Physiotherapy - Theses
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ItemPelvic floor disorders after gynaecological cancer treatment( 2023-05)Gynaecological cancers are the third most common type of cancer in women, accounting for 16% of cancers diagnosed in women worldwide. They include endometrial, cervical, ovarian, vulval, vaginal and fallopian tube cancers. The most common treatments for gynaecological cancer are surgery, most frequently hysterectomy, radiotherapy and chemotherapy. The sequelae of gynaecological cancer treatments impose a substantial burden on survivors and society. Gynaecological cancer survivors experience high rates of pelvic floor disorders, such as urinary incontinence, faecal incontinence and dyspareunia. However, many gynaecological cancer care pathways do not include screening for pelvic floor disorders, or only include screening and referral for sexual dysfunction, but not other pelvic floor disorders. Pelvic floor muscle training, an evidence-based treatment for urinary incontinence, faecal incontinence and dyspareunia in other populations, is currently not recommended in gynaecological cancer care pathways. More data are needed on the prevalence, history and experience of pelvic floor disorders in gynaecological cancer survivors, and the feasibility and effectiveness of pelvic floor muscle training in this population, before such recommendations can be included in gynaecological cancer care pathways. Therefore, this thesis aimed to investigate the prevalence and natural history of pelvic floor disorders after gynaecological cancer treatment, the experience of gynaecological cancer survivors with pelvic floor disorders and their preferences for treatment, and the feasibility and efficacy of pelvic floor muscle training for treating pelvic floor disorders in gynaecological cancer survivors. Study One documented the prevalence of pelvic floor disorders, including urinary incontinence, after gynaecological cancer surgery and involved the assessment of pelvic floor symptoms, health-related quality-of-life and physical activity before and after hysterectomy with or without radiotherapy or chemotherapy for gynaecological cancer. This study used psychometrically sound patient-reported outcomes completed before or in the first week after surgery, 6-weeks after surgery and 3-months after surgery. The prevalence of urinary incontinence and faecal incontinence were high, and rates of sexual activity were low both before and after surgery. Adjuvant therapy (radiotherapy or chemotherapy) was associated with increased odds of having moderate-to-very severe urinary incontinence. Symptoms of pelvic floor disorders 3-months after hysterectomy were associated with lower health-related quality-of-life, but not lower physical activity levels. These findings suggest that clinicians working with gynaecology-oncology patients undergoing hysterectomy may need to consider screening and offering treatment options for pelvic floor disorders. Study Two, a qualitative study, explored the experiences of gynaecological cancer survivors with pelvic floor disorders, and gynaecology-oncology clinicians. This included their attitudes to screening and management of pelvic floor disorders, and their perceptions of barriers and enablers to treatment for pelvic floor disorders after gynaecological cancer treatment. Differences between what participants had experienced and what they felt should happen highlighted a perceived need to improve the screening and management for pelvic floor disorders. Barriers to screening, disclosure and management of pelvic floor disorders identified by both gynaecological cancer survivors and clinicians included patients feeling unwell, emotional, and overwhelmed with the logistics of oncology appointments. Gynaecological cancer survivors also identified discontinuity of care as a barrier to disclosure of pelvic floor disorders, while clinicians identified time pressure as a barrier to screening for pelvic floor disorders. Enablers to screening, disclosure and management of pelvic floor disorders identified by both by gynaecological cancer survivors and clinicians included the patient-clinician relationship and patient agency. Opportunities for improving management included integrating nursing and pelvic floor physiotherapy with oncology appointments and providing streamlined referral pathways for treatment. Gynaecological cancer survivors and clinicians were supportive of integrated treatment pathways for pelvic floor disorders after gynaecological cancer treatment. Study Three was a systematic review and meta-analysis of conservative pelvic floor muscle therapies for pelvic floor disorders after gynaecological cancer treatment. Five randomised controlled trials and two cohort studies were identified, with moderate-level evidence that pelvic floor muscle training with core exercises (i.e. strengthening deep abdominal pelvic floor muscles, diaphragmatic breathing, and stretching of pelvic girdle muscles) or yoga improves health-related quality-of-life and sexual function, and very low-level evidence that high frequency of vaginal dilator training may reduce vaginal complications after treatment for endometrial and cervical cancer. There were insufficient data for meta-analysis of the effect of conservative pelvic floor therapies on bladder or bowel function. Given the levels of evidence found, a need for further high-quality studies was identified, especially studies investigating conservative pelvic floor muscle therapies for urinary and/or faecal incontinence after gynaecological cancer treatment. Study Four, a cohort clinical trial, investigated the feasibility of recruiting to and delivering a pelvic floor muscle training intervention via telehealth to treat urinary and/or faecal incontinence after gynaecological cancer surgery. Participants underwent a 12-week physiotherapist-supervised telehealth-delivered pelvic floor muscle training program. The intervention involved seven videoconference sessions with real-time feedback using an intra-vaginal biofeedback device, and a daily home pelvic floor muscle training program. Outcomes of high consent rates, participant engagement and retention, and self-reported acceptability and satisfaction support the feasibility and acceptability of telehealth-delivered pelvic floor muscle training to treat urinary and/or faecal incontinence after gynaecological cancer treatment. In conclusion, the findings of this thesis indicate that patients experienced high rates of pelvic floor disorders before and after gynaecological cancer. Gynaecological cancer survivors wanted more information on pelvic floor disorders and gynaecological cancer survivors and clinicians were supportive of integrated treatment pathways for pelvic floor disorders after gynaecological cancer treatment. There is emerging evidence for pelvic floor muscle training to improve health-related quality of life and sexual function for gynaecological cancer survivors. There is insufficient evidence for pelvic floor muscle training to improve urinary and/or faecal incontinence after gynaecological cancer treatment, however pelvic floor muscle training delivered via telehealth may be feasible and acceptable in this setting. The findings of this thesis have already informed the design of a large randomised controlled trial (ANZCTR registration ACTRN12622000580774) to investigate the clinical efficacy of pelvic floor muscle training delivered via telehealth for urinary incontinence after gynaecological cancer treatment. Future research should investigate which subgroups of patients with gynaecological cancer (e.g. type of gynaecological cancer, stage of cancer or treatment type/combinations) are most at risk of experiencing pelvic floor disorders, and which aspects of intervention (e.g. in-person or telehealth, starting before or after cancer treatment, using pelvic floor muscle training alone or multimodal pelvic floor physiotherapy interventions) provide the most feasible and effective treatment for pelvic floor disorders after gynaecological cancer treatment.