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Publication date: 01.06.2021

DOI: 10.51871/2588-0500_2021_05_02_1

UDC 618.14


A.V. Nadtochij, V.A. Krutova, K.V. Gordon, F.E. Filippov

Federal State Educational Institution of Higher Education "Kuban State Medical University" of the Ministry of Health of Russia, Krasnodar, Russia

Key words: biofeedback, electric pulse stimulation, extracorporeal magnetic stimulation, genital prolapse, menopause, pelvic floor surgery.

Annotation. The review is devoted to a relevant problem of modern gynecology – medical rehabilitation of menopausal patients, who do not go through the hormone replacement therapy and who have undergone surgical treatment of perineal ptosis. The authors of the article analyzed not only the main risk factors contributing to the recurrence of perineal ptosis after surgical correction, but also the sources of induction of perineal tissue failure in menopausal women. Features are examined, significant aspects of the health of the menopausal period of a woman's life are highlighted. Particular attention is paid to conservative hardware methods of medical rehabilitation of perineal tissues in the late postsurgical period, as a way to optimize the prevention of recurrence of genital prolapse and repeated surgical intervention in this regard in the future.

Introduction. The issue of perineal ptosis remains relevant to the modern population of women in both Russia and abroad, which is proven by the analysis of Russia-based and foreign literature sources. Up to 30% of cases in the structure of gynecological incidence in Russia are accounted for by serious surgical interventions for perineal ptosis and correction of complicated combined problems related to the failure of anatomical and functional structures of the pelvic floor. According to data given by a number of authors, menopausal patients make up the prevailing majority of women, for whom the failure of perineal structures became the cause of hysterectomy [3, 25, 14].

This refers to the need to solve issues of complicated combined urogynecological and proctologic states of this age group, when there is a number of moments, which are making the given situation worse, extragenital comorbidities in particular, among which it is necessary to mention diseases of the endocrine system (diabetes, dishormonal states of the thyroid), features of rheological behavior of the blood coagulation and anticoagulation systems, which accompany many somatic diseases, diseases of the cardiovascular and bronchopulmonary systems. Each of aforementioned states could pass into the decompensation state, despite the elective pharmacological support, complicating the course of both surgical aid and the early and long-term postsurgical periods [21, 1, 15].

Methods and organization. The content analysis of Russia-based and foreign literature sources was used as a research method.|

Results and discussion. As women's life expectancy increases, the progressive growth in the frequency of diagnosing genital prolapse is registered worldwide with a tendency to increase in older age groups, which gives a suggestion to think about the rate prognosis of undesirable outcomes of surgical treatment and complications in the postsurgical period. Moreover, a risk of conducting more surgeries for this group of patients grows. According to the opinion of American researchers, the annual incidence of genital prolapse is 18,6:1000 of cases in the age of 70-76 years, at the same time the annual incidence among women in the age of 30-39 years is 1,7:1000 of cases total. Thus, among patients of the older age group genital prolapse incidence is 10 times more frequent [2, 20].

Due to the increase in the perineal ptosis incidence, a risk of surgical aid complications also increases, among which the leading place is taken by the recurrence of pathological process (up to 40%, according to data of various authors, the risk of repeated surgeries is at 17% in the next 10 years), vaginal wall extrusion (30%), dyspareunia de novo (2,2-27,7%); erosion of the vaginal mucous coat occurs in a lesser extent (1-19%); vaginal synechiae (0,3%), erosions of the bladder’s mucous coat (0,2%), urethra-vaginal fistulae (0,15%) and prosthesis contractions (1%) appear; a persistent chronic pain syndrome forms (2,9-18,3%) [16, 23, 8].

As a rule, in case when the pelvic floor surgery was successfully conducted, all these complications are the consequence of morphologically changed perineal tissues in the previous time period, in which deep processes of dystrophia and anatomical and functional changes in the pelvic floor are already present at the moment of diagnosis verification and surgical correction planning. Therefore, it is important to consider a predictive value of risk factors of the perineal ptosis development, its progression to stages, which predetermine surgical treatment and the possibility of reccurence, especially among women of older age groups (Table 1) [10, 17, 22].

It is obvious, that predicting the perineal ptosis induction (Table 2) is not possible. In case of menopausal women, who do not go through the hormone replacement therapy, it is possible to identify a state of the already implemented spectrum of risk factors for the development of perineal tissue failure after the surgical correction of genital prolapse, which led to surgical treatment as an only possible method of life quality’s recovery [19].

Table 1

Perineal ptosis risk factors

Types of risk factors

Risk factors


- age

-genetic regulation of features of the biochemical composition of connective tissues, elastin, collagen

- relapse of pathological process



-reproductive loads

- increase in the estrogen synthesis

- low medical aid appealability

- the pelvic organ dysfunctions are not included into the clinical examination program


Table 2

Perineal ptosis induction

Types of induction sources

Induction sources

Exogenous induction factors

-psychosocial stress

-woodland deforestation


-environment pollution

Endogenous induction factors

-functional state of the organism’s regulatory systems



-morphofunctional state of the connective tissue system in whole


A so-called hypoxic perineal injury forms in menopausal patients due to the insufficiency of sex hormones in the organism, disorder in regional blood circulation (including venous outflow) and architectonics of the small pelvis. All of it has an unfavorable predictive value in relation to the tone and trophicity of muscles and the pelvic floor ligaments.

Thus, in modern female population, the issue of prediction of complications caused by the surgical treatment and prevention of genital prolapse recurrence in menopausal women, most of which do not go through the replacement hormonal therapy, remains extremely relevant.

How and by which methods in this situation is it possible to rehabilitate qualitative and functional parameters of already “compromised” perineal tissues in the examined cohort of patients? An active solution to this problem can be given by modern methods of medical rehabilitation, in the basis of which physiotherapeutic effects lie, specifically the effect of biofeedback and electric pulse impact on the anatomical and functional structures and neuromuscular communications of perineal tissues by applying modern high-technology hardware systems, the role of which consists in the effective transmission of physiotherapeutic effects to the destination area (anatomical and functional structures of the pelvic floor) in conditions of high safety.

The number of scientific works dedicated to this issue is small; however, V.A. Mityukov et al (2009) in their work on the physical rehabilitation in case of pelvic floor dysfunctions talk about the leading role in supporting tone and trophicity of pelvic floor muscles, estrogen deficit in menopause, influencing the structure composition and biochemical features of the connective tissue, note the frequent (83%) concomitance of urologic and proctologic dysfunctions and the need to implement modern methods of physical and physiotherapeutic rehabilitation for the given cohort of patients [12].

It is also important to note that the biofeedback method is based on fundamental primary mechanisms of regulation of physiological processes and the development of pathological processes, the study of which was actively started in the 50s of the XX century with the research of issues of rational ways to activate adaptation systems of the brain of a healthy and sick individual.

The direction of biofeedback therapy was formed in the 60s of the last century. It is important to note the names of great Russian physiologists – I.M. Sechenov and I.P. Parvov, as well as their continuators – K.M. Bykov, P.K. Anokhin and N.P. Bekhterev. Employees of the Institute of Experimental Medicine of the Russian Academy of Medical Sciences (RAMS) (Saint Petersburg) became the first researchers, who were developing this method. Currently, studies on the implementation of the biofeedback method in clinical practice are carried out in the Scientific Center for Mental Health of the Russian Academy of Science (RAS) located in Novosibirsk under the lead of the RAS member M.B. Shtark and in a number of other institutes [9].

 In order to show the large scale of interest and scientific activity in studying the effectiveness of biofeedback, there is a need to note the contribution made by the US scientists L. DiCara and N. Miller in 1968 (formation of conditioned reflexes of the operant type in animals), the study conducted by M. Sterman in 1980 (increasing the convulsion threshold after the conditional reflectory enhancement of the
sensory-motor rhythm in the central gyri of the brain of animals and humans), the discovery made by J. Kamiya in 1968 (capability of test subjects to voluntary change the electroencephalogram indicators).  Understanding the fact, that the operant control of the bioelectrical activity of the brain and the vegetative nervous system is of great significance for clinical practice, became the fundamental outcome. Today, the scientific progress allows using the biofeedback effect in therapy of not only diseases of the nervous system, but also the spectrum of somatic diseases and problems of the musculoskeletal system [18].

Results of studies conducted by N.S. Lutsenko, O.D. Mazur and I.A. Evteryaev (2016) show the effectiveness of the Biofeedback-phenomenon implementation in the program of conservative rehabilitation of patients with the pelvic floor failure [11].

V.A. Krutova and A.V. Nadtochij (2019), when summarizing the comparative prospective study on the effectiveness of the method of biofeedback and electric pulse stimulation of the neuromuscular apparatus in rehabilitation of patients with pelvic floor dysfunctions, note the absence of genital prolapse recurrence after the surgical correction of III and VI stages of the perineal ptosis, and also a significant improvement of the patients’ life quality after the pelvic floor conservative rehabilitation, which was proven subjectively by filling the validated questionnaire and objectively by the multiparametric ultrasound study in dynamics [7].

In 2018, E.N. Zhumanova, A.I. Myravlev, Ya.S. Savel’eva et all note the improvement of the state of anatomical and functional structures of the pelvic floor in patients of the perimenopausal and postmenopausal age after the surgical treatment of perineal ptosis in the early postsurgical and distant periods after implementing the therapy of biofeedback and electric pulse stimulation of the pelvic floor muscles [6].

The development of specialized vaginal catheter, with the advent of which it became possible to use the given technique in gynecological practice, became the main achievement. The hardware system is able to fixate the tension and relaxation of pelvic floor muscles (target group of muscles) in the real-time mode and transfer visual information to the patient in the form of cursor on the system display in animation programs (exterior feedback outline) through capabilities of the intuitive personified programming and international treatment protocols, installed in the software. Sessions consist of an active type of training of pelvic floor muscles, the result of which is an increase in muscle tone, a development of muscle skill and a formation of long-term muscle memory. When muscle strength is increasing within dynamics, it is possible to change training loads using the software by gradually increasing the level of set tasks for the patient [13].

According to the analysis of Russia-based and foreign literature, the electrical pulse effect of specific features (low-frequency) is considered as an effective addition to the biofeedback therapy [13].

Electric stimulation, as a conscious, intentional electricity implementation, based on the precise principles, exists for approximately 200 years. Since the 60s of the last century, intensive studies on the implementation of faradization and galvanization in case of various pathological state of organs and systems of a human were conducted, the technique of using electrotherapy was improved, devices (circuit breakers, switchboards, measuring technology) was also improved, therapists and physiologists carried out studies on the diagnosis of norm and pathology of nervous and muscular systems, in which Russian scientists
V.I. Drozdov, P.D. Shipulinskij, N.I. Pchel’nikov, V.O. Kovalevskij and others played an important role. The greatest role in the development of electrotherapy was played by the founder of Russian physiology I.M. Sechenov [24, 26].

In patients, who went through the surgery of the III and IV stage genital prolapse, the electric pulse stimulation is able to increase the level of motor act regulation, recover the muscle contraction function, form a new dynamic stereotype and activate functionally inactive neurons in the target area of impact. The electric pulse stimulation protects muscles from atrophy, stimulates blood and lymph circulation, improving trophic processes in them, succusses the neuromuscular transition of its pulses, recovering lost functions. Urologic dysfunctions are often associated with genital prolapse, and the correction of the thickening function of urethrovesical sphincters, the recovery of physiological phases of bladder repletion and ejection will allow solving sensible issues of women’s health.

The result of such impact is an ability of the patient to identify the target group of muscles, to form a central program of managing muscles of their own body and to increase the effectiveness of active training with using the biofeedback, which contributes to the improvement of the pelvic floor tissue trophicity, the improvement of blood and lymph circulation, the normalization of externally secreting glands and the recovery of the psychoemotional status.

The method, which not only recovers the architecture and design of the perineum, increases qualitative features of perineal tissues, but also has a favorable effect on psychoemotional and social spheres of patient’s life, is a combination of the biofeedback effect with the electric pulse effect. These physiotherapeutic effects are aimed at the usage of your own organism reserves while achieving following goals: learning to understand and differentiate clearly the target muscle group (pelvic floor muscles) of your own organism, to form a muscle skill, to develop a
long-lasting  muscle memory of the anatomical and functional elements of the pelvic floor for further independent out-patient work patients on keeping the tone of perineal muscle structures, which was set by the hardware system.

The biofeedback method in combination with the electric pulse stimulation of muscles is a worthy addition to the surgical treatment during late postsurgical period, increasing efficiency in the combined management program in conditions of outpatient facilities, day-care hospitals and institutions of the sanatorium and health resort complex of the practical healthcare [4, 5].

In reliance on the fundamental knowledge of etiology and pathogenesis of the development and progression of genital prolapse, capabilities of the modern pelvic floor surgery and statistical data of unfavorable outcomes of the surgical treatment, it is important to note a direct practicability of implementing the biofeedback therapy and electric pulse stimulation for the most vulnerable group of patients – menopausal women, as an obligatory stage of the pelvic floor rehabilitation.

Firstly, the biofeedback regulation recovers and supports homeostasis on many levels, including the balance of sympathetic and parasympathetic divisions of the vegetative nervous system. The therapy using the biofeedback method in combination with electric pulse effect supports a balance between brain hemispheres, as well as nervous and immune system, impacts physical, emotional, intellectual and social processes, manages the appropriate use of all capabilities of an individual.

Dynamics of qualitative and functional parameters of pelvic floor muscles have a great predictive value. Their decrease correlates with a high indicator of unfavorable results of the surgical treatment. It is obvious, that in case of not taking the adjustment of mechanisms of the abdominal pressure compensation in the form of basis tone and involuntary tension of the pelvic floor muscles because of anatomical reconstruction, these effects run the risk to be non-effective and long-lasting, leading to a high danger of repeated damage of tissues. That is reason why the increase in the quality of perineal tissues using physiotherapy is appropriate during the postsurgical period, and it becomes extremely necessary for the purposes of rehabilitation.

Conclusion. The main feature of our literature review is focusing attention on the need to conduct effective medical rehabilitation by using high-technology hardware systems with a  target impact on structures of the pelvic floor, which, according to studies, are more effective than standard recommendations on modifying lifestyle in relation to a vulnerable group of patients, who went through the surgery of the III and IV stage genial prolapse during menopause without support by the hormone replacement therapy.

 Despite the high incidence of failure of anatomical and functional structures of the pelvic floor, there is a low medical aid appealability (28% of cases) to gynecologists among women, who have these problems. Unfortunately, a high number of patients are left without medical help (do not have knowledge about preventive measures, about the conservative management of early signs of failure of pelvic floor structures, about the possibility of a timely surgical solution of the genital prolapse issue) in case of early signs of perineal ptosis, when visiting a gynecologist with already profound functional disorders of urologic and gynecologic areas of life.

Currently, there is a small number of studies dedicated to the topic of preventing the recurrence of the pelvic organ prolapse after surgical treatment, however, this direction should take a leading place in the coming years in order to improve quality of health and life of patients with genital prolapse of the senior age group.

Modern diagnostics and prediction of the pelvic floor state on various age stages of the woman’s life play an important role in the support of anatomical and functional safety of the perineal tissue system.

The low level of awareness of risk factors among women, awareness of features of clinical progression of genital prolapse among patients, as well as the insufficiency of coordinated tactics of medical community representatives in the aspect of prevention, ethiopathogenetic treatment and medical rehabilitation of the given group of patients, determine the present need to conduct studies in the area of pelviperineology, and they give their results high relevance and social significance.

Funding sources. The searching and analytical work on preparing the manuscript was carried out without funding sources.

Conflict of interest. The authors declare no conflict of interest.


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Information about the authors: Anna Vadimovna Nadtochij – Doctor of Physical Therapy of the Clinic in the FSBEI of HE “Kuban State Medical University” of the Ministry of Health of Russia, Krasnodar, e-mail: This email address is being protected from spambots. You need JavaScript enabled to view it., ORCID: https//; Viktoriya Aleksandrovna Krutova – Doctor of Medical Sciences, Professor of the Department of Obstetrics, Gynecology and Perinatology, Chief Physician of the Clinic in the FSBEI of HE “Kuban State Medical University” of the Ministry of Health of Russia, Krasnodar, Chief Non-staff Obstetrician-Gynecologist of the Southern Federal District of the Ministry of Health of Russia, e-mail: This email address is being protected from spambots. You need JavaScript enabled to view it., ORCID: https//; Kirill Vladislavovich Gordon – Doctor of Medical Sciences, Professor of the Department of Medical Rehabilitation in the Faculty of Staff Development and Professional Retraining of the FSBEI of HE “Kuban State Medical University” of the Ministry of Health of Russia, Krasnodar, e-mail: This email address is being protected from spambots. You need JavaScript enabled to view it., Author ID: 301234; Fyodor Evgen’evich Filippov – Student of the FSBEI of HE “Kuban State Medical University” of the Ministry of Health of Russia, Krasnodar, e-mail:  This email address is being protected from spambots. You need JavaScript enabled to view it..