J Sports Med Feb;48(4):

Physiotherapeutist’s studies revealed that 56-70% of women who performed Kegel's exercises improved their quality of life. Specialists underline that positive effect can be achieved only if exercises are performed in the proper way. It is not clearly stated, how to achieve the proper way of performing Kegel’s exercises Pelvic floor muscle training is effective in treatment of female stress urinary incontinence, but how does it work? Bo K. Int Urogynecol J Pelvic Floor Dysfunct.2004 Mar-Apr;15(2): Effect of pelvic floor muscle training during pregnancy and after childbirth on prevention and treatment of urinary incontinence: a systematic review Morkved S, Bo K Br J Sports Med Feb;48(4):

Ultrasound is more often used in urogynecology. There are different probes and modes extensively investigated in urogynecologic patient’s. One of the option is 2D transvaginal probe, which is found in nearly all gynecologic clinics. This option was not yet intensively studied. It’s usefullness fot teaching Kegel’s exercises was not evaluated yet.. Dietz HP. Pelvic floor ultrasound in prolapse: what’s in it for the surgeon? Int Urogynecol J Oct;22(10): Tunn R,Albric S, Beilecke K, Kociszewski J,Lindig-Knopke,Reisenauer C,Schwertner Tiepelmann,Kuhn A,Viereck V,Bjelic Radisic Vkolle D,Umek W, Bader W,Schwandner O,Lange RInterdisciplinary S2k Guideline: Sonography in Urogynecology: Short Version - AWMF Registry Number: 015/055.Geburtshilfe Frauenheilkd Dec;74(12):

PF-US performed with a transvaginal probe: Widely available Cheap Shows structures in a real time Allows to repeat the examination many times Slightly invasive Patient can observe the effects of her exercises on the monitor Abrams P., Cardozo L., Khoury S. et al. Incontinence 2009 Dietz HP. Pelvic floor ultrasound in prolapse: what’s in it for the surgeon? Int Urogynecol J Oct;22(10):

At rest During Kegel's exercises bladder urethra symphysis

Aim of study The aim of the study was to assess the usefulness of introital ultrasound for teaching the pelvic floor muscle exercises.

Methodology Prospective study Study group: 82 womed aged (average 58,2)

Methodology Step I – initial assessment of the ability to perform Kegel's exercises (Oxford scale) Step II – teaching how to perform Kegel's exercises with the use of ultrasound Step III – Reassessment of the ability to perform Kegel's exercises (Oxford scale)

Modified OXFORD SCALE- assessment of the ability to perform Kegel's exercises 1- no contraction 1,5- between 1 and 2 (flicker of movement) 2- Through full range actively with gravity counterbalanced 2,5- between 2 and 3 3- Through full range actively against gravity 3,5- between 3 and 4 4- Through full range actively against some resistance 4,5- between 4 and 5 5- Through full range actively against strong resistance Laycock J (1994) Clinical evaluation of the pelvic floor. In: Schuessler B Pelvic floor re-education: principles and practice. Springer, London, pp 42–48

Results

Patients from the OXFORD group 2 and 2,5(those who could perform exercises in an intermediate level) revealed statistically significant improvement. 33% of patients from OXFORD group 1 and 10% of patients from OXFORD group 1,5(those who cannot or barely can perform exercises)revealed slight improvement of the exercise efficiacy, although it was not statistically significant. Patients from OXFORD group ≥3 (those who can perform exercises well) didn't reveal statistically significant improvement.

Conclusion Teaching how to perform Kegel's exercises during an introital pelvic floor ultrasound performed with the transvaginal probe seems to be useful to improve the technique of doing Kegel's exercises.

Discussion Our study confirmed that high percentage of patients cannot perform Kegel’s exercises in the proper way. It suggests that patients should consult specialist before they start doing exercises on their own. Unproper training can increase symptoms of urinary incontinence and pelvic organ prolapse.

Discussion During ultrasound it was not possible to teach all patients how to perform Kegel’s exercises correctly. It concerned mainly those patients who initially were not able to contract their muscles (1 and 1,5 Oxford Scale). This study suggests that physiotherapy with the use of special equipment (electrostimulation, biofeedback) is necessary in many patients from Oxford group 1 and 1,5.

Discussion We prepared special leaflet for the patient informing how to perform Kegel’s exercises.

Leaflet for the patients Explanation of the Kegel exercise techinique. In the instruction we highlighted: it is not allowed to perform the exercise without previous consultation with the specialist, exercises performed incorrectly can lead to an opposite effect. The effects of physiotherapy for female urinary incontinence: individual compared with group treatment. Janssen CCM, Lagro-Janssen ALM, Felling AJA. BJUInt 2001; 87: 201^206. Is there still a place for physiotherapy in the treatment of female incontinence? Bo K. EAU Update Series, Female Urology, Volume 1, Issue 3, September 2003, Pages 145–153 Randomized controlled trial on the effect of pelvic floor muscle training on quality of life and sexual problems in genuine stress incontinent women Bo K., Talseth T., Vinsnes A Acta Obstet Gynecol Scand 2000; 79: 598–603 Pelvic floor muscle training is effective in treatment of female stress urinary incontinence, but how does it work? Bo K. Int Urogynecol J Pelvic Floor Dysfunct.2004 Mar-Apr;15(2): E pub 2004 Jan 24.

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