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Commented Abstracts

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  • Prevention of postpartum stress incontinence in primigravidae with increased bladder neck mobility: a randomized controlled trial of antenatal pelvic floor exercises.
    Reilly ET, Freeman RM, Waterfield MR, Waterfield AE, Steggles P, Pedlar F.
    BJOG 2002 Jan;109(1):68-76


OBJECTIVE: To test whether supervised pelvic floor exercises antenatally will reduce the incidence of postpartum stress incontinence in at-risk primigravidae with bladder neck mobility, ultrasonically proven. 

: Single blind, randomised controlled trial.

SETTING: Antenatal clinic in a UK NHS Trust Hospital.

SAMPLE: Two hundred and sixty-eight primigravidae attending an antenatal clinic at approximately 20 weeks of gestation with bladder neck mobility, on standardized valsalva, of 5 mm or more linear movement. The median age was 28, ranging from 16 to 47 years. 

INTERVENTION: Patients randomised to supervised pelvic floor exercises (n = 139) attended a physiotherapist at monthly intervals from 20 weeks until delivery. The exercises comprised three repetitions of eight contractions each held for six seconds, with two minutes rest between repetitions. These were repeated twice daily. At 34 weeks of gestation the number of contractions per repetition was increased to 12. Both the untreated control group and the study group received verbal advice on pelvic floor exercises from their midwives antenatally.

MAIN OUTCOME MEASURES: Subjective reporting of stress incontinence at three months postpartum. Pelvic floor strength, using perineometry, and bladder neck mobility measured by perineal ultrasound.

RESULTS: Of the 268 women enrolled, information on the main outcome variable was available for 110 in the control group and 120 in the study group. Fewer women in the supervised pelvic floor exercise group reported postpartum stress incontinence, 19.2% compared with 32.7% in the control group  (RR 0.59 [0.37-0.92]). There was no change in bladder neck mobility and no difference in pelvic floor strength between groups after exercise, although all those developing postpartum stress incontinence had significantly poorer perineometry scores than those who were continent.

CONCLUSIONS: The findings suggest that antenatal supervised pelvic floor exercises are effective in reducing the risk of postpartum stress incontinence in primigravidae with bladder neck mobility.

                                     EDITORIAL COMMENT

Birth is associated to the lesion of the pelvic floor with a potential to developing stress urinary incontinence and prolapse. The possibility of preventing these lesions by strengthening this musculature is encouraging. In this random single blind trial, the patients that do supervised exercises presented lesser rates of urinary incontinence than those that received only verbal orientation (19.2%against 32.7%). In what refers to the strengthening of the pelvic floor musculature these findings are similar to those of other authors that showed that the supervision should be fundamental for the correct realization of the exercises and the adherence of the patient to the proposed treatment. It is curious to observe that there was no significant difference in muscular strength measured with a among the groups that were studied. Only the patients with urinary incontinence showed significantly diminished muscular strength. We must make clear that the patients were pregnant for the first time, they were re-evaluated after three months of birth and the incontinence was classified as light in all the patients that presented urinary loss. In many cases a regression occurs regression of the complaints with a few additional months of follow-up, but these patients form a risk group for the development of SUI in long term.

Aparecido Donizeti Agostinho

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