Eficacia de las intervenciones realizadas en el posparto para prevenir la incontinencia urinaria: revisión sistemática

Saboia, Dayana Maia; Bezerra, Karine de Castro; Vasconcelos Neto, José Ananias; Bezerra, Leonardo Robson Pinheiro Sobreira; Oriá, Mônica Oliveira Batista; Vasconcelos, Camila Teixeira Moreira

doi:10.1590/0034-7167-2017-0338

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Revista Brasileira de Enfermagem

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Sumário

REVIEW • Rev. Bras. Enferm. 71 (suppl 3) • 2018 • https://doi.org/10.1590/0034-7167-2017-0338 copiar

Eficacia de las intervenciones realizadas en el posparto para prevenir la incontinencia urinaria: revisión sistemática

Autoría SCIMAGO INSTITUTIONS RANKINGS

RESUMEN

Objetivo:

analizar la eficacia de las intervenciones realizadas en el posparto para prevenir la incontinencia urinaria.

Método:

revisión sistemática de estudios aleatorizados controlados, realizada en las bases de datos MEDLINE, Cochrane, Scopus y Biblioteca Virtual en Salud - BVS.

Resultados:

seis artículos fueron incluidos en la revisión. Todos los estudios utilizaron el Entrenamiento de la Musculatura del Piso Pélvico como intervención principal para prevenir la incontinencia urinaria y los resultados de las intervenciones apunta a un efecto positivo y eficaz del mismo en el posparto.

Conclusión:

hay evidencias de que programas de ejercicios de la musculatura del piso pélvico realizados tanto en el posparto inmediato como en el tardío resultan en un aumento significativo de la fuerza muscular y contribuyen a la prevención de la incontinencia urinaria.

Descriptores:
Prevención Primaria; Eficacia; Diafragma de la Pelvis; Incontinencia Urinaria; Período Postparto

Component	Definition	Keywords
P: Population of interest	Women in vaginal post-partum with no urinary incontinence.	Postpartum Period; Postnatal Care; Postpartum Care.
I: Intervention	Conservative interventions.	Exercise Therapy; Muscle Strength.
C: Comparison	No treatment; routine treatment of the site of study; combination of other interventions.	No keywords were used.
O: Outcome	Primary: Prevalence of urinary incontinence. Secondary: assessment of the pelvic floor strength; adherence and characteristics of the intervention.	Urinary Incontinence; Stress Urinary Incontinence; Pelvic Floor.

Reference, year and quality of study	Sample (N)	Inclusion Criteria	Intervention performed	Comparison group	Period PP^* * PP: post-partum; of the intervention's onset	Frequency and length of the intervention	Duration of protocol	Follow-up time
Sllep; Grant, 1987. Jadad 3.	Initial: 1800 CG^≠ ≠ Control Group. : 900 IG^π π Intervention Group; : 900	Vaginal delivery	TPFM^β β Training of the Pelvic Floor Musculature; + Usual care	Usual care^ Usual care considered those performed as a routine in each study site.	24 hours	As many times as they remembered	4 weeks	Partial: 10 days Final: 3 months
Morkved; Bo, 2000. Jadad 3.	Initial: 198 CG^≠ ≠ Control Group. : 99/IG^π π Intervention Group; : 99 Final: 162 CG^≠ ≠ Control Group. : 81/IG^π π Intervention Group; : 81	Age: 19-40 years old Vaginal or caesarean deliveries Number of children: (1-5 kids)	TPFM^β β Training of the Pelvic Floor Musculature;	Usual care^ Usual care considered those performed as a routine in each study site.	8 weeks	- Once/week - 45 min/session	8 weeks	Partial: 8 weeks Final: 12 months
Chiarelli; Murphy and Cockburn, 2002. Jadad 4.	Initial: 720 CG^≠ ≠ Control Group. : 350/IG^π π Intervention Group; : 370 Final: 654 CG^≠ ≠ Control Group. : 348/IG^π π Intervention Group; : 328	Instrumentalized vaginal delivery and/or Newborns≥4000g	TPFM^β β Training of the Pelvic Floor Musculature; + Training Bladder	Usual care^ Usual care considered those performed as a routine in each study site.	Up to 48 hours	- 3x/day, - Daily	8 weeks	Partial: 8 weeks Final: 3 months
Chiarelli; Murphy and Cockburn, 2003. Jadad 4.	Initial: 720 CG^≠ ≠ Control Group. : 350/IG^π π Intervention Group; : 370 Final: 654 CG^≠ ≠ Control Group. : 348/IG^π π Intervention Group; : 306	Instrumentalized vaginal delivery and/or Newborns≥4000g	TPFM^β β Training of the Pelvic Floor Musculature; + Training Bladder	Usual care^ Usual care considered those performed as a routine in each study site.	Up to 48 hours	- 3x/day, - Daily	8 weeks	Partial: 8 weeks Final: 3 months
Chiarelli; Murphy and Cockburn, 2004. Jadad 4.	Initial: 720 CG^≠ ≠ Control Group. : 350/IG^π π Intervention Group; : 370 Final: 569 CG^≠ ≠ Control Group. : 275/IG^π π Intervention Group; : 294	Instrumentalized vaginal delivery and/or Newborns≥4000g	TPFM^β β Training of the Pelvic Floor Musculature; + Training Bladder	Usual care^ Usual care considered those performed as a routine in each study site.	Up to 48 hours	- 3x/day, - Daily	8 weeks	Partial: 8 weeks Final: 12 months
Assis et al, 2013. Jadad 3.	Initial: 40 CG^≠ ≠ Control Group. :/IG^π π Intervention Group; : without information Final: 23 CG^≠ ≠ Control Group. : 12/IG^π π Intervention Group; : 11	Age (18-35 years old) Number of children (2-4) Post-partum vaginal delivery of fetus at term	TPFM^β β Training of the Pelvic Floor Musculature;	Usual care^ Usual care considered those performed as a routine in each study site.	35 to 40 days of puerperium	- Twice/week - 40 min/session	8 weeks	8 weeks

Study	Number of series	Number of contractions	Characteristics of the contraction	Length of contraction (seconds)	Interval between contractions (seconds)	Positioning during the exercise
Sllep; Grant, 1987.	No information	No information	No information	No information	No information	No information
Morkved; Bo, 2000.	2	8 to 12	Slow	6 to 8	No information	No information
Morkved; Bo, 2000.	2	3 to 4	Rapid	No information	No information	No information
Chiarelli; Murphy, 2002; Chiarelli; Murphy and Cockburn, 2003; Chiarelli; Murphy and Cockburn, 2004.	3	6	Slow	3 to 6	No information	No information
Assis et al, 2013.	3	8 to 10	Slow	10	10	Dorsal decubitus lateral and ventral, hands and knees touching the floor, seated and standing.
	3	12 to 16	Slow	20	20
	3	3 to 5	Rapid	2	6

Study	Measured variables	Conclusions	Prevalence of UI^β β Urinary Incontinence; complaints after the intervention
Sllep; Grant, 1987.	• Prevalence and frequency of the UI^β β Urinary Incontinence; • Prevalence and severity of the perineal pain • Time of resumption of sexual relations • Prevalence of dyspareunia • Prevalence of faecal incontinence • General well-being	Women in the intervention group were more perseverant with their exercises when evaluated 3 months after the partum. There were no differences between the two groups in terms of frequency or severity of UI^β β Urinary Incontinence; , but women in the intervention group were less likely to report perineal pain and feelings of depression 3 months after the partum.	IG^π: 22.1% CG^≠ ≠ Control Group; πIntervention Group; : 22.1% (p> 0.05)
Morkved; Bo, 2000.	• Strength of the PFM^α α Pelvic Floor Musculature; : -Digital palpation, -Vaginal balloon catheter (to measure the pressure during PFM contractions) • Assessment of urinary loss: -Index of urinary loss measured by a Likert-type scale with 13 types of physical effort with each response ranging from 1=never to 5=always, -Padtest.	The analysis with the paired test of Wilcoxon showed a greater increase in muscle strength (p=0.001) between the 16^th week and one year after the partum in the intervention group (Average: 4.4 centimetres H, O; 95% CI 3.2-5.6), than in the control group (Average: 1-7 cm H, O, 95% CI 0.8-2.7). There was a significant difference (p=0.03) in the urinary loss assessed by the Padtest between the intervention and control groups, 16 weeks postpartum and after 12 months of follow up. When comparing the control and intervention groups, 16 weeks after the partum (p<0.05) fewer women in the training group reported urinary loss. The difference was persistent during the 12 months of follow-up.	16 weeks Post-Partum (p= 0.026) IG^π: 7.9% (n= 13) CG^≠ ≠ Control Group; πIntervention Group; : 22.2% (n= 24) 12 months Post-Partum (p= 0.003) IG^π: 31% (n= 25) CG^≠ ≠ Control Group; πIntervention Group; : 38% (n= 31)
Chiarelli; Murphy and Cockburn, 2002.	• Evaluation of the presence of urinary losses through a dichotomous outcome, yes or no; • Severity of urinary losses; • Performance in the Exercises	After 3 months, the two groups differed in relation to the TPFM performance (p=0.001). In the usual care group, 189 women (57.6%) and in the intervention group, 292 women (83.9%) reported TPFM^µ µ Training of Pelvic Floor Muscles; at adequate levels. The TMAP program presented a protective factor for women who participated in the intervention group with a 35% lower chance of developing UI (OR: 0.65 IC: 0.46-0.91; p<0.01).	IG^π: 31.0% (n= 108) CG^≠ ≠ Control Group; πIntervention Group; : 38.4% (n= 125) (p< 0.044)
Chiarelli; Murphy and Cockburn, 2003.	• Global acceptance of the program to promote continence for post-partum women. • Perceived use and utility of program components;	Most of the women (81.4%) reported having read the flyer and found it quite useful. However, most said that it would be less useful (84.5%) or not useful (5%) if handed out without the advice of the health professional. The dropout rates in the intervention and control groups were the same: intervention group (5.9%) and control group (6.3%).	The prevalence of urinary complaints after the intervention was not measured.
Chiarelli; Murphy and Cockburn, 2004.	• Presence of urinary loss after one year of intervention; • Performance of women in the pelvic floor exercises after one year of intervention.	Although the intervention had not promoted continence at 12 months postpartum when compared to the control group, it appears to have encouraged continued practice of pelvic floor exercises for many women in the intervention group. In order to encourage adherence at a level adequate enough to promote continence at 12 months postpartum it is necessary to consider behavioural principles which will increase the likelihood of behavioural changes being sustained. Ideally, women need feedback and support in the context of PFM assessment provided by a health care provider periodically over and possibly beyond a year postpartum.	3 months: (p< 0.044) IG^π: 31.0% (n= 108) CG^≠ ≠ Control Group; πIntervention Group; : 38.4% (n= 125) 12 months: (p= 0.340) IG^π: 34.4% (n= 101) CG^≠ ≠ Control Group; πIntervention Group; : 36.4% (n= 100)
Assis et al., 2013	• Muscle strength using the perineometer and digital palpation; • Urinary symptoms (measured with the ICIQ-SF¹ 1 International Consultation Incontinence Questionnaire - Short Form; ).	The exercise program resulted in a significant increase in PFM strength (p<0.001). There was good correlation in the two evaluations (before and after the intervention) between the vaginal muscle strength measured by digital palpation and by the perineometer (1^st evaluation: r=0.889, p<0.001; 2^nd evaluation: r=0.925, p<0.001), indicating that vaginal palpation can be used in clinical practice because it is a low-cost method and demonstrated a significant correlation with an objective method, the perineometer.	IG^π: 0% (n= 00) CG^≠ ≠ Control Group; πIntervention Group; : 25% (n= 03) (p< 0.001)

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[1] CORRESPONDING AUTHOR: Dayana Maia Saboia. E-mail: day_saboia@yahoo.com.br