Effects of Kegel exercise combined with rational emotive behavior therapy on pelvic floor muscle function and sexual life quality in patients with total hysterectomy: A retrospective study.

Total hysterectomy is a radical method for the treatment of uterine diseases, for example, uterine fibroids and adenomyosis. Recent years, total hysterectomy has become one of the most common types of gynecological operation worldwide. [ 1 , 2 ] As the uterus is an important part of female reproductive organs, surgery can lead to negative effects on physical, psychological, and life for patients. [ 3 ] This kind of operation completely removes the uterine body and cervix and cuts off part of the uterine ligament, which can cause the anatomical and functional changes of pelvic cavity, and may even lead to urinary incontinence, pelvic organ prolapse as well as other pelvic floor dysfunction diseases. [ 4 ] In the operation, the uterine blood vessels are destroyed, which affects the pelvic nerves and pelvic floor structures, and also inhibits ovarian function and alters vaginal environment. Due to the loss of the above gender characteristics, several negative emotions such as stress, sadness, and anxiety may arise after surgery. Negative avoidance way may be used to deal with the psychological crisis, which seriously affects the quality of the couple sex life. [ 5 ] Kegel exercise is a method of pelvic floor rehabilitation, which enhances the normal muscle tension of the pelvic floor and improves the vaginal contractile via training of the pubococcygeus muscle. Moreover, Kegel exercise promotes the early recovery of pelvic floor function and sexual function. [ 6 , 7 ] Rational emotive behavior therapy (REBT) is a way of cognitive psychotherapy, which guides patients to rebuild scientific disease cognition, change irrational ideas, reduce negative emotions, establish positive thinking beliefs, and ultimately improve compliance with treatment and rehabilitation training. [ 8 , 9 ] Since 2019, Kegel exercise with or without the combination of REBT has been applied in our center. In this study, we investigated the effects of Kegel exercise combined with REBT therapy on patients undergoing total hysterectomy, and the results are reported as follows.

Conceptualization: Fang Jia. Data curation: Man Zhang, Ming Zhu, Xianglian Zhang. Funding acquisition: Juan Ren. Investigation: Man Zhang, Xianglian Zhang. Methodology: Ming Zhu. Software: Ming Zhu. Validation: Juan Ren, Fang Jia. Writing – original draft: Man Zhang. Writing – review & editing: Ming Zhu, Fang Jia.

Patients who underwent total hysterectomy in the Department of Gynaecology of the General Hospital of Wanbei Coal-Electric Group from Jan 2019 to Dec 2021 were retrospective reviewed. Inclusion criteria: diagnosed with benign uterine lesions and underwent total hysterectomy; received Kegel exercise with or without the combination of REBT; vaginal delivery ≤ 3 times, premenopause; received regular outpatient review and follow-up, and preoperative and postoperative pelvic floor muscle function, medical coping style, and quality of sexual life were assessed; have never received psychiatric or psychological treatment. Exclusion criteria: with malignant lesions of uterus and other sites; with severe organ function impairment; with uterine organ prolapse and urinary incontinence; combined with immunological or hematological diseases; absence of clinical data. A total of 91 eligible patients were collected in this study: 39 patients in Kegel group and 52 patients in combination group. Patients received Kegel exercise and routine care after hysterectomy in the Kegel group. In contrast, in the combination group, patients received Kegel exercise combined with REBT. This study was approved by the Ethics Committee of the General Hospital of Wanbei Coal-Electric Group (No.2018006). In addition, written informed consent was obtained from all patients. At 4 days after surgery, patients were instructed to perform Kegel exercise in both groups. Patients were in supine position with flexion of both lower limbs. They tightened perineum and anus for 10 seconds during inspiration, and then relaxed for 5~10 seconds during exhalation. Patients could exercise in any position after they got out of bed. At 4 weeks after the operation, abdominal breathing exercises were performed. Patients inhaled slowly when the abdominal muscles contracted. When the air was full, patients slowly exhaled with abdominal bulge and the anus became relaxed. After exhalation, the contraction of the anus was tighter due to abdominal muscle compression. Patients continuously exercised for 15~30 minutes, 3 times per day, and 4 weeks was a course of treatment. In the combination group, the specific measures of REBT were as follows: [ 10 ] In terms of stimulating events, the reasons leading to patients’ negative emotions, such as concerns about surgical risk, postoperative pelvic sagging, and sexual life disorders, were summarized through personal interviews. Before surgery, the perioperative examination, treatment and nursing process were introduced to assist patients’ psychological adjustment as well as to improve patients’ compliance in diagnosis and treatment. In terms of individual cognition and evaluation of the disease, patients were encouraged to vent their bad emotions and were guided to express their views on the disease. Therefore, patients’ wrong views and opinions were corrected, and a scientific attitude toward disease cognition was established. In terms of individuals’ emotional outcome and behavioral consequences of the disease, patients’ emotional state was assessed and personalized counseling was performed, and the causes of subjective negative emotions were transformed into cognitive attitudes towards evoked events. Therefore, patients could realize the importance of positive emotions and self-management for improving surgical prognosis. In the stage of reeducation, all aspects of REBT were consolidated, patients’ negative emotions were corrected for many times, correct cognition was strengthened, and encouraging words were used to cultivate patients’ self-protection and resilience. Reasonable emotional intervention was performed for 30~60 minutes each time, twice a week for 4 weeks. Kegel training and psychological intervention were regularly guided by members of the research group during hospitalization. After discharge, follow-up via telephone and wechat was performed to guide training and understand psychological behavior status. Pelvic floor muscle function, psychological state and sexual quality were evaluated before surgery, and at 3 and 6 months after surgery. The modified Oxford scale, [ 11 ] which could be divided into 0~5 grades (1 (no contraction), 2 (weak), 3 (moderate), 4 (good) to 5 (strong)), was used to evaluate the pelvic floor muscle function. The normal rate of pelvic floor strength: cases of 3~5 grades/total cases × 100%. The Chinese version of medical coping modes questionnaire (MCMQ) [ 12 , 13 ] was used to assess medical coping style. A total of 20 items were included in 3 dimensions, namely confrontation, avoidance, and acceptance-resignation. A scale of 1~4 score was used in each dimension, and higher score indicated that patients were more inclined to adopt such coping style. Among the 3 dimensions, confrontation was a positive way and another 2 dimensions were negative ways. According to the total score, coping was rated as high (41~80 points), average (30~40 points) and low (20~29 points). The female sexual function index (FSFI) was used to evaluate the quality of sexual life. FSFI was a self-assessment tool for assessing female sexual function, which was developed by an American scholar in 2000. In 2011, Sun et al introduced the tool into China and verified its good reliability and validity. [ 14 ] There were 19 items in the scale, including 6 dimensions of sexual desire, sexual arousal, vaginal lubrication, orgasm, sexual satisfaction and pain of intercourse. The 5-level scoring method was applied, and the higher the score, the better the quality of sexual life. The total score <26.55 was judged as sexual dysfunction. Propensity score matching (PSM) with a 1:1 ratio was conducted to avoid the selection bias. The propensity score covariates in this study included age, body mass index (BMI), number of births, level of education, and disease type (Table 1 ). After matching, P values between the 2 groups were all >.05, indicating a good balance. After PSM, 35 patients were in Kegel or combination group. All data were statistically analyzed by SPSS 25.0 software. Measurement data were described as (x̄±s), difference was compared by t test, q test, or variance analysis. χ 2 test and rank sum test were used to compare the difference of categorical data. P 0.05 was considered statistically significant. Comparison of baseline information between the 2 groups. Data are Mean ± SD or n (%). Bold values mean P < 0.05. BMI = body mass index, PSM = propensity score matching.

A total of 91 patients with total hysterectomy were recruited. Amongst, 39 patients received Kegel exercise alone and 52 patients received Kegel exercise combined with REBT. As shown in Table 1 , age and BMI were significantly different between the 2 groups. After PSM with 1:1 ratio, there were 35 patients in each group with well-balanced baseline characteristics (Table 1 ). The results showed that the normal rates (3~5 grades) of pelvic floor muscle in the combination group and the Kegel group were 88.57% (31/35) and 68.57% (24/35) respectively, and the difference was statistically significant (Table 2 , χ 2  = 4.158, P  = .041). Comparison of postoperative pelvic floor muscle function between the 2 groups. Data are n (%). Before surgery, there were no significant differences between the 2 groups in the 3 subscales of confrontation, avoidance, and acceptance-resignation ( P  > .05). At 3 months after surgery, the score of confrontation was higher and the scores of avoidance and acceptance-resignation were lower in the combination group than those in the Kegel group ( P  < .05). At 6 months after surgery, the score of confrontation was higher and the score of acceptance-resignation were lower in the combination group than those in the Kegel group ( P  < .05). Intra-group comparison showed that there were statistically significant differences in the scores of the 3 subscales between pre-operation and post-operation both in the combination group and in the Kegel group (Table 3 , P  < .05). Comparison of preoperative and postoperative medical coping style between the 2 groups. Data are Mean ± SD. T1 = before surgery, T2 = 3 months after surgery, T3 = 6 months after surgery. Compared with preoperative score, P  < .05. #Compared with the score at 3 months after surgery, P   .05). At 6 months after operation, the total score of FSFI and the score of each dimension were higher in combination group than those in Kegel group ( P  < .05). Intra-group comparison showed that, compared with pre-operation, the postoperative total score of FSFI and score in all dimensions were lower both in the combination group and in the Kegel group (Table 4 , P  < .05). Comparison of sexual life quality between the 2 groups. Data are Mean ± SD. T1 = before surgery, T3 = 6 months after surgery. Compared with pre-operative score, P  < .05.

As an main female reproductive organ, uterus plays an important role in breeding offspring and in maintaining physiological function. Total hysterectomy shows a radical effect on uterine tumors, bleeding and other diseases. However, it also brings about some adverse outcomes, such as vital organ defects, pelvic sagging, negative emotions and sexual function decline. [ 15 ] With the development of the modern medical model of “bio-psycho-social,” more and more researchers have paid attention to the psychological status and sexual quality of patients with total hysterectomy. For these patients, to improve the function of pelvic floor muscle, to actively cope with the disease and to enhance the quality of sex life, it is of great significance to attach importance to the pelvic floor muscle exercise and emotional intervention. Several studies have shown that Kegel exercise is effective in restoring the pelvic floor muscle. [ 7 , 16 , 17 ] In Kegel exercise, regular exercise repeatedly contracts and dilates the perineum and anal muscles, inhibits the excitation of pelvic sympathetic nerve, improves the supporting tension of pelvic organs, and strengthens the endurance of pelvic floor muscle. Abdominal breathing combined with Kegel exercise can avoid the injury caused by the incoordination between breathing and muscular movement. It is an easy-to-operate, scientific, and effective exercise mode, and could ultimately restore the normal tension of the relaxed pelvic floor muscle, so as to prevent and cure pelvic floor dysfunction. Negative emotions such as anxiety, fear and depression are relatively common during the perioperative period of total hysterectomy. An increased stress response can lead to negative, avoidant coping styles in the face of treatment. In addition, after discharge, patients have to bear the pressure from family and society. We showed that, compared with Kegel group, the postoperative score of confrontation was higher, while postoperative scores of avoidance and acceptance-resignation were lower in the combination group, indicating that REBT can relieve the pressure and improve the negative emotion via a positive coping way. Bhardwaj et al showed that, in patients with stroke, REBT had the potential to reduce the risk of mental health problems such as anxiety, depression and sleep disorders, relieve stress, strengthen beliefs, and thus improved quality of life. [ 18 ] REBT is also effective in reducing depression in adults with congenital heart disease. [ 19 ] In addition, REBT could contribute to the improvement of female college students’ health and quality of life. [ 20 ] Female sexual function is significantly correlated with age, hysterectomy and mental health, and the level of sexual quality depends on physiological, psychological and social factors. [ 21 ] We found that, compared with preoperative levels, the postoperative total FSFI score and scores of all dimensions were lower, indicating that total hysterectomy significantly affected the sexual life quality. After the operation, the patient body could not fully recover and hormone levels are insufficient. Patients worry that sex will affect their recovery, so they are on the defensive in marital life, leading to a decline in the quality of sex. Therefore, interventions should be taken to improve sexual function in patients with total hysterectomy. Several studies have shown that Kegel exercise could improve some domains of sexual function in women, however, Kegel exercise alone shows limited efficacy and is not satisfactory. [ 22 – 24 ] Farajkhoda et al showed that, in female patients with cardiac rehabilitation, REBT counseling could improve the sexual function. [ 25 ] Our study firstly indicated that, the combination of Kegel exercise and REBT could improve the sexual function of patients who underwent total hysterectomy. Kegel exercise can effectively restore the tissue nerves damaged by surgery, promote the release of sex hormones, increase the pelvic blood supply, tighten the vaginal muscles, and thus improve the sexual excitement. In contrast, REBT can change patients’ negative emotions into positive coping, and patients no longer avoid reality. Therefore, the relationship between husband and wife is greatly improved and the quality of sex life is increased accordingly. There were several limitations in this study. Firstly, the sample size in the single center study was relatively small and the follow-up time was insufficient. Second, many of the participants did not receive higher education, which may affect the efficacy of the questionnaires. Therefore, it is necessary to enlarge the sample size, extend the follow-up time and stratify patients to confirm the clinical effect. In summary, this study initially verified that, in patients with total hysterectomy, Kegel exercise combined with REBT improves the pelvic floor muscle function, adopts positive medical coping methods, increases the level of sexual life, and is worthy of clinical promotion and application.

We thank Prof Xiaosi Hu from the First Affiliated Hospital of Anhui Medical University for providing writing assistance and Prof Qing Pang from Bengbu Medical College for providing language help and statistical analysis.