Int Urogynecol J (2015) 26:1709–1712
DOI 10.1007/s00192-015-2698-5
IUJ VIDEO
Virtual reality: a proposal for pelvic floor muscle training
Simone Botelho 1,2 & Natalia Miguel Martinho 1 & Valéria Regina Silva 1,2 &
Joseane Marques 1,2 & Leonardo C. Carvalho 1 & Cássio Riccetto 2
Received: 20 January 2015 / Accepted: 17 March 2015 / Published online: 30 April 2015
# The International Urogynecological Association 2015
Abstract
Introduction and hypothesis This video’s proposal was to
present one of the pelvic floor muscle (PFM) training pro-
grams, used in our research, that we designed as a virtual
reality intervention protocol and investigated its effects on
PFM contractility.
Methods Two clinical, controlled and prospective studies
were conducted, one with 19 nulliparous women without uri-
nary symptoms, who were evaluated by both electromyogra-
phy and digital palpation (DP) and another with 27 postmen-
opausal women with mixed urinary symptoms (assessed by
both ICIQ UI-SF and ICIQ-OAB), evaluated by vaginal dy-
namometry and DP, with a total of 46 women in both studies.
This study was presented in the Podium Video Session at the 44th Annual
Meeting of the International Continence Society in Rio de Janeiro- Brazil,
2014
Study conducted by the UroFisioterapia Laboratory of the Course of
Physiotherapy (Nursing School) of the Federal University of Alfenas
(UNIFAL/MG)—Alfenas, Minas Gerais, Brazil
Electronic supplementary material The online version of this article
(doi:10.1007/s00192-015-2698-5) contains supplementary material. This
video is available to watch on http://springerlink.com/. Please search for
this article by the article title or DOI number, and on the article page click
on ‘Supplementary Material’.
* Simone Botelho
simone.botelho@unifal-mg.edu.br
1
Course of Physiotherapy, Nursing School, Federal University of
Alfenas (UNIFAL-MG), Building A, Room 107-D, Av. Jovino
Fernandes Sales, 2600—Santa Clara, Alfenas, MG CEP: 37130-000,
Brazil
2
Department of Surgery/Faculty of Medical Sciences, State University
of Campinas (UNICAMP), São Paulo, Brazil
This protocol was designed so that the participant would play
a video game, seated on a pressure base platform, while com-
manding it through her pelvic movements. Using a virtual
reality game, five activities were performed during 30 min,
twice a week, with a total of 10 sessions.
Results A significant increase in PFM strength was found in
both the nulliparous (p=0.0001) and the postmenopausal (p=
0.0001) groups of women, as ascertained by DP. A significant
increase in postmenopausal women’s muscle strength and en-
durance assessed by dynamometry (p=0.05) and a concomi-
tant decrease in their urinary symptoms, were observed.
Conclusion This virtual reality program promoted an increase
in PFM contractility and a decrease in postmenopausal urinary
symptoms.
Keywords Virtual reality exposure therapy . Pelvic floor .
Electromyography . Muscle strength dynamometer . Digital
palpation . Urinary symptoms
Introduction
The use of both didactic and ludic means could be a useful tool
toward the population’s awareness of the importance of
preventing and treating pelvic floor dysfunction. Currently,
virtual reality has been used within scientific fields [1] and is
defined as an interactive experience based on a tridimensional
computer system. It is a simple, low-cost movement simulator
that allows sensorial feedback in addition to the participant’s
interaction through enjoyable and adequate therapeutic ses-
sions that are suitable for her condition [2–4]. Thus, our pro-
posal was to design an intervention protocol for pelvic floor
muscle training by virtual reality and to investigate its effects
on PFM contractility.
1710 Int Urogynecol J (2015) 26:1709–1712

Fig. 1 Study population surface

electromyography (SEMG)

Materials and methods approved by the Federal University of Alfenas (UNIFAL/

Design and participants
Two clinical, controlled and prospective studies were conduct-
ed. The first one, called study 1, was carried out with 19
nulliparous women without urinary symptoms, who were
evaluated by both electromyography and digital palpation.
The second one, called study 2, was performed with 27 post-
menopausal women with mixed urinary symptoms (assessed
by both the International Consultation on Incontinence Ques-
tionnaire Urinary Incontinence Short Form, ICIQ UI-SF [5],
and the International Consultation on Incontinence Question-
naire Overactive Bladder, ICIQ-OAB [6]), who had been eval-
uated using vaginal dynamometry and digital palpation, with a
total of 46 women in both studies, as shown in Fig. 1.
The participants were selected from the university exten-
sion project called Woman Health Attention (PREAE n.2026),
which promotes women’s health activities in patients from the
public health network in the city of Alfenas/MG, and was
MG, Brazil).
These studies received ethical approval from the
regional ethics review board (protocols: CAAE:
19625113.5.0000.5404—study 1 [7]/CAEE 0306.0.213.000-
07—study 2 [8]) and all participants gave their informed and
written consent according to the Declaration of Helsinki, be-
fore the initial assessment.
Assessment methods
Digital palpation
During digital palpation, which was used in both studies, the
examiner introduced the index and middle fingers, 2–3 cm
into the vaginal introitus, performing an abduction movement,
while the patient was asked to perform a maximum contrac-
tion of the PFM, lifting inward and squeezing around the
fingers [9]. The muscle strength was graded according to the
Modified Oxford Grading Scale (0–5 points) [9].

Table 1 Pelvic floor muscle

contractility in the nulliparous Nulliparous women (n=19) Digital palpation Electromyography
women group, assessed by digital
palpation and electromyography, Pre-training Post-training Pre-training Post-training
pre- and post-treatment
Mean (SD) 3.1 3.4 45.7 45.2
(±0.9) (±0.8) (±15.9) (±23.1)
p value* 0.0001 0.79
Power** 0.2 0.05
Effect size** 0.3 0.03

The table presents the pelvic floor contractility pre- and post-training as the mean (standard deviation), accom-
panied by the p value (*Wilcoxon test; p<0.5), the power analysis and the effect- size calculation (**G.Power
version 3.1.7) in the nulliparous group
Int Urogynecol J (2015) 26:1709–1712 1711

Table 2 Pelvic floor muscle contractility in the postmenopausal women group, assessed by digital palpation and dynamometry, and urinary symptoms
pre- and post-treatment

Postmenopausal women (n=27) Digital palpation Dynamometrya ICIQ UI-SF ICIQ-OAB

Pre-training Post-training Pre-training Post-training Pre-training Post-training Pre-training Post-training

Mean (SD) 2.3 (±0.7) 2.3 (±0.7) 3.1 (±1.7) 4 (±2.4) 6.2 (±5.9) 3.1 (±4.6) 3.6 (±2.7) 2.0 (±1.6)
p value* 0.0001 0.05 <0.0001 0.003
Power** 0.9 0.6 0.9 0.9
Effect size** 0.7 0.4 0.6 0.7

The table presents the pelvic floor contractility pre- and post-training, and the urinary symptom evaluation as the mean (standard deviation), accompanied
by the p value (*Wilcoxon test; p<0.5), the power analysis and the effect size calculation (**G.Power v. 3.1.7) in the postmenopausal group
a
Dynamometry (endurance parameter—seconds; n=20)

Surface EMG
As an objective PFM evaluation, surface electromyography
(EMG System do Brasil®) was used in study 1, where a vag-
inal probe (Physio-Med Services®), with two opposing metal
sensors placed laterally, was manually inserted into the vagina
by the researcher, with the aid of hypoallergenic gel [10]. The
reference surface electrode was positioned on the right wrist
(between the radius and the styloid process of the ulna).
The surface electromyography (sEMG) evaluation protocol
consisted of three maximal voluntary PFM contractions, re-
corded by the vaginal probe. The PFM contraction had been
previously taught to the volunteers, where they had to lift the
probe in a cranial direction and observe its contraction graphs
on the computer screen. Each requested contraction, was per-
formed with a rest period of 3 min, to avoid muscle fatigue
[10, 11].
Vaginal dynamometry
As an objective PFM evaluation, a vaginal dynamometer
(EMG System do Brasil, model DFV 020101/10®) was used
in study 2. The vaginal dynamometer was inserted into the
vaginal cavity, covered with a condom, which was lubricated
with hypoallergenic gel. Then the participant was asked to
perform three maximal voluntary PFM contractions, recorded
for 15 s [10–12] with a rest period of 3 min after each one,
according to Martinho and collaborators [12].
Urinary symptom assessment
Two questionnaires, from the International Consultation on
Incontinence Questionnaires, were used to assess urinary
symptoms: the ICIQ UI-SF [5] and the ICIQ-OAB [6].
PFMT protocol
The protocol was designed so that the participant would play a
video game, seated on a pressure base platform, and command
it through her pelvic movements. Thus, the participants were
guided to maintain a mild contraction of the transverse ab-
dominal muscle, while performing pelvic anteversion, retro-
version, lateral tilting, and circumduction movements. The
games were carried out without any verbal commands for
the performance of direct PFM contractions. Using an avail-
able virtual reality game (Wii Fit PlusTM), five activities were
performed over 30 min, twice a week, with a total of 10
sessions.
Results
A significant increase in PFM strength was observed by dig-
ital palpation in the nulliparous women group, although, this
finding was not observed through sEMG (Table 1). In fact,
this study included only 19 nulliparous women, presenting
only preliminary findings.
On the other hand, a significant increase in postmenopausal
women’s muscle strength and endurance (digital palpation
and vaginal dynamometry) and a concomitant decrease in
their urinary symptoms (ICIQ UI-SF and ICIQ-OAB) were
observed, as shown in Table 2.
Conclusion
Pelvic floor muscle training by virtual reality promoted an
increase in pelvic floor muscle contractility and a decrease in
postmenopausal urinary symptoms. Therefore, it can be used
in clinical practice.
Acknowledgements CAPES (Coordenação de Aperfeiçoamento de
Pessoal de Nível Superior); FAPEMIG (Fundação de Amparo à Pesquisa
do Estado de Minas Gerais)—(APQ-02794–11); UNIFAL/MG
(Universidade Federal de Alfenas) for granting both the PIB Pós scholar-
ship and CEAD (Centro de Educaçao a Distancia).
Conflicts of interest None.
1712
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Consent
Written informed consent was obtained from the patient for publication of
this video article and any accompanying images