7F - To contract or not to contract: Should we use pelvic floor muscle exercises in the treatment of dyspareunia?

Part of the special issue: Abstract of the National Congress of the Italian Society of Urodynamics (SIUD 2024), 20-22 June 2024 • Catania, Italy • Publication of this supplement is supported by the Società Italiana di Urodinamica – SIUD.Introduction and aim of the study/Introduzione e scopo dello studio: Dyspareunia is a common condition of the chronic pelvic pain that affect sexual activity. Within the physiotherapy community and on social media platforms, there is a prevailing belief that relaxation techniques should be prioritized for managing pain associated with dyspareunia, while exercises targeting the pelvic floor muscles (PFM) should be avoided. This research evaluates the existing literature to explore the role of PFM exercises in the treatment of dyspareunia, aiming to discern both the benefits and limitations of this treatment modality. Furthermore, it investigates the rationale behind the recommendation to avoid PFM exercises in cases of dyspareunia. Materials and methods/Materiali e metodi: Studies included in this review were derived from searches conducted for the purpose of other reviews performed by the authors of this paper conducted in January 2023 and updated in December 2023. Additionally, complementary searches were carried out in PubMed in December 2023, utilizing a combination of keywords associated with dyspareunia, physiotherapy, and pelvic floor exercises. We also searched reference lists of previous review articles in this area. Results/Risultati: Depending on the specific type of dyspareunia and treatment objectives, PFM exercises may enhance muscle contractility and relaxation, boost strength and endurance, and improve blood flow. These exercises can also improve the condition and elasticity of vaginal mucosal tissue. Furthermore, they may foster greater bodily awareness, motor acuity and sensation. Recent systematic review on PFMT showed effectiveness of PFM exercises, also in terms of improvements in sexual pain. Interpretation of results/Discussione: The evidence presented indicates that PFM exercises can be effective in treating dyspareunia. Their efficacy is particularly notable when the exercises are performed thoughtfully and under supervision, emphasizing precise contraction, relaxation, and awareness, rather than being carried out automatically without consideration. Therefore, the objective of PFM exercises in addressing pain in dyspareunia may encompass not only traditional strengthening but also fostering awareness, coordination, and enhanced relaxation. Conclusions/Conclusioni: Based on the presented data, PFM exercises may have multiple applications in the treatment of dyspareunia. It appears essential to consider them as a multifaceted intervention that can be adapted in various forms and for diverse objectives, which extend beyond simple strengthening. PFM exercises have been widely incorporated in research studies, which suggest positive outcomes and the safety of the interventions implemented, contrary to the prevailing beliefs

239 - What is the most effective pelvic floor muscle training type, dose, and delivery method for females with urinary incontinence? A Cochrane review with meta-analysis

Hypothesis / aims of studyWe updated the 2011 Cochrane review comparing different approaches to pelvic floor muscle training (PFMT) [1] to treat female urinary incontinence (UI) for two reasons. First, to address ongoing uncertainties as a scoping search suggested many more potentially eligible randomised controlled trials (RCTs) were published. Second, neither the previous review nor the most up-to-date alternative [2] applied ‘Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) to gauge evidence certainty to underpin clinical decision-making. Therefore, we aimed to complete a systematic review and meta-analysis, using contemporary Cochrane methods, of RCTs comparing different approaches to PFMT to increase the power, accuracy, and certainty in effect estimates. We investigated differences in exercise type, dose, and intervention delivery.Study design, materials and methodsSystematic review methods were according to the Cochrane Handbook for Systematic Reviews of Interventions (version 6.4). The previous review was, as per Cochrane practice, the published protocol for the update [1].Eligible trials were RCTs (excluding cross-over RCTs) in females with UI. Trials with pregnant or postpartum participants or those with neurological conditions were excluded. To investigate different pelvic floor muscle (PFM) exercise types, eligible RCTs compared coordinated (voluntary PFM contraction with other body movement, e.g. squats), or functional (voluntary PFM contraction within activities of daily living, e.g. the Knack), or indirect (exercise to improve PFM function without voluntary PFM contraction) or combined (indirect with direct) training versus direct PFMT (repeated, isolated, voluntary PFM contractions). To investigate exercise dose, eligible trials had the same exercise type and delivery method in both trial arms but with differences in exercise dose (e.g. more versus fewer training sessions per week). For exercise intervention delivery eligible trials compared different methods of delivery/supervision (e.g. more versus less in-person clinic supervision).The Cochrane Incontinence Specialised Registry was searched on 27 September 2023, with no date or language limits. The register comprises studies identified from: the Cochrane Central Register of Controlled Trials, MEDLINE, CINAHL and handsearching. Study records were screened in Covidence. Each review stage was completed by two independent reviewers with any disagreements resolved through discussion: title and abstract screening, full text screening, data extraction onto a template revised from the previous review to include Consensus on Exercise Reporting Template PFMT (CERT-PFMT) items [3], and risk of bias (RoB) assessment using Cochrane ROB tool v1. All records were re-screened and evaluated regardless of inclusion or exclusion from the previous review. Two reviewers (JHS, MSP) cross-checked all RoB assessments, and completed the GRADE certainty of evidence ratings. Decision-rules were documented to ensure consistency.The primary outcome was incontinence or lower urinary tract symptom specific quality of life (QoL) at the primary endpoint (as defined by trialists), measured using any instrument rated A or A+ by the 7th ICI based on psychometric properties [2]. We contacted study authors if data were collected but missing, incomplete, or reported in unusable format. The secondary outcomes (incontinence episode frequency, incontinence symptom severity, patient-reported improvement, patient-reported satisfaction, and adverse events) are not reported here.A standardised mean difference (SMD) with inverse variance weighted method was used in RevMan Web 2023 for meta-analysis. Thresholds suggested by Cohen (1988) were used for interpretation: a small (> 0.2 to <0.5), moderate (> 0.5 to < 0.8), and large (> 0.8) effect. Effect sizes under 0.2 were considered unimportant even if statistically significant.Data were pooled in subgroups only; subgroups organised data by intervention and comparator. If within subgroup heterogeneity was substantial (I2 > 50%) we conducted a sensitivity analysis (low versus higher risk of selection bias, and attrition bias). If the between subgroup heterogeneity was substantial, we narratively summarised plausible explanations.ResultsAfter removing duplicates, we screened 2385 records and excluded 2172 based on title/abstract. From 213 full texts retrieved, 87 were excluded, most commonly for an ineligible comparison. The remaining full texts represented 126 trials (some with more than one full text): 64 included trials, 40 eligible ongoing trials, and 22 trials awaiting classification (i.e. missing information precludes eligibility decision). Trials included 4972 participants: previous review included 21 trials, 1490 participants [1].Sixty-one RCTs were parallel designs, and three were cluster RCTs. Sample sizes ranged from 11 to 362. Nine trials recruited > 50 participants per trial arm. The nine larger trials contained 42% of participants (2090/4972) but three of them reported no outcome of interest or usable data.No trial was conducted in a low-income country. Seven were completed in lower-middle income countries but 3 reported no outcome of interest or usable data.Overall RoB rating considered selection, attrition, reporting and other bias with five at low risk overall, six at high risk, and the remainder at unclear risk. Regarding selection and attrition bias, on which sensitivity analysis was based, there were 19 low and six high risk, and 22 low and 27 high risk trials respectively. Risk of bias rating did not consider blinding because all outcomes of interest in the review were patient-reported.UI diagnoses were stress UI (n=36), stress predominant mixed UI (n=10), stress or mixed UI (n=6), stress, urgency, or mixed UI (n=7), and undefined “urinary incontinence” (n=4). Trial participants were typically aged from 45 to 65 years and parous, with no prior incontinence treatment or pelvic surgeries, or other appreciable pelvic floor dysfunction.Trials compared exercise type (27 trials; 3 subgroups), dose (11 trials, 4 subgroups) and intervention delivery (26 trials; 5 subgroups with data, and one without any usable data). Correct voluntary PFM contraction was confirmed for all women (35 trials), in one trial arm (five trials), or not mentioned.In addition to reporting only QoL here, we do not report findings from subgroups containing a single, small trial; in those instances, the number of downgrades of evidence quality precluded a certainty of evidence statement.Summary of findings is presented in Table 1.Interpretation of resultsThe number of trials, and participants, has trebled. Progress is being made toward addressing the highest priority uncertainty in incontinence research—what is the optimal PFMT protocol—identified by Buckley and colleagues using a James Lind Alliance approach in 2010. However, the specific uncertainties they mentioned—training frequency and duration, and the optimal training for different patterns of UI—remain. Too few trials investigate exercise dose or recruit females with diagnoses other than stress or stress predominant UI.There is now some moderate certainty evidence to support clinical decisions about PFMT and its delivery in mid-age and older women. There is probably not support for indirect training approaches, alone or in combination with direct PFMT. Adding a resistance device to PFMT probably adds no benefit. There is probably no important difference in incontinence QoL outcome between individual and group supervision of PFMT; a correct contraction was confirmed prior to group supervision in 3 of 6 trials (209/280 women, 75%). Using e-health for delivery of PFMT is probably better than written instructions only.To increase evidence certainty for clinical decision-making, in addition to the usual improvements in trial size, methods and reporting, we need to address important uncertainties such as those identified by Buckley and colleagues.Concluding messageOf the many methods of training that appear to be used in practice, direct PFMT is probably the intervention of choice. In-person supervision can probably be offered individually or in groups after confirmation of a correct PFM contraction. If supervision is not-in-person then e-health is probably better than written instruction.Funding None Clinical Trial No Subjects Non

26 - Can digital palpation accurately assess pelvic floor muscle tone? Comparing palpation to ultrasound and dynamometry.

Hypothesis / aims of study: Alterations in pelvic floor muscle (PFM) tone play a key role in the pathophysiology of various pelvic floor disorders, such as incontinence and vulvodynia. While various methods exist for evaluating PFM tone [1] digital palpation remains widely used in clinical practice as it is inexpensive, readily available, quick, and easy to perform. However, its clinimetric properties are not well supported empirically, with limited evidence available to substantiate its validity and sensitivity. No study has yet investigated a large number of participants with different PFM tone levels and compared subjective digital palpation measures with more validated, objective in vivo measurements. To address this gap in knowledge, this original study aimed to assess the validity of digital palpation in evaluating PFM tone using the Reissing scale by: (1) examining the association between palpation scores and both dynamometry and ultrasound imaging, and (2) determining whether the scale's levels can be distinguished using dynamometry and ultrasound imaging. Study design, materials and methods: The cross-sectional data used for this study were derived from two large multicenter randomized controlled trials, which included nulliparous women with provoked vestibulodynia (PVD) and postpartum women with stress or mixed urinary incontinence (UI). PFM tone was evaluated via digital palpation at the 6 o'clock position (toward the posterior fourchette) using the Reissing scale, ranging from -3 (no resistance) to +3 (very firm resistance). Dynamometry evaluation included assessment of passive PFM forces at a 15 mm vaginal aperture and flexibility, defined as the distance between the device's branches at the maximal tolerated vaginal aperture. Transperineal 3D/4D ultrasound imaging was used to measure the levator hiatus area and anteroposterior diameter at rest. Results: The study sample included 528 women aged 18-45: 209 (40%) with PVD and 319 (60%) with UI. They were assessed by 34 physiotherapists with 0.05). For levator hiatus anteroposterior diameter, significant difference was obtained for the following Reissing scores: 3-1; 3-0; 3-(-1); 3-(-2); 2-1, 2-0; 2-(-1); 2-(-2); 1-(-1); 1-(-2) (post hoc p<0.05). Interpretation of results: The findings of this study showed that PFM tone assessed with digital palpation was significantly associated with more objective tools, such as dynamometry and ultrasound imaging. While physiotherapists could discriminate between several levels of the palpation scale, the ability to distinguish between adjacent scale levels was lower, particularly at the negative scores of the scale (decreased tone scores). Concluding message: Digital palpation may serve as a valid tool for providing an approximate assessment of PFM tone and can be useful in clinical practice. However, it lacks the sensitivity to detect small differences in PFM tone and may not be suitable for assessing treatment effects or for research purposes.Funding This study was supported by the Canadian Institutes of Health Research [grant numbers 148493, MOP-115028]. The laboratory infrastructures were funded by the Canadian Foundation for Innovation. Dr. Starzec-Proserpio received a fellowship from the Canadian Institutes of Health Research [MFE-194010]. Dr. Morin received a salary award from Fonds de recherche du Québec – Santé. The study funders had no role in the design, conduct and reporting of the study. Clinical Trial No Subjects Human Ethics Committee Research Ethics Committee of Centre intégré universitaire de santé et de services sociaux de l'Estrie - Centre hospitalier universitaire de Sherbrooke. Helsinki Yes Informed Consent Ye

242 - Dry needling to treat provoked vestibulodynia: results of a feasibility and acceptability randomized controlled trial

Hypothesis / aims of study: Provoked vestibulodynia (PVD), the most common subtype of vulvodynia, is characterized by chronic sharp pain at the vaginal entry upon pressure or attempted penetration. Despite the high prevalence of this condition, patients face a scarcity of effective therapeutic options [1]. Dry needling (DN) has shown promising results in treating various musculoskeletal conditions by targeting abnormally increased muscle tone, a key factor in the pathophysiology of PVD [2]. However, this treatment approach has never been examined for the treatment of PVD. This study aimed to 1) assess the feasibility and acceptability of using DN to treat women with PVD, and 2) explore the effects of realDN compared to shamDN on pain intensity. Study design, materials and methods: A parallel, 2-group, randomized feasibility and acceptability study was conducted. The design and methodology complied with the recommendations of the CONSORT extension for feasibility trials. Forty-six women aged 18 to 45 years old and diagnosed with PVD by a gynecologist on our team were randomly assigned (1:1) to receive either weekly sessions of realDN or shamDN for six weeks. Feasibility was measured throughout the study and included adherence to treatments, completion of questionnaires, retention rates and side effects. Acceptability was assessed at posttreatment with a validated questionnaire. Pain intensity during intercourse (numerical rating scale 0-10) was measured at baseline and posttreatment. The sample size of 46 participants was calculated a priori based on adherence (>70%) and retention (>85%) rates, using a one-sample, two-sided test with a 5% alpha level, 80% power, and a 10% anticipated dropout rate [3]. Linear mixed model, following an intention-to-treat approach, was used to examine the effects of DN on pain. Results: Women in the realDN group attended 99% of the scheduled treatment sessions, compared to 91% in the shamDN group (p >.05). Additionally, 100% of the questionnaires were completed in the realDN group, compared to 93% in the shamDN group (p >.05). All participants in the realDN group completed the study, whereas two participants in the shamDN group withdrew. Regarding the main side effects, 96% of the participants in the realDN group and 52% in the shamDN group experienced muscle aches (p .05). Women in the realDN group showed a greater reduction in pain than those in the shamDN group, with a mean difference at posttreatment of 2.4 [95%CI 1.4; 3.3] (p < .001). Interpretation of results: This study was the first to examine the feasibility, acceptability and effects of DN for treating PVD. The high adherence rates to treatment and questionnaire completion, along with a very low dropout rate, surpassed our predetermined feasibility benchmarks. The overall perception of the acceptability of DN was high in both groups. These findings support the feasibility and acceptability of using DN to treat women suffering from PVD. In accordance with the literature, no major side effects occurred. This study demonstrated that realDN resulted in a statistically significant and clinically meaningful greater reduction in pain intensity during intercourse compared to shamDN. Concluding message: This study's findings support DN's feasibility and acceptability in treating women with PVD. They also demonstrated a clinically and statistically significant effect on pain. The results lay the groundwork for a larger randomized controlled trial needed to establish the efficacy of DN in that population.Funding This work was supported by the Partenariat de recherche clinique en physiothérapie of the OPPQ/ REPAR and the National Women's Health Research Initiative of the Canadian Institutes of Health Research. Melanie Roch received a doctoral scholarship and Melanie Morin, a salary award from Fonds de Recherche en Santé du Québec. Clinical Trial Yes Registration Number ClinicalTrials.gov, NCT05797480 RCT Yes Subjects Human Ethics Committee This study was approved by the Human Ethics Committee of CIUSSS de l’Estrie-CHUS approval #2023-4686. Helsinki Yes Informed Consent Ye