盆底本体感觉训练联合常规疗法治疗女性压力性尿失禁的额外益处（英文）

Additional benefits of pelvic floor proprioceptive training combined with conventional therapy in the treatment of female stress urinary incontinence

摘要

目的 压力性尿失禁(stress urinary incontinence，SUI)是女性的一种常见疾病，严重损害其生活质量。盆底本体感觉训练(pelvic floor proprioceptive training，PFPT)因其在增强盆底肌肉功能和改善SUI症状方面的潜在作用而日益受到关注。本研究旨在观察和比较PFPT联合电针、电刺激和生物反馈疗法，与只应用电针、电刺激和生物反馈的常规疗法在治疗女性SUI中的临床疗效，并探讨PFPT在改善患者症状和功能结局方面的作用。 方法 本研究为随机对照试验，于2021年12月至2023年10月从中南大学湘雅三医院康复医学科招募72例轻中度SUI患者，随机分配至试验组(n=36)和对照组(n=36)。2组均接受健康教育，对照组接受电针、电刺激和生物反馈的常规疗法；试验组在对照组治疗的基础上增加PFPT，每周3次，持续4周。主要结局指标采用国际尿失禁咨询委员会尿失禁问卷简表(International Consultation on Incontinence Questionnaire-Short Form，ICIQ-SF)进行评估，次要结局指标包括盆底肌力、膀胱颈移动度和平衡能力。患者在治疗后1、3、6和12个月时使用ICIQ-SF进行重新评估。 结果 2组治疗前后的各项参数差异均有统计学意义(均P<0.05)。然而，大部分结局指标在2组之间差异均无统计学意义(均P>0.05)。试验组治疗后闭眼单足站立持续时间较对照组长(左下肢P=0.026，右下肢P=0.006)，且治疗后持续时间显著增加(P<0.001)。治疗后6个月，试验组的治愈率高于对照组(P=0.037)。 结论 常规疗法能有效改善SUI症状，但增加PFPT可带来显著的额外益处，包括增强平衡能力和维持中期治愈率。这提示PFPT为标准SUI管理方案中的一种有价值的辅助手段。

Abstract

Objective Stress urinary incontinence (SUI) is a common condition among women that severely impairs quality of life. Pelvic floor proprioceptive training (PFPT) has attracted increasing attention for its potential to enhance pelvic floor muscle function and alleviate SUI symptoms. This study aims to observe and compare the clinical efficacy of PFPT combined with electroacupuncture, electrical stimulation, and biofeedback therapy versus conventional therapy consisting of electroacupuncture, electrical stimulation, and biofeedback alone in women with SUI, and to explore the role of PFPT in improving symptom and functional outcomes. Methods In this randomized controlled trial, 72 women with mild to moderate SUI were recruited from the Department of Rehabilitation Medicine at Third Xiangya Hospital, Central South University, between December 2021 and October 2023. Participants were randomly assigned to an experimental group (n=36) or a control group (n=36). Both groups received health education. The control group underwent electroacupuncture combined with electrical stimulation and biofeedback therapy, while the experimental group additionally received PFPT 3 times per week for 4 weeks. The primary outcome was assessed using the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF). Secondary outcomes included pelvic floor muscle strength, bladder neck mobility, and balance ability. The ICIQ-SF was reassessed at 1, 3, 6, and 12 months post-treatment. Results Both groups showed statistically significant improvements in all parameters after treatment (all P<0.05). However, there were no statistically significant differences between groups in most measures (all P>0.05). The experimental group demonstrated longer single-leg stance duration with eyes closed than the control group (left leg: P=0.026; right leg: P=0.006), with a significant increase from baseline (P<0.001). At 6 months post-treatment, the cure rate in the experimental group was significantly higher than that in the control group (P=0.037). Conclusion Conventional therapy effectively improves SUI symptoms, but adding PFPT provides notable additional benefits, including enhanced balance ability and sustained mid-term cure rates. These findings suggest that PFPT is a valuable adjunct to standard SUI management strategies.

Graphical abstract

关键词

压力性尿失禁 / 盆底本体感觉训练 / 电针 / 盆底电刺激 / 盆底生物反馈

Key words

stress urinary incontinence / pelvic floor proprioceptive training / electroacupuncture / pelvic floor electrical stimulation / pelvic floor biofeedback

Stress urinary incontinence (SUI) refers to the involuntary leakage of urine from the urethral opening during activities that increase abdominal pressure, such as physical exertion, coughing, or sneezing^[1]. Epidemiological study^[2] has shown that approximately 18.9% of adult women in China are affected by SUI. Another study^[3] has also demonstrated that the risk and prevalence of SUI increase gradually with age. Although SUI does not pose a direct threat to life, it imposes significant inconvenience and distress on the daily lives and social activities of affected individuals. Patients often need to rely on sanitary pads or diapers to manage urine leakage, which not only affects their self-esteem and confidence but also results in social activity limitations and feelings of depression^[4-5]. Despite this, the rate of seeking medical care for SUI is low. A cohort study^[6] showed that only 30.7% of SUI patients sought clinical consultation.

The European Association of Urology (EAU) guidelines recommend pelvic floor muscle training (PFMT) as the first-line treatment for SUI^[7]. Multiple studies^[8-9] have shown that PFMT can effectively cure or improve the symptoms of SUI patients and enhance their quality of life with no adverse effects. However, it should be noted that a single treatment method may have difficulty ensuring effective contraction of the pelvic floor muscles (PFM). Additionally, studies^[10-12] have shown that without proper guidance for PFMT, 25% of patients may be unable to correctly contract their PFM. It is undeniable that the therapeutic effects of PMFT may vary due to individual differences, and in certain situations, adjunctive therapy may be necessary.

Researches^[13-15] have shown that some adjunctive treatment methods combined with PMFT have a positive impact on improving SUI and patients’ quality of life. A randomized controlled study^[13] demonstrated that combining PFMT with electroacupuncture treatment can reduce urinary leakage volume and the average number of incontinence episodes by over 50% in SUI patients, leading to a significant improvement in treatment outcomes. Electroacupuncture can promote and enhance the neuroreinnervation of PFM, as well as stimulate muscle contractions, thereby improving symptoms of urinary incontinence^[16]. In addition, according to international guidelines, incorporating biofeedback and supervised training programs can provide greater benefits for SUI patients. These benefits include improved treatment outcomes, enhanced patient convenience and compliance, as well as reduced treatment costs^[17-18]. Biofeedback techniques can help patients better understand the status of their PFM activity by providing auditory or visual feedback^[19]. The purpose of electrical stimulation is to induce contractions of the PFM by stimulating nerves, thereby enhancing the intrinsic components of the urethral sphincter closure mechanism^[20].

Another factor that may contribute to the variability in PFMT treatment efficacy is the abnormal timing sequence of muscle contractions, indicating that muscle strength is not the sole factor to consider when it comes to PFMT^[21]. Therefore, it is particularly important to accurately grasp the timing of PFM contractions in order to reduce the occurrence of SUI, proprioception plays an important role in timing and motor control^[22]. Study^[23] has shown that after proprioception training combined with biofeedback electrical stimulation treatment, PFM strength and endurance were significantly improved in patients with SUI, and the incidence of SUI was reduced. Proprioception training stimulates the local proprioceptors of the PFM, increases sensory input to the motor cortex of the brain, and enhances the ability of the corresponding neuromuscular response. It plays a role in promoting muscle function recovery^[24].

This study aims to investigate the therapeutic effect of combining pelvic floor proprioceptive training (PFPT) with electroacupuncture, electrical stimulation, and biofeedback in the treatment of SUI, and to provide clinical practice and research insights for the rehabilitation of SUI patients. Through this study, we hope to provide a more scientifically based treatment approach to improve the rehabilitation outcomes of SUI patients.

1 Subjects and methods

1.1 Ethics statement

This randomized controlled trial was conducted between December 2021 and October 2023 and adhered to the principles of the Helsinki Declaration and obtained approval from the Ethics Committee. We have fully informed all participants of the purpose and procedures of this study, and obtained informed consent from all participants. Our study follows the Consolidated Standards of Reporting Trials (CONSORT) guidelines for clinical controlled trials reporting. This study was registered through the China Clinical Trial Registry (Registration Number: ChiCTR2400083584).

1.2 Subjects

The subjects were recruited from the Department of Rehabilitation Medicine at Third Xiangya Hospital, Central South University. The inclusion criteria were as follows: 1) Age between 20 and 45 years with a history of childbirth; 2) meeting the diagnostic criteria for SUI according to the International Continence Society, experiencing unintentional urine leakage during exertion, sneezing, or coughing; 3) judged as mild to moderate severity of SUI based on the Ingelman-Sandberg scoring criteria^[25] (mild is defined as leakage during coughing and sneezing without the need for sanitary pads; moderate is defined as leakage during vigorous activities such as running and brisk walking, requiring the use of sanitary pads); 4) no pelvic floor-related treatment in the past 3 months; 5) willingness to participate in this study. The exclusion criteria were as follows: 1) Urgency, mixed, and other types of urinary incontinence; 2) pregnancy; 3) pelvic organ prolapse; 4) history of pelvic surgery; 5) urinary tract infection; 6) severe SUI or previous pelvic floor treatment; 7) suffering from various serious illnesses or having poor cognitive ability and unable to cooperate; 8) implanted cardiac pacemaker or psychological disorders; 9) urinary retention; 10) active vaginal bleeding; 11) vaginal stenosis; 12) urinary or genital tract infections; 13) pelvic or abdominal tumors. A total of 72 women (36 in each group) agreed to participate in the study, and only 69 (95.8%) completed the intervention treatment (Figure 1).

1.3 Randomization and blindness

The subjects were randomly assigned to an experimental group and a control group using a random number table method, and were aware of the pelvic floor treatment they received. During the study, the following personnel were blinded: 1) The assessors and therapists (assessment, treatment, and collection of questionnaire data were conducted by physicians who were unaware of the group assignments); 2) the statistical analysts who were not informed of the group assignments until completion of the result analysis; 3) patients were requested not to discuss their study subgroup status with the physicians performing the assessment and treatment.

1.4 Interventions

The control group received electroacupuncture, biofeedback, and electrical stimulation treatment, while the experimental group received PFPT in addition to the treatment given to the control group. The treatment was administered 3 times a week (every other day), for 4 weeks.

1.4.1 Pelvic floor proprioceptive training

1.4.1.1 Five-minute perineal sensory input training

In a quiet and private environment, the operator used a sterilized cotton swab to train the localization, 2-point discrimination, and graphic perception of the perineum. Vibration sensory training was conducted using a 128 Hz tuning fork. Five different weighted vaginal dumbbells (23 g/33 g/45 g/56 g/66 g) were placed on the perineum for weight discrimination training. Perineal localization training: In the lithotomy position, a sterilized cotton swab was used to draw a grid of 9 squares on the perineum (with a distance of approximately 10 centimeters in the anterior-posterior direction from the pubic area to the vaginal opening, and approximately 5 centimeters in the left-right direction between the base of the legs). The clinician then sequentially showed the patient the 9 areas of the grid and uses a sterilized cotton swab to point to a specific area, asking the patient to identify the precise location where the cotton swab was placed. Perineal 2-point discrimination: A caliper was used to measure the patient’s ability to discriminate between 2 points on the perineum. The distance between the 2 points was gradually reduced, and the shortest distance at which the patient can differentiate between the 2 points was recorded. A smaller distance indicates a better ability to discriminate between 2 points. Graphic perception: Using a sterilized cotton swab, arabic numerals from 0-9 or uppercase letters from A-Z were drawn on the perineum. The patient was then asked to identify the written number or letter. Vibration sensory training: A 128 Hz tuning fork was used to provide vibratory stimulation to the perineum, allowing the patient to perceive the stimulation of their PFM.

1.4.1.2 Five-minute intravaginal PFM sensory input training

The operator wore disposable latex gloves coated with lubricant, inserted the index finger of the right hand into the patient’s vagina to feel the tension of the PFM and performed the first stretch, and relaxation if the muscles were tense or spasmodic.

1.4.1.3 Five-minute pelvic and PFM sensory training

First, a pelvic model was given to the patient to introduce the basic anatomy of the pelvis and PFM. The patient was then instructed to stand with their feet shoulder-width apart, allowing them to touch and locate the pubic symphysis, ischial tuberosity, anterior superior iliac spine, and coccyx. Next, the patient stood with their toes slightly turned outward, performed hip external rotation, and then flexed the hips to enter a semi-squat position, feeling the stretching of the 2 sides of the ischial tuberosity moving away from each other, the 2 sides of the anterior superior iliac spine getting closer to each other, and the stretching of the PFM. Then, the patient stood up from the semi-squat position and felt the ischial tuberosities moving closer to each other, the anterior superior iliac spines moving away from each other, and the PFM contracting.

1.4.2 Electroacupuncture

1.4.2.1 Acupuncture points

Huyang acupoint (BL35), Zhongji acupoint (RN3), Qihai acupoint (BL24), Guanyuan acupoint (RN4), Shang Liao acupoint (BL31), Ci Liao acupoint (BL32), Zhong Liao acupoint (BL33), Xia Liao acupoint (BL34), Sanyinjiao acupoint (SP6), Shenyu acupoint (BL23), Zusanli acupoint (ST36).

1.4.2.2 Acupoint localization

Referring to the 2006 National Standard of the People’s Republic of China (GB/T12346-2006) “Names and Localization of Acupoints”, Qihai acupoint (BL24): 1.5 inches below the umbilicus on the midline of the abdomen. Guanyuan acupoint (RN4): 3 inches below the umbilicus in the midline of the abdomen. Zhongji acupoint (RN3): 1.5 inches below the umbilicus on the midline of the abdomen. Sanyinjiao acupoint (SP6): on the inner side of the lower leg, 3 inches above the tip of the inner ankle, at the posterior margin of the inner edge of the tibia. Shang/Ci/Zhong/Xia Liao acupoint (BL31/32/33/34): Located in the first, second, third and fourth post-sacral foramina respectively. Shenyu acupoint (BL23): Located below the spinous process of the 2nd lumbar vertebra, 1.5 inches to the side. Huyang acupoint (BL35): In the sacral region, 0.5 inches beside the end of the tailbone. Zusanli acupoint (ST36): On the lateral side of the lower leg, 3 inches below Dubi acupoint (ST35), on the line between ST35 and Jiexi acupoint (ST41).

1.4.2.3 Procedure

First, the patient was placed in a supine position, and the acupuncture points were locally disinfected with 75% alcohol. The BL24, RN4, SP6, and ST36 acupoints were needled with a 40 mm needle, and the needle was evenly lifted and twisted several times until a local soreness was felt. The RN3 acupoint was needled obliquely with a 50 mm needle, with the needle tip pointing towards the perineum until the needle sensation was transmitted to the perineum. The RN4 and BL24 acupoints were connected to an electroacupuncture instrument (Suzhou Hualun Medical Supplies Co., Ltd.). Then, the patient laid prone, and the acupuncture points were located and disinfected with 75% alcohol. The BL23 acupoint was needled with a 40 mm needle, and the needle was lifted and twisted evenly several times until a local soreness was felt. The BL31/32/34 acupoints were needled with a 60 mm needle until a soreness was felt in the pelvic area. The BL35 acupoint was needled slightly upward and outward with a 50 mm needle until local soreness was felt. The 2 sides of BL34 and BL35 were connected to an electroacupuncture instrument to enhance the needling sensation.

The 2 groups of acupoints were treated alternately with acupuncture every other day, and the needles were left in place for 25 minutes each time, for a total of 12 treatments.

Electroacupuncture parameters: Sparse-dense waves, frequency of 10/50 Hz, current intensity of 1-5 mA, adjusted according to the patient’s tolerance level.

1.4.3 Electrical stimulation and biofeedback

The Pelvic Health Rehabilitation Therapy Device, PHENIXUSB4 (Guangzhou Huibo Information Technology Co., Ltd.), was used for both electrical stimulation and biofeedback. After applying conductive gel, and the treatment probe was inserted into the patient’s vagina, and the grounded electrode piece was fixed at the anterior superior iliac spine, and the other 2 pieces were fixed to the rectus abdominis and internal and external abdominal obliques in the lower abdomen.

The prescription for pelvic floor electrical stimulation involves a current frequency of 50 Hz and a pulse width of 250 Hz. The current intensity should gradually increase until the patient feels a noticeable contraction of the PFM, but without experiencing pain. The current intensity can be gradually increased to 1-5 mA based on the patient’s adaptation. The electrical stimulation should last for 10-15 minutes.

The prescription for biofeedback therapy involves continuous contractions and rapid contractions of the PFM, targeting Type I and Type II muscle fibers respectively. It also includes incorporating simulated scenario training, such as performing PFM contractions in advance when coughing (A3 reflex training). The biofeedback therapy should last for 15-20 minutes.

All participants avoided receiving any other pelvic floor-related treatments during the course of this trial.

1.5 Outcome measures

1.5.1 International Consultation on Incontinence Questionnaire Short Form

The International Consultation on Incontinence Questionnaire Short Form (ICI-Q-SF) is concise and easy to use, making it suitable for clinical environments. It is used to assess the severity of urinary incontinence symptoms in SUI patients, as well as their impact on quality of life. In this study, the questionnaire was administered in Chinese. The Chinese version of the questionnaire^[26] had been validated and included 4 components: Frequency of urinary incontinence, amount of urinary leakage, impact on daily life, and type of urinary incontinence. The questionnaire was scored on a scale ranging from 0 (the best) to 21 (the worst) (2.52 as the smallest clinically important difference) to assess the impact of urinary incontinence on quality of life^[13]. A higher score indicates more severe urinary incontinence. Evaluations were conducted before the treatment, as well as at 1, 3, 6, and 12 months post-treatment.

1.5.2 Pelvic floor ultrasonography

Pelvic floor ultrasonography provides a clear, dynamic, and visual depiction of the pelvic floor anatomy. Parameters such as bladder neck mobility and bladder urethral angle are of significant value in diagnosing SUI^[27]. Before conducting this examination, it is necessary to ensure that the patient’s bladder and rectum are moderately empty. The residual urine volume in the bladder should be less than 50 mL. First, the patient was positioned in lithotomy position. The examiner placed a disposable examination cover over the probe and applies an appropriate amount of sterile coupling gel to both the inner and outer layers of the cover. The probe was then positioned and fixed in the perineal area of the patient. Next, a two-dimensional mid-sagittal plane scan was performed, which provided a clear display of the anterior, middle, and posterior pelvic structures, as well as the lower margin of the pubic symphysis. The position of the bladder neck and bladder urethral angle should be recorded in both resting and maximum Valsalva states.

1.5.3 Pelvic floor electrophysiologic examination

Measurement of PFM strength, fatigue, and muscle potentials by means of a vaginal built-in myoelectric probe.

1.5.4 Single-leg standing time with eyes closed

The measurement of single-leg standing time with eyes closed before and after treatment reflects changes in the patient’s balance ability.

1.5.5 Treatment efficiency

Based on the ICIQ-SF scores, the efficiency of the 2 treatment modalities at 1, 3, 6, and 12 months post-treatment was calculated by using the formula for calculating the efficacy index of the nimodipine method, ICIQ-SF minus=[(pre-treatment score-post-treatment score)÷total pre-treatment score]×100%. Among them, cure was defined as no urine leakage during increased abdominal pressure, ICIQ-SF score of 0 points; effective was defined as decreased frequency and volume of urine leakage during increased abdominal pressure, ICIQ-SF reduction rate ≥50%; ineffective was defined as no decrease in frequency and volume of urine leakage during increased abdominal pressure, ICIQ-SF reduction rate<50%. Treatment effectiveness rate=(number of cured cases+number of effective cases)/total number of cases×100%.

1.6 Statistical analysis

The data were statistically analyzed using SPSS 25.0 software. For continuous data, normally distributed variables were presented as mean±standard deviation and compared between groups using independent sample t-tests. Non-normally distributed variables were presented as median (1st quartile, 3rd quartile) and compared using Mann-Whitney U tests. For categorical data, frequencies (percentages) were used to present and χ² test was used to compare. A P<0.05 was considered statistically significant for indicating differences.

2 Results

During the study, 1 patient in the experimental group was lost to follow-up and withdrew due to incomplete treatment, and 2 patients in the control group withdrew for the same reason of incomplete treatment. Eventually, 69 (96%) participants completed this study without reporting any adverse reactions after the intervention. The patients in the 2 groups had similar demographic and clinical characteristics, indicating comparability (Table 1).

Before the treatment, there were no statistically significant differences between the 2 groups in terms of ICI-Q-SF scores, posterior bladder urethral angle, bladder neck mobility, PFM fatigue (Type 1 and Type II), and muscle potential (all P>0.05). After the treatment, there were still no significant differences in these indicators between the 2 groups (all P>0.05). However, significant differences were observed within each group when comparing the indicators before and after the treatment (P<0.05, Table 2).

Before the treatment, there were no statistically significant differences between the 2 groups in terms of PFM strength (P>0.05). After the treatment, the PFM strength of both groups improved significantly, and there was no significant difference between the 2 groups (P>0.05). However, there were statistically significant differences within each group before and after the treatment (P<0.001, Table 3).

Before the treatment, there were no statistically significant differences in the comparison of one-leg standing time with eyes closed between the 2 groups (both P>0.05). However, after the treatment, there were statistically significant differences between the 2 groups, as well as within each group before and after the treatment (all P<0.05). The experimental group showed a more significant improvement in one-leg standing time with eyes closed compared to the control group (Table 4).

There was no significant difference in the cure rates between the 2 groups at 1, 3, 6 and 12 months post-treatment (all P>0.05). However, at 6 months post-treatment, the experimental group showed a higher cure rate compared to the control group (P=0.037, Table 5).

3 Discussion

Our results showed that both treatments significantly improved patients’ symptoms and quality of life, with the combined PFPT group being more effective in improving patients’ balance and having significant long-term efficacy. This finding underscores the additional benefits of incorporating PFPT into conventional therapy, which not only enhances balance but also contributes to long-term symptom management.

Currently, proprioceptive training is widely applied in the fields of musculoskeletal disorders, neurological diseases, and sports. An 8-week proprioceptive training program for athletes with ankle sprains showed that proprioceptive training improved stability, muscle control, and posture^[28]. Hupperets, et al^[29] found that home proprioceptive training was effective in preventing recurrent ankle sprains following an initial ankle sprain. These researches clearly demonstrate that proprioceptive training improves motor function, enhances muscle control, and prevents disease recurrence. These findings align with our study’s results, highlighting the broader implications of PFPT beyond immediate symptom relief, including its role in preventing disease recurrence and improving motor function.

Research^[30] has indicated that women with urinary incontinence exhibit delayed PFM contractions during activities such as coughing and sneezing. During pregnancy and childbirth, excessive stretching of the PFM can result in nerve and muscle damage, leading to structural and functional disruptions of the PFM where proprioceptors receptors are located^[31], consequently affecting proprioception. PFPT used in this study is a relatively new treatment for SUI and has been less reported in the relevant literature. Vibration, position and 2-point discrimination sensations have been reported to enhance proprioception and improve motor function^[32-33]. The hospital where the authors are affiliated has been using this PFPT for over 6 years, and clinically, this training has been found to be more effective in treating patients with pelvic floor dysfunction, particularly for patients who have difficulty correctly contracting their PFM, with significant improvements observed. Pelvic floor proprioceptive measurements have not been reported. The PFM are part of the core muscle group, and posture control can affect balance and motor control. Research^[34] has shown that the balance ability of women with SUI is worse than that of healthy women. Therefore, this study measured the time of closed-eyes single-leg standing, which can reflect the recovery of proprioception in patients with SUI. The results of this study showed that there was no significant difference in closed-eyes single-leg standing time between the experimental group and the control group before the treatment; after the treatment, patients in the PFPT group had a significantly longer closed-eyes single-leg standing time than the control group, indicating that the PFPT used can indeed improve the overall stability and motor control ability of patients with SUI. This improvement in balance and motor control represents an additional benefit of PFPT, which is crucial for the overall functional recovery of patients with SUI.

At the 1st, 3rd, and 12th month after the treatment, there were no significant differences between the experimental group and the control group in terms of ICI-Q-SF scores, posterior vesicourethral angle, bladder neck mobility, PFM strength and fatigue, electromyographic activity, and cure rate. However, at 6 months post-treatment, the cure rate in the experiment group was significantly better than that in the control group. This suggests that the PFPT did not improve short-term efficacy but contributed to improving mid-term efficacy. PFPT plays a crucial role in mastering the timing of PFM contractions and improving motor control ability. By training SUI patients to contract their PFM at the right time, it is possible to effectively improve urinary incontinence symptoms and enhance quality of life^{[21-22, 35]}. Therefore, in addition to PFM strength, pelvic floor proprioception is also important for urinary control. However, the lack of significant difference in short-term efficacy may be because the treatment plan for the control group has already improved PFM strength and urinary control function in the short term. On the other hand, it may be because this study only had a sample size of 69 patients, which is relatively small and may not fully demonstrate the advantages of PFPT. Moreover, the lack of significant difference in cure rates between the 2 groups at the 12-month follow-up post-treatment may be attributed to multiple factors. One potential factor is the natural course of the disease. Some patients may experience spontaneous improvement or stabilization of symptoms over time, which could obscure the differences in treatment effects between the 2 groups at the 12-month follow-up post-treatment. Another possible factor is long-term patient adherence to the treatment regimen. Although standardized treatment protocols were strictly followed during the study period, patient compliance may have declined over the 12-month follow-up period.

However, this study still has certain limitations. First, due to the absence of a placebo control group in the study design, it is difficult to completely eliminate the effects of electroacupuncture, electrical stimulation, and biofeedback therapies on the outcomes, making it impossible to accurately isolate the individual therapeutic effect of PFPT. Secondly, the sample size is relatively small, and long-term follow-up was affected by the pandemic (such as exacerbated coughing symptoms due to COVID-19 infection in 2023), which may limit the generalizability and representativeness of the study results for a larger population of women with SUI. Future research could employ a three-arm design (PFPT alone, standard treatment alone, and combined treatment), as well as expand the sample size to verify the independent contribution of PFPT.

Although the addition of PFPT to electroacupuncture, electrical stimulation, and biofeedback therapy did not significantly enhance short-term efficacy, it improved the patients’ balance function and demonstrated a higher cure rate at the 6-month follow-up post-treatment. This suggests that PFPT may enhance long-term outcomes in SUI patients by strengthening PFM proprioception and motor control abilities.

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基金资助

the Natural Science Foundation of Hunan Province(2024JJ8121)

the Natural Science Foundation of Hunan Province(2024JJ6626)

the Hunan Provincial Key Research and Development Program(2023SK2038)

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©Journal of Central South University (Medical Science). All rights reserved.