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The urodynamic evaluation has not been a routine in the treatments with perineal exercises. Different studies showed non-comparable results.
KUJANSUU 27 did not observe any difference in the pre and post-treatment of the urodynamic study in women submitted to non supervised perineal exercises. As the pelvic floor exercises do not alter the maximum pressure of the urethral closing, it is possible that the success is related to the improvement of the reflex of the contraction of the pubococcigeus muscle during effort. Patients with light urinary incontinence present better results than those with severe incontinence. Despite that they use objective criteria in these studies, the exercise programs were not monitored properly in its intensity and frequency, besides the lack of follow-up at a long term. TCHOU et al
28 evaluated women carriers of genuine urinary incontinence, as a previous urodynamic control, and had perineal exercises twice a week, for 30 minutes, and after 4 weeks they obtained a negative stress test, and a subjective improvement in the symptoms. Notwithstanding, they did not observe any significant statistical differences, being in the urethral pressure profile, or in the functional length of the urethra. After urodynamic studies, TAPP et al 29 observed that, those women in pre-menopause with a precocious symptomatology, but with urodynamic evidence of an adequate urethral function, would be the ones that would benefit the most with the perineal exercises. BENVENUTI et al 30 using a physiotherapeutic program during three months, with a urodynamic evaluation and a radiological study, pre and post-treatment, observed 32% of cure of urinary incontinence with an emphatic improvement. The urodynamic study revealed a significant increase of a maximum pressure of urethral closing and the functional urethral length post-treatment. The tonic contractibility and fascia of the pubococcigeus muscle was enlarged in all the patients that were examined. In the follow-up between 12 and 36 months they noted that in 77% of the cases, the results were maintained. The urodynamic study must be used in the selection and indication of the physiotherapeutic treatment that is more adequate.
Pelvic Floor exercises may be used concomitantly to electric stimulation 31 or to vaginal cones 32 .The comparisons between the physiotherapeutic treatment and surgical, are rare in literature. KLARSKOV et al 33 compared 24 women treated by non-surgical methods against 26 women treated by retro pubic colposuspension means or vaginal way, with a follow-up of four to six months, they showed that the results of the surgery were significantly better than those of the physiotherapeutic treatment of the pelvic floor, by objective and subjective criteria. Meanwhile, the patients treated satisfactorily through perineal exercises, 42% wanted surgery. Despite the different results obtained in literature using pelvic floor exercises, there does not exist a detailed description or even a standardized type of exercises to be used, we recommend highly a sequence of exercises that act in strengthening the pelvic floor muscles, abdominal and gluteus (Fig. 1,2,3). The strengthening of the abdominal muscle concomitant to the pelvic floor is important, using respiratory exercises, if we consider the pulley system formed by the respiratory diaphragm and urogenital. MOREIRA AND AMARO (non published data), in a preliminary study with 15 patients carriers of stress urinary incontinence, using an exercise program supervised three times a week, during 14 weeks, obtained good results in 88% of the cases, in 28% cure (dry patient), and in 60% improvement (in 40% a change of the pad/day and in 20% 2 changes/day). The perineal exercises, as a therapeutic modality, in a supervised training program of the pelvic floor are an alternative to surgery for some selected cases of stress urinary incontinence. Also in those patients that must be submitted to a surgical procedure, this training program might improve the results obtained used as a helping therapy. Physiotherapy through an exercise program will not produce a cure or improvement in all the cases of stress urinary incontinence, but, appropriate supervises techniques and muscular rehabilitation, done rigorously, may have a significant part in SUI 34. The perineal exercises may be used in selected cases as a new option in the treatment of urinary incontinence, being in the pre operative, in those cases where surgery failed, or as an isolated treatment in the expectation of reducing urine loss or curing urinary incontinence.