The treatment of the female urinary incontinence has been mainly surgical but, in spite of the bother if urinary loss, some women are reluctant to have surgical intervention, that may lead to postoperative complications. Also, there are clinical contraindication for the realization to the surgical anesthetic procedure.
The levator ani muscles, the most important component of the pelvic floor, give support to the pelvic organs and it also helps in the action of the urethra sphincter, vagina and rectum 5. This muscle is composed of two types of muscle fibres,Type I, corresponding to 70% of fibres ( slow contractions ) and Type II that appear in 30% of the fibres ( fast contractions ). This composition allows the maintenance of tone over a long period of time, as well as increasing tone to compensate increase of intra-abdominal pressure that occur with coughing, sneezing and other kind of physical efforts 5. The previous evaluation of the pelvic muscles contraction is an important factor, to determine the adequate therapy for each case.
The exercise programs are aimed to strenghten the pelvic musculature, specifically the ani levator muscle, this way the strenghtening of the peri urethral component of the external uretrhral sphincter occurs, increasing the tone and improving the pressure transmission in the urethra, this way, reinforcing the continence mechanism 6.
HENRIKSEN observed that the act of starting or interrupting the urinary stream during micturition, led to the strenghtening of the sphincter and consequently to the decrease of urinary loss 2.
In 1948 Arnold Kegel, was the first to describe in a systematic way, a, method of evaluation and an exercise program for the strenghtening of the muscles of the pelvic floor 7. He used two different methods for the tone evaluation of the pelvic musculature, subjectively by digital palpation of the vaginal vestibulum, and objectively through a perineometry. Kegel emphasizes the importance of supervision and encouragement in the treatment of these patients and recomended that control should be done weekly. The recovery of tone and muscle function, could happen according to the author, after 20 to 60 days after the initial treatment. He studied 64 women with stress urinary incontinence, using the perineometry for 20 minutes, 3 times a day, for a period of one to two weeks, he obtained continence in all cases, with a follow-up of 14 months. In another series, he observed a cure rate of 84% studying 500 patients 8. Other authors refer to similar results 9,10. He noticed that there were no failures of this therapeutical modality when urinary incontinence was due mainly to the relaxing or partial atrophy of the muscles of the pelvic floor 7.
BO et al 11 (1990) showed that an adequate supervision may improve the results obtained by perineal rehabilitation. There exists a dependency relation between perineal rehabilitation and urinary incontinence, meaning, the failures are larger in the patients that do not follow adequtely the exercise protocol. The inadequate utilization of Kegel’s exercises may lead to worse results 11.
The pelvic exercises are effective and do not present colateral effects. Doubts exist as the best way to execute these exercises for the muscles of the pelvic floor.
The utilization of equipment that allow to inform the patient by way of visual or sonorous signals ("biofeedback"), which muscle or muscle groups to be used in each exercise, thus allowing to have an idea of a muscle that has not been used like the ani levator. In this way it is possible to modify or intensify a muscular activity.
Kegel’s perineometry is a feedback instrument and other similar equipments have been developed 11.
Different authors have used pelvic floor exercises using or not biofeedback. STORDDARD 12 (1983), using a supervised program of exercises, during 10 weeks with a perineometry, on 34 women with stress urinary incontinence, noted a subjective improvement in 91% of the patients of which 38% had become continent, 32% presented an important improvement and 21% a slight improvement.
CASTLENDEN et al 13 (1984) studying 19 incontinent women, carried out in one group, only supervised exercises and in another group with biofeedback, with the help of a perineometry. The authors had better results with the patients that did exercises with biofeedback. SHEPHERD & MONTGOMERY 14 (1983) made a similar study on 22 women.On ten of the eleven women that used biofeedback there was a subjective improvement, compared to 6 of the 11 using only the exercise program.
BURGIO et al15 (1985) using exercises with biofeedback for the rehabilitation of the pelvic floor, observed an average of 82% reduction in incontinence episodes. They made a new evaluation on the 6th and 12th month after treatment, and noted that the results had been maintained.
The urodinamic evaluation has not been a routine in the perineal rehabilitation programs.Different studies show non comparable results. KUJANSUU 16 (1983) did not observe any difference in the pre and postoperative study treatment in women submited to non supervised perineal rehabilitation. As the exercises of the pelvic floor do not alter after the maximum pressure of the urethral closing, it may be that the success is related to the improvement of the contraction reflex of the pubococcygeous muscle during stress. Patients with light urinary incontinence show better results than those with severe incontinence. Even though they use objective judgement in these studies, the exercise programs were not well monitored in their intensity or frequency, besides the lack of continuation in a long period of time.
TCHOU et al 17 (1988) evaluated women with genuine urinary incontinence, with a urodinamic control previous and after 4 weeks of perineal rehabilitation, twice a week for 30 minutes. They obtained a negative stress test and subjective improvement on the symptoms.Even though they did not observe significant statistical differences, in the urethral pressure profile, or, the urethral functional length.
After urodinamic studies TAPP et al 18 (1988) observed that, those women that were in pre-menopause with a precocious symptomatology, but with urodinamic evidence of adequate urethral function, would be the ones that would benefit the most with perineal rehabilitation. BENVENUTI et al 19 (1987) using a physiotherapeutical program during three months with a urodinamic evaluation and a radiological study, pre and post treatment, observed 32% of cure of urinary incontinence and 68% of a pronounced improvement. The urodinamic study revealed a significant enlargement of the maximum pressure of urethral closing and the urethral functional length in the post treatment. The tonic contractility of the pubococcygeus muscle was enlarged in all the examined patients. In the follow-up between 12 and 36 months, it was noted that in 77% of the cases, the results were maintained.
Pelvic floor exercises may be used concomitant to electric stimulation 18,21,22,23,24 or to the vaginal cones 25,26,27.
Comparations between surgical and physiotherapeutical treatment are rare in literature. Not withstanding, KLARSKOV et al 27 (1989), compared 24 women treated by non surgical methods against 26 women treated by retropubic colpourethrocystopexy or vaginal aproach, and they showed that the results of the surgery were much better than the physiotherapeutic treatment of the pelvic floor, by objective and subjective criteria. Meanwhile, the patients treated satisfactorily by perineal rehabilitation, 42% rejected surgical intervention.
MOREIRA et al (unpublished)   in a preliminary study with 25 patients carriers of stress urinary incontinence, using a program of exercises supervised three times a week during 14 weeks, got good results in 88% of the cases, being 28% cure (dry patient), and in 60% improvement (in 40%, 1 pad change per day and in 20% 2 pad changes per day).
Perineal rehabilitation as a therapeutic modality, in a supervised training program of the pelvic floor is an alternative to surgery for a few selected cases of stress urinary incontinence. Also in those patients that have to be submitted to a surgery procedure, this program training could better the obtained results when used as an assisting therapy.
In the future, perineal rehabilitation may be used in selected cases as a new option in the treatment of female urinary incontinence, being in the preoperative, in the cases of surgical failure or as an isolated treatment in the expectation of reducing urine loss or curing urinary incontinence.