Evolution des indications et des protocoles de rééducation des incontinences urinaires et fécales et des troubles de la statique pelvienne: une question d’intégration
Developments in indications and rehabilitation protocols for urinary and fecal incontinence and for static pelvic disorders: a question of integration
Pelvic perineology is an emerging new discipline that represents fundamental developments in the care of continence and static pelvic disorders with reference to embryological, anatomical and physiological information, enabling recommendations for a comprehensive, multidisciplinary approach. Within this context, it was of interest to reassess developments related to perineal sphincter rehabilitation, the resulting implications on pelvic perineology and to try to address basic questions: what outcomes can be expected from rehabilitation in the care of urinary or fecal incontinence? At what stage should it be integrated into the therapeutic protocol? What guidelines should be used?
With this in mind we reviewed the literature regarding the indications, objectives and the results of rehabilitation as well as predictive factors in these results based on information from clinical examinations, physiotherapy reports and examinations of ano-rectal functioning, urodynamics, electrophysiological or medical imaging. The numerous studies are not really comparable and it is difficult to clearly identify predictive factors. There is agreement that the essential first phase of care is a complete and detailed clinical report. The selection of patients and especially their motivation are recognized predictive factors while there does not seem to be agreement on physical examinations apart from the anatomical integrity and the absence of pudendal neuropathy. With regard to fecal incontinence, the incontinence history and the severity of the symptoms do not seem to interfere with the quality of the results, while the absence of defecation disorders and the recuperation of rectal sensitivity and recto-striated sphincter reflex (RSSR) seem to he strong determinants. For women with urinary incontinence hormone replacement weak urethral mobility are important parameters. Determining parameters in rehabilitation are the improvement of muscular coordination and spontaneous contractions during effort.
The evolution of perineal rehabilitation towards pelvic perineology came about by integrating new physiological and functional data, the literature of which we have also reviewed. In maintaining an overall view, taking into consideration the pelvic-lumbar static, the management of hyperpressive ingredients of effort, muscular synergy and the clever integration of the abdominal band, rehabilitation aims to develop four abdomino-perineal abilities: abdomen competency, which means its ability to contract during effort; pelvic-floor competency or perineal locking; abdomino-perineal synergy which corresponds to perineal contraction created by a contraction of the abdominal band; and the tonic abdominoperineal coordination which ensures the abdomino-perineal pre-contraction state.
competence, pelvic floor, pelvic perineology, predictive factors, rehabilitation, review of the literature