Introduction
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Atrophy of the tunica mucosa and the tunica spongiosa (estrogen deficiency, e.g., postmenopausal)
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Dysfunctional tunica muscularis (e.g., due to surgical interventions such as transurethral prostate resection or radical prostatectomy or trauma)
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Weak pelvic floor muscles and ligaments
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Pregnancy
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Vaginal delivery
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Instrumental delivery (vacuum or forceps)
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Episiotomy
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Maternal age at first delivery ≤30 years
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Parity, increasing after three or more deliveries
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Being overweight [25 ≤ body mass index (BMI) < 30]
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Consuming carbonated drinks
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Age
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Increasing severity of the SUI
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Previous conservative treatment for SUI with an unfavorable outcome
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SUI during pregnancy and during the first 3 months after delivery
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Number of pregnancies
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Prolonged second stage of labor
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Severe prolapse [Pelvic Organ Prolapse Quantification system (POP-Q) stage 3 or 4]
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Being overweight
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Presence of other diseases or disorders, such as chronic obstructive pulmonary disease (COPD) and cardiovascular diseases
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Psychological strain
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Patient-perceived low physical condition
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Higher educational level
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Higher level of motivation for and adherence to a pelvic floor training program
Literature search
Intervention | Diagnostic accuracy of study | Harm/side-effects, etiology, prognosisa
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---|---|---|
A1: Systematic review of at least two independent A2-level studies | ||
A2: Randomized, double-blind, comparative clinical trial of good quality and sufficient sample size | Study compared with a reference test (gold standard) with predefined cutoff values and independent assessment of outcomes of the test and the gold standard, based on a sufficiently large sample of consecutive patients, all of whom have undergone the index and reference tests | Prospective cohort study with sufficient sample size and follow-up, effectively controlled for confounding and with effective measures to prevent selective follow-up |
B: Comparative study not meeting all criteria mentioned under A2 | Study compared with a reference test, not meeting all criteria mentioned under A2 | Prospective cohort study not meeting all criteria mentioned under A2, or retrospective cohort study |
C: Noncomparative study | ||
D: Expert opinion | ||
Level of conclusions. | ||
Conclusion based on: | Recommendations based on conclusion level: | |
1. Study at A1 level or at least two independent A2-level studies | It has been demonstrated that… | |
2. One study at A2 level or at least two independent B-level studies | It is plausible that… | |
3: One B- or C-level study | There are indications that… | |
4. Expert opinion | In the opinion of the guideline development team, … |
Establishment of consensus
Diagnostic process
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Level of voluntary and involuntary control of the pelvic floor, coordination of the pelvic floor muscles (PFM), and synergistic activity
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Quantification and symmetry of (in)voluntary PFM contraction and relaxation
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Other PFM functions, such as endurance, fatigue
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Whether and to what extent other aspects of the musculoskeletal system, such as respiration, lower back, pelvis, and hip, are hampering PFM function
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Any local and other (i.e., general) unfavorable prognostic factors
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Assess whether the patient is able to voluntarily contract and relax the PFM, and evaluating the performance
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Assess the effectiveness of voluntary contraction and relaxation of the PFM
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Assess the effectiveness of involuntary contraction of the PFM associated with a sudden increase in intra-abdominal pressure (forceful coughing) and subsequently during coughing after the patient has been instructed to contract their pelvic floor first
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Assess the effectiveness of involuntary relaxation of the PFM during straining
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Observe the voluntary contraction and relaxation of the PFM in relation to the abdominal muscles
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Establish any differences between the right and left sides while the patient contracts and relaxes the PFM
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Quantify the strength, endurance, and explosive strength of the PFM
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Patient’s sitting and standing posture (urethral angle, anorectal angle, abdominal pressure, and toileting behavior)
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Respiration (breath holding and vocal behavior)
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Movements (mobility and tonicity of the spinal column, abdominal, and pelvic regions and movement patterns)
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Abdominal, buttock, and leg muscles (patients with fatigued PFM often show increased activity of other muscles)
Measurement instruments
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SUI with PFM dysfunction:
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The patient is unable to identify their PFM, has no awareness, cannot manage contraction or relaxation, shows no effective involuntary contraction of the PFM associated with increased abdominal pressure
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The patient is unable to identify their PFM, has no awareness, cannot manage contraction or relaxation, shows some involuntary contraction of the PFM associated with increased abdominal pressure, but contraction is ineffective
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The patient is unable to identify their PFM, has no awareness, cannot manage contraction or relaxation, but shows effective involuntary contraction of the PFM associated with increased abdominal pressure
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The tone of the PFM is measurably too high, and the patient is unable to reduce this on demand (with or without voluntary tightening and with or without effective involuntary contraction associated with increased abdominal pressure)
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The patient is able to tighten and relax the PFM but has no effective involuntary control over the PFM associated with increased abdominal pressure
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The patient has both voluntary and involuntary control over the PFM, but the PFM are too weak
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The functioning of other parts of the musculoskeletal system, e.g., in relation to respiration, voiding posture, and toileting behavior, adversely affects PFM function
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SUI without PFM dysfunction:
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SUI plus local and/or other (general) unfavorable prognostic factors that may have adverse local or general effects on recovery and/or adjustment processes, and which may or may not be modifiable by physical therapy interventions
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Treatment plan
Therapeutic process
Preventing SUI
Evaluation
Interaction between physiotherapists and other health-care providers
Discussion
Conclusion
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A summary of recommendations follows:
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Identifying etiological factors—the therapist should systematically identify etiological factors in order to assess the nature of the dysfunction of the continence mechanism (level 4)
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Establishing the type of incontinence—the guideline development team recommends using the 3IQ test to establish the type of incontinence (level 1)
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Palpation—the guideline development team recommends the use of the assessment procedure described in the practice guideline to evaluate PFM function (level 2)
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Functional examination—the guideline development team recommends that breathing patterns, postural control, voiding posture, and toileting behavior be examined in relation to functioning of PFM (level 3)
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PRAFAB questionnaire—the guideline development team recommends using the PRAFAB questionnaire to assess changes in the patient’s health status and the effect of physical therapy intervention (level 1)
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Quantifying the loss of urine—the guideline development team recommends quantifying the loss of urine using the 24-h pad test in case of uncertainty about the quantities of urine being lost (level 3)
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Patient-Specific Complaints (PSC)—the guideline development team recommends using the PSC both to identify the health problem and to evaluate the effect of treatment (level 2)
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Global Perceived Effect (GPE)—the guideline development team recommends using the GPE to evaluate the health status improvement perceived by the patient (level 2)
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Micturition diary—the guideline development team recommends having patients keep a micturition diary in order to identify the severity of the loss of urine and to evaluate the results of treatment (level 1)
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Information and advice—the guideline development team recommends the use of anatomical plates and pelvic phantoms, as well as other educational materials such as lifestyle advice (level 4)
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Improving general physical condition—the guideline development team recommends the inclusion in the treatment plan of interventions to improve the patient’s general physical condition (level 4)
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Frequency and performance of PFMT—the guideline development team recommends treating SUI by means of daily PFMT with sufficient intensity and duration while paying attention to the correct performance of the exercises and integrating the exercises into activities of daily life (level 1)
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Selective contraction of PFM—the guideline development team recommends combining PFM exercises with electrostimulation in patients who are unable to voluntarily and/or selectively contract their PFM (level 3)
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PFM training to promote postoperative recovery after prostatectomy—the guideline development team recommends preoperative PFM training for men who have to undergo prostatectomy (level 2)