The main aim of this study was to assess the pelvic floor muscles (PFM) function through digital palpation and four-dimensional translabial ultrasound (4D TLUS); and compare these findings among women with operated endometrial cancer (EC) and cervical cancer (CC) who underwent pelvic radiotherapy (RT) with or without previous surgery. The secondary aim was to correlate PFM function assessed by 4D TLUS with variables of cancer treatments for CC and EC separately.

This was a cross-sectional study. After reviewing medical records, 130 women with a history of CC or EC, treated with pelvic RT with or without previous surgery, were invited to participate in the study. Were recruited women diagnosed with CC or EC who had finished RT at least 6 months ago, menopausal, from 18 years old and literate. Were excluded women with stage IV of disease according to the International Federation of Gynecology and Obstetrics (1), with evidence of disease progression, neurological or muscle deficit, previous perineal surgery, history of another type of cancer and who were undergoing PFM training supervised by physiotherapist. When accepting to participate in the study and signing the Informed Consent Form, a day was scheduled with the participant to carry out the exams pertinent to the study. After that, of the 130 women previously recruited, 70 attended scheduled assessment. Then, 6 had to be excluded due to loss of ultrasound volumes. Therefore, a total of 64 women were included in the study, 26 with CC and 38 with EC. The participants had their medical records reviewed, underwent an interview for anamnesis, gynecological physical examination and 4D TLUS. The same researcher, previously trained, performed all these exams. PFM function was assessed by digital palpation, grading muscle strength according to the modified Oxford scale (2) and by 4D TLUS. 4D TLUS was performed using the GE Voluson 730 Expert equipment (GE Medical System Kretz-technik GmbH and Co OHG, Zipf, Austria) and the RAB4-8L convex transducer, as previously described (3). The analyzed ultrasonographic parameters were: levator plate angle, hiatal area, puborectalis muscle thickness, puborectalis strain and levator ani muscle integrity. The analysis of ultrasound volume data sets were performed using the 4D View 10.0 software (GE Medical Ultrasound; Ryde NSW, Australia), by a second researcher who was blinded to the participant’s characteristics. Statistical analysis included Chi-Square, Fisher's exact, Mann-Whitney, Kruskal-Wallis tests and Spearman coefficient, adopting a significance level of 5% (p<0.05).

Regarding personal and sociodemographic data, it was found that women with CC were younger (p<0.001), had a lower BMI (p=0.015), longer study time (p=0.003) and shorter menopause time (p=0.013) when compared with those with EC. Regarding clinical history related to cancer, it was observed that all patients with EC had undergone previous surgery as a form of cancer treatment (p<0.001), had more exclusive brachytherapy (p=0.003) and received lower doses of teletherapy (p=0.007) when compared to those with CC. Although these differences between groups, no significant difference was found in PFM strength between women with CC and EC, when assessed by digital palpation (p=0.747). Similarly, no significant differences were found in the PFM function when assessed through 4D TLUS, except for the puborectalis muscle thickness where women with CC presented greater puborectalis thickening during PFM contraction compared to women with EC (p<0.001) (Table 1). However, the women with CC who ended RT more than 60 months ago (p<0.001) or who underwent a higher dose of teletherapy (p=0.039; r=-0.4) had worse PFM function than those women with CC who ended RT less than 60 months ago or those who underwent a lower dose of teletherapy. Similarly, women with EC who had more advanced disease (stages 2 or 3) (p=0.046) and those who had underwent higher doses of teletherapy (p=0.014; r=-0.4) also had worse PFM function than those who had more initial disease (stage 1) and those who had underwent lower dose of teletherapy, as shown on table 2.

The treatments with RT are effective in increasing survival of population with gynecological cancer; however, it is not exempt from acute and late complications. PFM can suffer direct and indirect effects from pelvic RT, as they are in close contact with vaginal cavity, when receiving this type of treatment. In this context, injuries to their muscle tissues may occur, which will lead to deterioration in their function, such as decreased muscle contraction capacity. Although no significant PFM function differences were found between women with CC or EC submitted to pelvic RT, it was possible to observe that the time after RT, the dose of teletherapy and the stage of the disease implied in PFM function.

There were no major differences in the PFM function between women with CC and EC who underwent pelvic RT. However, the variables related to the RT treatment (like the higher dose of teletherapy and the long time after RT) seem to be of most importance for PFM function impairment, as well as the stage of the disease.

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