Urogynecological rehabilitation is the functional recovery of the dynamic system of the lower urinary tract, or the urinary-bladder system. The main objective is the recovery of continence.
REHABILITATION OF THE PELVIC FLOOR BEFORE AND AFTER CHILDBIRTH
There is a close correlation between the reproductive activity of women and their chances of developing a pelvic floor dysfunction in the medium to long term, and it is possible to identify before, during and immediately after pregnancy, regardless of the anamnestic, clinical and instrumental criteria adopted, the general population of women that are most at risk of developing symptomatic static pelvic alterations. Such alterations are susceptible to an effective conservative outpatient and/or home treatment. The implementation of conservative rehabilitative therapies at different times of the natural symptomatic history offers the possibility of a tertiary prevention of pelvic floor dysfunction (in which the symptom is stabilized and consolidated), or primary and/or secondary prevention (in which the emergence of symptoms is prevented or the symptoms are treated early on). In the prevention of pelvic floor dysfunction, pelvic floor rehabilitation (PFR) plays an undisputed role. The use of the ante-partum PFR, from the 20th week of pregnancy, for a total period of at least 28 days, in a population of 268 pregnant women with urethral hypermobility (UH), has been shown to be accompanied by a significant reduction of post-partum UH (19.2% vs. 32.7%, with an RR of 0.59 – Reilly 2002). Researchers agree, however, that the treatment protocol with the supervision of a healthcare professional is clearly more effective than simple verbal instruction (Bump 1991, Wilson 1996, Sampselle 1998, Reilly 2002). Ante-partum PFR, on the other hand, is accompanied by high drop-out rates (Toozs 1997, Chaliha 2000, Glazener 2001), though pelvic floor improvements reached in the ante-partum period are maintained in the post-partum period (Sampselle 1990). Additionally, this non-surgical, behavioural, rehabilitative and conservative therapy for post-partum UH shows a cure or improvement subjectively in 59% of cases and objectively in 49% of cases (Wijma 2001). Studies of primiparous women, assessed at 9 weeks and then at 10 months post partum, have shown a 19% reduction in urinary incontinence if preventively subjected to physiokinesitherapy, compared to a spontaneous regression of the symptoms of 2% seen in the control group not subjected to rehabilitation. PFR after pregnancy appears to be effective in the treatment of post-partum symptomatic UH in the short term, with results also maintained in the medium term (Nielsen 1988, Wilson 1998, Morkved 1997-1999-2000, Glazener 2001). Many physio-pathological and therapeutic aspects remain to be properly investigated and researched. According to the international scientific literature, it is clear, however, that rehabilitative therapies offer the possibility to adopt effective primary and secondary prevention of pelvic floor dysfunction and currently represent the only effective treatment in the face of the controversial and unjustified use of elective caesarean section. The current prevailing attitude in the use of urorehabilitation in the tertiary prevention of stabilized symptomatic cases should be supported and/or replaced by a new strategic vision of diagnostic and therapeutic intervention based on early conservative treatment of the general female population at risk, not only immediately post-partum, but also and especially in the early stages of pregnancy or, as in the most recent perineal care programs, even before conception. Effective and widespread information programs must be implemented and professionals trained in specific skills in order that they learn to take appropriate account, in this particular population, not only the symptoms of UH, but also the high morbidity frequently associated with it (including faecal incontinence, perineal pain, haemorrhoids and sexual, relationship and emotional issues).