Neurourology and Urodynamics 31:121–125 (2012) Can Hypopressive Exercises Provide Additional Benefits to Pelvic Floor Muscle Training in Women With Pelvic Organ Prolapse? Ana Paula Magalha ˜es Resende, 1 * Liliana Stu ¨pp, 1 Bruno Teixeira Bernardes, 2 Emerson Oliveira, 1 Rodrigo Aquino Castro, 1 Manoel Joa ˜o Batista Castello Gira ˜o, 1 and Marair Gracio Ferreira Sartori 1 1 Gynecology Department of Federal University of Sa˜o Paulo, Brazil 2 Gynecology and Obstetrics Department of Federal University of Uberla ˆndia, Brazil Aims: The aim of the study was to compare the effect of hypopressive exercises including pelvic floor muscle contrac- tion, pelvic floor muscle training (PFMT) alone and control on pelvic floor muscle function in women with pelvic organ prolapse (POP). Methods: Fifty-eight women with a mean age of 55.4 (Æ9.8) years old with stage II POP were ran- domly assigned to participate in the PFMT group, the hypopressive exercises associated with PFMT (HE þ PFMT) group or the control group. Each treatment group underwent a 3-month course of treatment. The three groups received lifestyle advice regarding weight loss, constipation, coughing, and the avoidance of heavy lifting. Participants were evaluated before and after the treatment. Maximal voluntary contraction (MVC) and endurance were assessed using the Modified Oxford grading system. To evaluate muscle activation, surface electromyography (SEMG) was used. Results: The two treatment group significantly increase pelvic floor muscle function as measured by MVC (P < 0.001) using the Modified Oxford grading system, as well as muscle activation (P < 0.001), measured by SEMG. The PFMT group was superior regarding endurance (P ¼ 0.007). Both groups were superior to the control group regarding MVC, endurance and muscle activation. Conclusion: Adding hypopressive exercises to PFMT does not improve PFM func- tion. Both treatment groups performed better than the control group. Neurourol. Urodynam. 31:121–125, 2012. ß 2011 Wiley Periodicals, Inc. Key words: hypopressive exercises; pelvic floor; pelvic organ prolapse INTRODUCTION Pelvic floor muscle training (PFMT) has been recommended for the treatment of pelvic floor dysfunction, with level A evi- dence in cases of urinary incontinence. 1 Its effectiveness has been proved in numerous randomized, controlled trials. 1,2 Recently, PFMT has shown to improve pelvic organ prolapse (POP). 3,4 Hypopressive exercises were proposed by Caufriez. 5 Accord- ing to Caufriez, these exercises objective ‘‘pelvic floor toning, abdominal wall toning, and normalization of tension struc- tures muscle-aponeurotic antagonists. The decrease of abdominal pressure obtained by hypopressive technique cre- ates a reflex activity type I in the muscles of abdominal wall and pelvic floor with a latency of several seconds’’ (p. 29). 5 In the long term, these exercises would strengthen these muscles. 5 This author also argues that during the practice of hypopressive exercises, ‘‘there is a decrease in muscle stiffness of aponeurotic structures antagonists as respiratory dia- phragm, quadratus lumborum, and hamstrings’’ (p. 29). 5 The exercises are performed in three steps: (a) slow, dia- phragmatic inspiration, (b) total expiration, and (c) diaphrag- matic aspiration – a movement that brings the abdominal wall to the lumbar spine (posterior and superior movement of the abdominal wall), which leads to a superior displacement of the respiratory diaphragm cupolae and supposedly decreases intra-abdominal pressure. 5 Thus, one of the indica- tions of these exercises is to treat POP. 5 This routine could be a complementary method to PFMT. However, there is no evidence that hypopressive exercises can effectively influence PFM function. Furthermore, this treat- ment has been widely used and disclosed in some countries, although it is strongly recommended that patients should only be treated using theories that are supported by scientific evidence. 6 Thus, this study aimed to evaluate the impact of a 3-month hypopressive exercise routine in combination with PFMT (HE þ PFMT) versus a PFMT regimen only on pelvic floor muscle strength and activation and to compare these groups with a control group. MATERIALS AND METHODS This was a single-blind study. All participants, after their first evaluations, underwent a 3-month intervention accord- ing to their group allocation, and they received a second evaluation after the intervention period. This study was approved by the Regional Ethics Committee and was regis- tered at ClinicalTrials.gov (NCT01196598). Women with stage II POP, as graded by a gynecologist according to the POP-Q 7 during a routine consultation, were asked to participate. Those who agreed were included, and they provided written informed consent for their participa- tion. The women who took part in the present study also participated in a randomized, controlled trial on PFTM to Conflict of interest: none. Linda Brubaker led the review process. Grant sponsor: State of Sa ˜o Paulo Research Foundation (FAPESP). *Correspondence to: Ana Paula Magalha ˜es Resende, Department of Gynecology, Section of Urogynecology and Pelvic Surgery, Federal University of Sa ˜o Paulo,Rua Borges Lagoa 783, conjunto 31, 38 andar, Zip Code: 04038-031 Sa ˜o Paulo, SP, Brazil. E-mail: anapaulamrb@gmail.comReceived 5 January 2011; Accepted 7 April 2011 Published online 28 October 2011 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/nau.21149 ß 2011 Wiley Periodicals, Inc.