Pelvic floor dysfunction is a suffering that presents which combines weakness, laxity of the pelvic muscles and ligaments and can cause some problems, for example, pelvic organ prolapses (POP) or urinary incontinence (UI) (Hadizadeh-Talasaz et al., 2019). These problems can have negative effects on women's sexual function (Hadizadeh-Talasaz et al., 2019; Rosenbaum, 2007), when appearing, for example, urine leaks during intercourse or dyspareunia; which decrease the pleasure of the sexual act (Kao et al., 2015). Pelvic floor dysfunction is favoured by risk agents specifically family history, obesity or instrumental births (Wu et al., 2014).
Previous research has identified that there is a lack of information among the female population worldwide, about pelvic floor dysfunctions and their therapeutic alternatives (Bo et al., 2017; Buurman & Lagro-Janssen, 2012; Caagbay et al., 2017; Campos et al., 2022; Hill et al., 2017). In addition, it has been seen that a significant percentage of women feel shame and anguish when communicating these dysfunctions to health professionals (Caagbay et al., 2017; Campos et al., 2022; Hill et al., 2017). Likewise, they are sometimes not sufficiently sensitized to this problem and its consequences (Bo et al., 2017; Buurman & Lagro-Janssen, 2012; Caagbay et al., 2017).
It has been seen that weak pelvic floor musculature can provide insufficient blood flow to the clitoris to reach orgasm (Hadizadeh-Talasaz et al., 2019). In addition, strong muscles, especially the hamstring muscle, are known to be important for achieving satisfactory arousal and achieving orgasm (Hadizadeh-Talasaz et al., 2019). In fact, the sexual pleasure of both partners is known to be increased by genital contraction of the levator of the anus, which involves the pubococcygeal and iliococcygeal muscles (Hadizadeh-Talasaz et al., 2019). Therefore, it is thought that sexual function can improve with the strengthening of the pelvic floor muscles (Ferreira et al., 2015; Rosenbaum, 2007).
There are several treatment options in relation to the level of affection of the pelvic floor involvement (Doaee et al., 2014). However, many investigations, which converge that pelvic floor muscle training is the treatment of choice for pelvic floor dysfunction (Kolberg Tennfjord et al., 2016); and that it can prevent sexual dysfunction (Boyle et al., 2014; Dean et al., 2008). Female sexual dysfunction (FSD) is a complex, multifactorial problem defined as ‘a deviation from the normal sensation and/or function experienced by a woman during sexual activity’ (Bo et al., 2017). These dysfunctions have been classified as sexual interest/arousal disorder, orgasmic disorder and genito-pelvic penetration/pain disorder (Sungur & Gündüz, 2014). For all this, for the female population, the use of pelvic floor muscle training (PFMT) is favoured to control sexual dysfunction (Ferreira et al., 2015), due to its low cost (Wagner et al., 2017) and its low risks (Dumoulin et al., 2018; Wagner et al., 2017).
RationalePelvic floor muscle training is negligibly aggressive and considerably approved by patients (Wu et al., 2018). It is based on a structured series of conscious and repeated contractions of the pelvic floor muscles (Wu et al., 2018). It was first described in 1936 as an option to prevent and treat both faecal and urinary incontinence in women (Price et al., 2010).
Pelvic floor muscle training became popular after the 1950s when Kegel for female urinary incontinence (UI) noted a number of cases of successful therapy through biofeedback exercises (Cox, 1995). Currently, PFMT encompasses a variety of therapeutic alternatives that include periodic voluntary contractions of the pelvic muscles (Kegel exercises) with or without the incorporation of vaginal weights, electrical stimulation and biofeedback therapy (Wu et al., 2018).
Research that has examined the impact of pelvic floor exercises on female sexual function is sparse and has reported conflicting results (Hoseinkhani & Taghian, 2018; Kolberg Tennfjord et al., 2016; Pourkhiz et al., 2017). This may be because studies have used very heterogeneous pelvic floor muscle training programs and have been performed with small and very diverse samples such as healthy women (Ferreira et al., 2015), with urinary incontinence problems (Haddow et al., 2005), pregnant and postpartum (Kolberg Tennfjord et al., 2016; Wu et al., 2021), women with POP symptoms (Braekken et al., 2014; Due et al., 2016; Li et al., 2016; Wiegersma et al., 2014) or women after surgery (Sobhgol et al., 2019). Moving on from this, to this day, women are sometimes favoured to practice PFMS to improve sexual function (Wu et al., 2018).
ObjectiveIn view of the above and taking into account that the preparation of a systematic review is an excellent way to synthesize the evidence, to date there is a lack of an integrative systematic review that evaluates the impact of PFMT on sexual function of women.
METHODOLOGY DesignA systematic review with possible meta-analysis will be conducted strictly following the requirements of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guide (Page et al., 2021) and the Standards for Systematic Reviews of the National Academy (Eden et al., 2011).
RegistrationThe protocol for this review was submitted to the International Prospective Register of Systematic Reviews of PROSPERO in April 2022 before commencing the review (PROSPERO registration number: CRD42022328033).
Study selectionWe will determine as eligible studies in Spanish, English or Portuguese published in the last 10 years (2012–2022). The studies will be selected from the components of the PICOS format (Stone, 2002).
Participants (P)This review will consider studies involving adult women (≥18 years) who have received a pelvic floor muscle training program.
- Later, nine subgroups of women will be established: (1) healthy women, (2) women with urinary incontinence, (3) women with pelvic organ prolapse, (4) postpartum women, (5) women after reconstructive vaginal surgery, (6) older women, (7) women with multiple sclerosis, (8) women with dyspareunia and (9) women with pelvic pain.
Studies evaluating a structured PFMT program in women to prevent or treat sexual dysfunction will be included.
- PFMT could include different teaching methods: Strength, coordination and/or relaxation training of the pelvic floor muscles by performing exercises individually or in groups, with or without the help of electrostimulation, vaginal weights or biofeedback.
- PFMT can be instructed and/or controlled by any healthcare professional or performed by themselves without supervision.
- PFMT may have different duration and different types and number of contractions.
Studies that include psychological therapies, sexual health counselling or education alone without a PFMT program will be excluded.
Comparisons (C)Comparison could be made with surveillance or other types of therapies (electrotherapy; botulinum toxin; amitriptyline administration; surgical treatment).
Outcomes (O)Sexual function, assessed using standardized clinical questionnaires. The efficacy of PFMTs on female sexual function will be established from the results of these clinical questionnaires.
Study design (S)Only randomized controlled trials (RCTs) published in peer-reviewed journals will be included.
In this way, the chosen RCTs are expected to answer the research question:‘Does pelvic floor muscle training prevent or improve sexual function in women?’
Search strategyBetween January and February 2023, two independent researchers (CSO, ESG) will systematically search in the following electronic databases: Cochrane Library, CINAHL, MEDLINE, EMBASE, PsycINFO, Web of Science and Scopus. The electronic databases will be accessed through the University of Valencia (Spain). Pilot searches will be conducted to test both recovery ratios and accuracy for recovery. Advice will be sought from both Pelvic Floor experts and librarians on the search strategy. The search for articles will be carried out using keywords based on the terms Medical subject heading (MeSH) (Table 1).
TABLE 1 Search terms.
| Women | Female |
| Pelvic floor | Pelvic floor disorders |
| Sexual dysfunctions, physiological | Sexual dysfunctions, psychological |
| Clinical trial | Intervention study |
Furthermore, the reference lists of located articles will be handsearched and grey literature will be consulted through ProQuest Dissertations & Theses. It will also be consulted in the Google Scholar metasearch engine. The search strategy can be found in Table 2.
TABLE 2 Search strategies.
| Search data | Keywords/descriptors | Search algorithm | Potential articles | |
| Databases | ||||
|
Pubmed (MEDLINE)
|
2023-02-24 |
#1 randomized controlled trial (Publication Type) #2 controlled clinical trial (Publication Type) #3 randoma (Title/Abstract) #4 trial (Title/Abstract) #5 pelvic floor (Title/Abstract) #6 sexuality (MeSH Terms) #7 sexa (Title/Abstract) |
(#1 OR #2 OR #3 OR #4) AND(#5) AND (#6 OR #7) | 159 |
|
Web of Science
|
2023-02-24 |
#1 pelvic floor #2 sexa |
(#1) AND (#2) | 102 |
|
Cochrane Library
|
2023-02-24 |
#1 pelvic floor: ti,ab,kw #2 sexa: ti,ab,kw |
(#1) AND (#2) | 3 |
|
CINHAL
|
2023-02-24 |
#1 pelvic floor: MH #2 sexuality: MH |
(#1) AND (#2) | 68 |
|
EMBASE
|
2023-02-24 |
#1 Title, abstract, keywords: (pelvic floor) #2 Title, abstract, keywords: (sexuality) |
(#1) AND (#2) | 42 |
|
Scopus
|
2023-02-24 |
#1 SU: (pelvic floor) #2 SU: (sexuality) |
(#1) AND (#2) | 36 |
|
PsycINFO
|
2023-02-24 |
#1 SU: (pelvic floor) #2 SU: (sexuality) |
(#1) AND (#2) | 1 |
| Grey literature databases | ||||
|
ProQuest Dissertations & Theses
|
2023-02-24 |
#1 SU: (pelvic floor) #2 SU: (sexuality) |
(#1) AND (#2) | 15 |
|
Google Scholar
|
2023-02-24 |
#1 allintitle: “pelvic floor” #2 allintitle: “sexuality” |
(#1) AND (#2) | 26 |
aTruncation; ti, Title Word; ab, Abstract Word; kw, Key Words (MeSH and other); MH, CINAHL heading; SU, subjects.
Selection of studiesFirst, the records obtained in the initial systematic search will be transferred to the Refworks bibliographic manager. With the help of the bibliographic manager, duplicate records will be identified and removed.
Second, two researchers (CSO, ESG) will independently review the titles and abstracts of the records to verify compliance with the inclusion criteria.
Third, the records that meet the inclusion criteria will be obtained in full text, and two researchers (CSO, ESG) will independently read them in their entirety to determine their inclusion in the review. In the event of discrepancies between the two researchers regarding the inclusion of a record, a third researcher (MLBT) will be consulted.
Quality and risk of biasThe quality and risk of bias of the included records will be assessed using the Cochrane Risk of Bias (Higgins et al., 2019). This tool to evaluate RCTs includes eight domains: (1) random sequence generation; (2) allocation concealment; (3) blinding of participants and researchers; (4) binding of outcome assessment (patient-reported outcomes); (5) blinding outcome assessment (all-cause mortality); (6) the presence of incomplete data (short term); (7) the presence of incomplete data (long term) and (8) selective reporting (Higgins et al., 2019). The answers to these domains can be ‘yes’, ‘no’, or ‘uncertain.’
Each study will be classified by two independent researchers as ‘high’, ‘low’ or ‘unclear’ risk of bias based on the responses given to the first three domains (Moher et al., 2015): Studies in which at least one of the first three domains is rated ‘no’ will be considered ‘high risk’. Studies in which at least one of the first three domains is rated ‘uncertain’ will be considered ‘unclear risk’. Studies whose first three domains are classified as ‘yes’ will be considered as ‘low risk’. In the event that disagreements appear between the two researchers, these will be resolved through discussion. A third researcher (MLBT) will be available if any disagreement cannot be resolved by discussion. All studies classified as ‘high risk’ of bias will be excluded from the review.
Data extractionFrom the Cochrane Collaboration Handbook for Systematic Reviews, a form will be developed to be used for data collection (Higgins et al., 2019; Table 3).
TABLE 3 Data extracted from the included studies.
| First Author, Year |
| Location |
| Design |
| Multicenter Study |
| Objective/Question |
| Participating characteristics |
| Distribution of participants |
| Variables |
| Results |
Note: Items recommended by the Cochrane Collaboration Handbook for Systematic Reviews.
Two researchers (CSO, ESG) will extract data from each study separately. If there is any contradiction between the researchers, a third person (MLBT) will be assisted to reach an agreement. In the presence of missing data, we will contact the authors of the study.
Data synthesis and analysisTo determine inter-researcher agreement for ‘study selection’ and ‘risk of bias’ we will calculate statistics and Kappa agreement using the statistical software package SPSS for Windows (Version 25; SPSS Inc). Kappa values > 0.75 are considered to reflect excellent concordance (Higgins et al., 2019).
A meta-analysis of the RCTs will be performed using Comprehensive Meta-analysis Version 2 software (Biostat). We will combine the results on sexual function from all studies, regardless of the type of PFMT program (intervention). Studies should present at least the mean and standard deviation of sexual function before and after the intervention. The main measure of effect for the meta-analysis will be the mean difference between the intervention and control groups. Standardized mean difference (SMD) will be used if studies measure sexual function outcomes on different scales/tools/questionnaires.
Heterogeneity (variability in outcomes between studies) will be assessed using the Cochrane Q test and the I-square index (I2 index). Random-effect models will be used for meta-analysis if I2 is ≥50%, indicating heterogeneity and fixed-effect models will be used if I2 is <50%.
To assess publication bias, it will be represented visually by funnel plots and statistically with the EGGER test, reported probabilities (p-value) will be bilateral and p < 0.05 will be considered publication bias (Egger et al., 1997).
The level of statistical significance was set at p < 0.05.
Proposed timetableThe proposed timeline with priority dates for fulfilling the key tasks of this review is presented in Table 4.
TABLE 4 Proposed timetable.
| Month | Activity |
| 1–2 | Preparation of the protocol |
| 3–8 | Searches for published and unpublished studies |
| 2–3 | Pilot test of elegibility criteria |
| 3–8 | Evaluation of the inclusion of studies |
| 3 | Pilot test to evaluate “Risk of bias” |
| 3–10 | Validity evaluations |
| 3 | Pilot test of data extraction |
| 3–10 | Data extraction. |
| 3–10 | Data entry in RevMan |
| 5–11 | Tracking lost data |
| 8–10 | Analysis |
| 1–11 | Preparation of the review report |
| 12 | Maintenance of the updated review |
The systematic review will include data published in RCTs without identifying any participants. In these cases, the approval of the ethics committee is not necessary to carry out the research.
DISCUSSIONSexual function is an aspect that determines the quality of life, which is made up of various agents, which can be physical, psychological and social. On the contrary, it represents a key aspect in women's pelvic health (Campos et al., 2022; Yong, 2022).
Female sexual dysfunctions can have various causes, however, they are very common among women with pelvic floor problems, for example, pelvic organ prolapses (POP) or urinary incontinence (UI) (Bø, 2012; Frigerio et al., 2022; Hwang et al., 2021; Pruijssers et al., 2021; Wharton et al., 2022), which may influence sexual satisfaction and functioning. Midwives and nurses, as fundamental professionals in the accompaniment of women throughout their sexual and reproductive lives (Beek et al., 2019), must be able to address this problem effectively.
Several studies have been published linking pelvic floor muscle training with improved female sexual function; however, some issues need to be discussed further, requiring strong evidence through systematic reviews and meta-analyses. In light of these concerns, the importance of this research lies in the fact that, to the authors' knowledge, it is the first to comprehensively assess the efficacy of pelvic floor exercises on sexual function in women. It will also be intended to examine the subgroups of women who may benefit most from these programs. The Randomized Controlled Trials design will be chosen, as they present the highest level of evidence. The accuracy, transparency and standardization of the review process will be facilitated by adhering to Cochrane Guidelines, PRISMA (Page et al., 2021) and PRISMA-P (Moher et al., 2015).
It is hoped to obtain robust and conclusive evidence, which would be useful for women, midwives, nurses and other health professionals, promote women's sexual health, strengthen clinical practice and encourage and contribute to new studies on the subject.
LimitationsAmong the limitations that could be anticipated, the studies found could have a small sample size. There could also be heterogeneity in relation to participants and intervention. In addition, the sample studies could use different instruments to measure sexual function, apart from the fact that some data could be of insufficient quality or be omitted. These setbacks initially identified could limit the feasibility of preparing a meta-analysis.
CONCLUSIONSThis study will help determine the degree to which pelvic floor muscle training can improve women's sexual function, given that in our view, published studies have not yet been able to draw a firm conclusion.
The findings of this systematic review and possible meta-analysis are contemplated to help midwives, nurses and other health professionals in the prevention and treatment of sexual dysfunctions related to pelvic floor problems and women contributing to their quality of life. All of this can help strengthen the evidence-based knowledge and contribute to recommendations for further research.
AUTHOR CONTRIBUTIONSCS-O and ES-G: Made substantial contributions to conception and design, acquisition of data or analysis and interpretation of data, involved in drafting the manuscript or revising it critically for important intellectual content, and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. CS-O, ES-G, AM-S, EC-S, and MLB-T: Given final approval of the version to be published. Each author should have participated sufficiently in the work to take public responsibility for appropriate portions of the content.
ACKNOWLEDGEMENTSNot applicable.
FUNDING INFORMATIONFinancial aid is received from the Colegio Oficial de Enfermería de Valencia, being granted by the Consejo General de Enfermería de España.
CONFLICT OF INTEREST STATEMENTNo conflicts of interest have been declared by the authors.
DATA AVAILABILITY STATEMENTData sharing is not applicable to this article as no new data were created or analysed in this study.
PATIENT OR PUBLIC CONTRIBUTIONDue to the nature of the design, this study was conducted without patient or public contribution.
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Abstract
Aim
To recognize, appraise and summarize the research evidence that has explored the results of pelvic floor muscle training on female sexual function.
Design
Systematic review and possible meta-analysis.
Methodology
Between September and October 2022, the Cochrane Library, CINAHL, MEDLINE, EMBASE, PsycINFO and Scopus electronic databases will be searched. We will include RCT's in English, Spanish and Portuguese that investigate the results of pelvic floor muscle training on female sexual function. The data will be extracted by two researchers independently. Risk of bias will be measured from the Cochrane Risk of Bias Tool. The meta-analysis of the results will be performed using Comprehensive Meta-Analysis Version 2.
Results
This systematic review and possible meta-analysis will contribute significantly to the promotion of pelvic floor health and women's sexual function and to strengthen clinical practice and define other areas of study.
You have requested "on-the-fly" machine translation of selected content from our databases. This functionality is provided solely for your convenience and is in no way intended to replace human translation. Show full disclaimer
Neither ProQuest nor its licensors make any representations or warranties with respect to the translations. The translations are automatically generated "AS IS" and "AS AVAILABLE" and are not retained in our systems. PROQUEST AND ITS LICENSORS SPECIFICALLY DISCLAIM ANY AND ALL EXPRESS OR IMPLIED WARRANTIES, INCLUDING WITHOUT LIMITATION, ANY WARRANTIES FOR AVAILABILITY, ACCURACY, TIMELINESS, COMPLETENESS, NON-INFRINGMENT, MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. Your use of the translations is subject to all use restrictions contained in your Electronic Products License Agreement and by using the translation functionality you agree to forgo any and all claims against ProQuest or its licensors for your use of the translation functionality and any output derived there from. Hide full disclaimer
Details
; Sierra-Garcia, Ester 2
; Martínez-Sabater, Antonio 3
; Chover-Sierra, Elena 4
; Ballestar-Tarín, María Luisa 5
1 Nursing School La Fe, Adscript Centre to the University of Valencia, Valencia, Spain; Research Group GREIACC, Health Research Institute La Fe, Valencia, Spain
2 University and Polytechnic Hospital La Fe of Valencia, Valencia, Spain
3 Nursing Care and Education Research Group (GRIECE), GIUV2019-456, Nursing Department, Universitat de Valencia, Valencia, Spain; Care Research Group (INCLIVA), Hospital Clínico Universitario de Valencia, Valencia, Spain
4 Nursing Care and Education Research Group (GRIECE), GIUV2019-456, Nursing Department, Universitat de Valencia, Valencia, Spain; Internal Medicine, Consorci Hospital General Universitari de Valencia, Valencia, Spain
5 Nursing Care and Education Research Group (GRIECE), GIUV2019-456, Nursing Department, Universitat de Valencia, Valencia, Spain