Scientific Validation of the Active Perineal Rehabilitation Protocol to Stress Urinary Incontinence Treatment

Ramos L1, Pereira R2, Girão M1

Research Type


Abstract Category


Abstract 791
Non Discussion Abstract
Scientific Non Discussion Abstract Session 37
Incontinence Conservative Treatment Rehabilitation Physiotherapy Pelvic Floor
1.Universidade Federal de São Paulo, 2.Centro de Endometriose Santa Joana


Hypothesis / aims of study
Urinary incontinence is a chronic and limiting disease that affects both men and women but is more common in women. A conservative treatment is prescribed as a first therapeutic option for this illness, but we do not know what the appropriate dosage for the exercises is, nor is there a consensus on whether individual sessions are more effective than group sessions, or whether other additional techniques should be used in conjunction with the exercises. This study aims to evaluate the Active Perineal Rehabilitation (APR) protocol in the treatment of stress urinary incontinence.
Study design, materials and methods
Sixty-one women between the ages of 35 and 78 with complaints of urinary incontinence were selected and underwent one of two treatments: The APR protocol, carried out in individual sessions with  a combination of kinesiotherapy with biofeedback, electrical stimulation, vaginal cones and home  exercises, over a period of three months; or group exercises (GE), carried out in groups of three to five participants, over a period of six months. The volunteers were divided into three groups according to the pelvic floor muscle (PFM) force and the treatment undertaken: APRa (n=14) patients with force 0 or 1, and treated with APR protocol; APRb (n=21) patients with force between 2 and 5, and treated with APR protocol; and GE (n=26) patients with force between 2 and 5, and treat with group exercises.
Active Perineal Rehabilitation is composed by 14 sessions, that respects the 3 phases of rehabilitation: sessions 1 to 4 - teaching the correct movement; sessions 5 to 8 - muscle agility; sessions 9 to 14 - muscle strength.  In each session, the patient will make kinesiotherapy with EMG biofeedback and electrical stimulation with a vaginal or anal probe. To home, they will perform a series of exercises and will use vaginal cones. All the 14 sessions gradually increase the intensity of exercises and last for 12 weeks. In the first month the sessions take place twice a week, in the second month they are weekly, and in the last month, they are every two weeks. Each of the 14 sessions is programmed in a medical device. Because it uses EMG biofeedback each session is individualized for each patient using a percentage of her/his maximum muscle strength. The user can constantly monitor his/her performance and the biofeedback graphics make the session more interesting as well as help in the exercise performance.
The APR protocol is based on exercise physiology, taking in consideration the cognitive, neuromuscular, and metabolic alterations caused by the rehabilitation, with the objective of rehabilitating pelvic floor muscles so that they are able to perform all their functions.
It can be used by both female and male users to prevent or to treat urinary incontinence, sexual dysfunction, fecal incontinence, constipation, pelvic pain, and pelvic organs prolapse in women. When these conditions are in a more advanced stage and surgery is required, the protocol is recommended before and after surgery as a complementary treatment.
There is no medical device on the marketing with a protocol that the user can follow session by session; the protocols that are available only offer isolated exercises without a sequence of use. A device using Active Perineal Rehabilitation will be a significant innovation because the user will have a list of sessions, from 1 to 14, and he/she will know exactly what is required in each session; and will follow a sequence, session by session.
All patients in the three groups had a significant improvement in the number and quantity of urine loss, with no statistical difference between the groups. At the end of the treatment, 33.3% of the APRa group, 70.6% of the APRb group and 68.8% of the GE group said that they had seen an improvement. In the follow-up six months after the last session these percentages were 57.6%, 75%, and 53.8%, respectively.
Interpretation of results
Even all patients in the three groups had a significant improvement, APR protocol has 3 months duration and group exercises 6 months, what we can conclude APR protocol can archive its goals in the half of time. After the follow-up, the patients in the APR protocol continued improving their results, we believe it is because of the vaginal cones. Because it is a protocol with defined steps is easy to follow patients evolution.
Concluding message
The APR protocol is as effective as group exercises in the treatment of stress urinary incontinence. A great APR differential is that it can be indicated to patients with PFM force 0 or 1, still then physical therapy was not considered adequate to treat these patients.
  1. Active Perineal Rehabilitaion
<span class="text-strong">Funding</span> Grant of CNPQ, Brazilian govermnet <span class="text-strong">Clinical Trial</span> Yes <span class="text-strong">Registration Number</span> Scientific Validation of the Active Perineal Rehabilitation Protocol to Stress Urinary Incontinence Treatment <span class="text-strong">RCT</span> Yes <span class="text-strong">Subjects</span> Human <span class="text-strong">Ethics Committee</span> Universidade Federal de São Paulo <span class="text-strong">Helsinki</span> Yes <span class="text-strong">Informed Consent</span> Yes