© Borgis - New Medicine 1/2008, s. 8-12
*Krystyna Garstka-Namysł1, Juliusz Huber2, Magdalena Pisarska3, Grzegorz H. Bręborowicz4, Łucja Pilaczyńska-Szcześniak5
CHANGE IN THE ASSESSMENT OF SEXUAL INTERCOURSE OF WOMEN AFTER GYNAECOLOGICAL OPERATIONS CAUSED BY DISORDERS OF MICTURITION UNDER THE INFLUENCE OF ELECTROSTIMULATION OF PELVIC FLOOR MUSCLES AND OVERVERTEBRAL ELECTROSTIMULATION
1Section of Recreational Sports in the Chair of Pedagogy of Leisure and Recreation of the University School of Physical Education in Poznań Head of Section: Krystyna Garstka-Namysł PhD 2Department of Pathophysiology of Motor Organs of the University of Medical Sciences in Poznań 3Clinic of Operative Gynaecology of the University of Medical Science in Poznań 4Chair and Clinic of Perinatology and Gynaecology of the University of Medical Science in Poznań 5Department of Hygiene of the University School of Physical Education in Poznań
Summary
Background: Symptoms of urinary incontinence (UI) and pelvic floor muscle (PFM) and nerve activity disorders in women after gynaecological operations (OP) significantly affect the subjective assessment of quality of sexual life (QSL).
Aim of the study was to compare the changes in PFM activity resulting from electrotherapy using objective SEMG methods and to assess their influence on QSL.
Material and methods
27 women after OP with UI underwent gynaecological and global SEMG tests using a vaginal probe and an examination of motor evoked potentials (MEP) induced by a magnetic field. The parameters of 8-week home continued FES and EMS were individually set. Statistical analysis using Wilcoxon´s signed rank test and a T-test for dependent samples in the present and in the future was carried out.
Results
In 27 patients the EMG and MEP tests indicated a neurogenic cause of complaints in the form of axonopathy of motor fibres rather than weakened impulsation at the level of neurons of the motor centre. PFM resting tone improved from an average of 2.52 ěV before to 1.87 ěV after therapy, and strength of contraction from 14.7 ěV before to 16.9 ěV after. QSL was assessed on average as 3.41 before and 4.37 after the therapy (scale 1-5). Satisfaction with QSL and life optimism increased statistically significantly in each case.
Conclusions
The individually set FES and EMS therapy resulted in a statistically significant improvement of the functional state of motor units confirmed by objective SEMG and MEP tests. The therapy may lead to significantly QSL improvement.
Background
A gynaecological operation, like a hysterectomy, may result in a fundamental change in a woman´s life, particularly if it is related to disorders in sexual function and micturition. The social and psychological identity of women after hysterectomy loses its previous stability, as a result of giving up former social roles, and requires discovery of new ways to fill up time [1, 2, 3, 4]. The loss of personal independence enforces the search for new values inside a person which would ensure self-acceptance [5, 6]. Career, social life and sexual activity have basic significance for self-assessment [5, 7]. The adverse effect of an operation on sex life is an important element of deterioration in a subjective assessment of the sense of life quality. Functional disorders of pelvic floor muscles and nerves require physiotherapy [8, 9, 10, 11] and electrostimulation is an effective method of treatment [12, 13, 14]. Electrotherapy using intra-vaginal electrostimulation of pelvic floor muscles and oververtebral, transcutaneous FES stimulation should be individually planned and adjusted for the patient´s needs [15, 16, 17, 18]. Preliminary diagnostics of disorders of muscle activity using a urodynamic test and global electromyography is of basic significance for clinical practice [19, 20, 21].
AIM
Aim of the study was to compare the changes in PFM activity resulting from electrotherapy using objective SEMG methods and to assess their influence on QSL. As the nerves and muscles subject to stimulation in case of incontinence symptoms are also significant for sexual functions, we decided to investigate the relation between individually planned electrotherapy and EMG biofeedback exercises with the subjective assessment of quality of sex life. We believe that the full assessment of the value of individually planned therapy cannot be based exclusively on objective results of medical examinations, but should also include subjective aspects of physical, social and psycho-emotional health. [13, 20].
For the psychological assessment of changes in sexual life of the studied women we used the scale of sense of quality of life according to A. Campbell with the authors´ own modification [2, 3, 13, 21] in order to find behavioural and experience indicators and their significance for women after hysterectomy and sensitivity to the planned therapy.
Material and methods
The study included 27 women randomly selected from a group of 238 women after gynaecological operations (from 2 to 18 months, M=8.6 months after an operation) with symptoms of urinary incontinence. All women from the experimental group were qualified for the study (gynaecological, ultrasonographic, urodynamic, psychological, neurophysical examinations) and their socio-demographic characteristics were established. From the group of 27 patients subject to preliminary assessment, 18 have completed and 9 continue the planned electrotherapy.
The qualified patients underwent global electromyo-graphy and a standardised exercise test Work/Rest Assessment using a 2-channel device for EMG and EMG biofeedback (NeuroTrac(r)ETS – Verity Medical Ltd.) and a vaginal probe (Veriprobe). In biofeedback exercises before the therapy, the patients learned how to do contractions properly. Visualisation of the contraction on the computer screen helped them to understand the conscious effect on pelvic floor muscles and motivated them for the exercises. Before and directly after the therapy, motor evoked potentials (MEP) induced by the magnetic field within the motor centre of neurosegments of the sacral spinal cord were recorded.
Therapy
The patients were equipped with a specialist pelvic floor muscle and nerve stimulator NeuroTrac 4-Continence (Verity Medical Ltd.) and a vaginal probe (Veriprobe) and a set of self-adhesive electrodes 50x100 mm (Verity Medical Ltd.) for oververtebral stimulation FES (Fig. 1). The simulator allows individual settings of stimulation parameters.
Fig.1 Vaginal probe, stim unit, global EMG unit (VerityMedical Ltd.) and electrode placement for oververtebral FES.
On the basis of collected diagnostic data, individually for each patient parameters of muscular stimulation (NMES) and nervous functional oververtebral stimulation (FES) were selected. After thorough training on the use of equipment and providing detailed written indications for the performance of the treatment, the patients continued the therapy for 8 weeks at home. It was recommended to carry out 10-15 minute NMES stimulation of pelvic floor muscles twice a day and oververtebral stimulation FES 2 to 3 times a day according to established parameters.
Psychological tests
Using the Scale of Sense of Life Quality according to A. Campbell [4, 13] with a modification from the authors´ own perspective, satisfaction with life was measured using a 5-degree approximate scale, where 1-2 are dissatisfaction with life, 4-5 mean a high level of satisfaction with life, and 3 is a neutral attitude to life. The questions related to global assessment of quality of life and partial marks, both in the present and in the future, included 20 spheres of life: marriage, family life, career, health, neighbours, friends, household activities, leisure, eating, living in Poland, education, earnings, savings, living conditions, place of residence, living standard, medical care relating to the operation, availability of post-operative rehabilitation, sex life, and (me) self-assessment. Getting to know these spheres of life and ways of their assessment allows one to specify which of them are particularly important for carrying out normal life activities and for the possibility of full, active living and also the psychological consequences (changes in assessment) of a gynaecological operation and individualised electrotherapy.
Results
Out of 27 patients who underwent urodynamic tests a neurogenic component of the disorders was found in the majority (85%) (23 patients – difficulties in bladder emptying, overflow incontinence, urethrovesical dysfunction), and in 4 patients a mixed form of urinary incontinence (stress + urge) was found. As a result of EMG tests before the therapy, a neurogenic cause of complaints was found in the form of axonopathy of motor fibres and, to a lesser degree, weakening of impulsation at the level of neurons of the motor centre, which coincides with the results of urodynamic tests.
In the comparison of the results of EMG tests before and after the therapy, in 18 women it was found that individually set parameters for NMES and FES therapy beneficially affected the lowering of muscle resting tone amplitude (improvement by 26%). A significant improvement (by 48%) in the functional state of motor units in the conditions of maximum contraction was noted, as well as a better stability of relaxation stage (by 69%) (Table 1). In the MEP tests after electrotherapy an improvement in conductivity from the motor centre to a muscle was noted in all studied women. All patients who completed the therapy (N=18) noted regression of incontinence symptoms. These beneficial effects of individually planned therapy may be understood as an improvement in nervous and muscular co-ordination as a result of improved nervous conductivity or partial regeneration of damaged motor nerve axons. An increase in maximum contraction level and decreased during the therapy intensity of stimulation (in mA) necessary to cause a muscle contraction reported by patients implies a strengthening of muscles, their better adherence to the wall of the vagina and an improvement of function in sensory nerves. Patients also reported decrease in pain, better uninterrupted sleep, better bladder emptying, rare cases of urgency, giving up wearing sanitary pads, good well-being, improved moisture in the vagina, better satisfaction with sex life, increased libido, more frequent social contacts, and higher self-esteem.
Table 1. Effect of electrotherapy on muscle function.
| Stage | N | Muscle resting tone before exercise in ?V (mean value) | % change indicator for relaxation | Mean value of strength in the contraction stage in ?V |
| Before therapy | 27 | 2.52 | 11.39 | 11.41 |
| After therapy | 18 | 1.87 | 7.83 | 16.92 |
| % change | | +26% | +69% | +48% |
* prepared by K.Garstka-Namysł
Psychological tests relating to the psycho-social condition of functioning and quality of sex life showed an increase in the level of satisfaction with life on a global scale and in partial dimensions by 17% in the present and by 14% in the future (Tables 2 and 3). The greatest statistically significant positive changes (p=0.000, p=0.004, p=0.002) were noted in partial assessment of the subjective sphere of life, namely sex life, both in the present and in the future (Table 4). Positive physiological changes resulted in an increase of the level of life satisfaction, higher self-esteem and improved well-being resulting from the assessment.
Table 2. Assessment of global life quality, statistics for dependent samples (T-test)
Global Sense of Life
Quality | Measurement | Mean | Standard deviation | Standard error of the mean |
| SLQ present | 1 | N=27 | .47287 | .09100 |
| SLQ future | 1 | N=27 | .47069 | .09058 |
| SLQ present | 2 | N=18 | .48423 | .11414 |
| SLQ future | 2 | N=18 | .43853 | .10336 |
* prepared by K.Garstka-Namysł
Table 3. Life optimism as an indicator of sense of life quality in women after hysterectomy undergoing individual therapy.
| Global Life Quality |
| Present (P) Vs. future (F) | Difference for dependent samples
(T-Test) | Significance (bilateral) |
| Difference between measurements | Mean | Standard deviation | Standard error of the mean | t | Df | p |
SLQ 1 -P
SLQ 1 - F | .75169 | .61946 | .11921 | -6.305 | 26 | .000 |
SLQ 2 - P
SLQ 2 - F | .65967 | .50220 | .11837 | -5.573 | 17 | .000 |
SLQ 1-P
SLQ 2-P | .47441 | .47538 | .11205 | -4.234 | 17 | .001 |
SLQ 1 - F
SLQ 2 - F | .35625 | .55695 | .13127 | -2.714 | 17 | .015 |
* prepared by K.Garstka-Namysł
Table 4. Change in the assessment of sex in women after hysterectomy under the influence of individual therapy.
Sex after operation
Ordinal data differences using Wilcoxon signed rank test |
| Sphere of life present (P) vs. future (F) | Rank | N | Mean rank | Total of ranks | Wilcoxon´s test NPAR Z | Asymptotic significance (two sided) p |
Sex 1 (F)
Sex 1 (P) | Negative
Positive
Tied
Total | 2
18
6
26 | 4
11.22 | 8
202 | -3.657 | 0.000 |
Sex 2 (F)
Sex 2 (P) | Negative
Positive
Tied
Total | 0
10
6
16 | .00
5.50 | .00
55 | -2.850 | 0.004 |
Sex 2 (P)
Sex 1 (P) | Negative
Positive
Tied
Total | 0
12
4
16 | .00
6.50 | .00
78 | -3.090 | 0.002 |
* prepared by K.Garstka-Namysł
Conclusions
1. Psychological tests relating to the psycho-social condition of functioning of women after gynaecological operations with disorders of pelvic floor muscles showed that individually planned FES, EMS and EMG biofeedback therapy beneficially affects global feeling of quality of life both in the present and in the future.
2. Positive, subjective feelings of the patients are confirmed by objective results of medical tests such SEMG and MEP readings.
3. Two-month therapy of women after gynaecological operations with disorders of pelvic floor muscles according to the methods adopted in our study results in a radical improvement of subjective assessment of quality of sex life, both in the present and in the future.
4. Due to a clearly positive influence of the individually planned physiotherapy on various spheres of lives of women after gynaecological operations, which was documented with our study, we suggest that such therapy should be included in the standard post-operative procedure for these women.
Piśmiennictwo
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