Hypothesis / aims of study Although intravaginal dynamometry (IVD) is recommended as the best approach to assess levator ani muscle (LAM) function in research settings, it may not be accessible nor acceptable in some populations, including older females, children/adolescents, or transgender men. Transperineal ultrasound imaging (USI) may be a more acceptable alternative for the assessment of LAM function. Indeed, transient changes in pelvic morphology, including shortening of the levator plate and bladder neck excursion are strongly correlated with LAM electromyography when measured in supine [1]. However, we don’t know whether it is valid to use transient changes in pelvic morphology measured using USI as an indirect measurement of LAM force-generating capacity. Further, the relationship between transient changes in pelvic morphology and LAM force-generating capacity may differ in supine vs upright positions. The aims of this study were to 1) evaluate whether body position (supine vs. standing) impacts measures of pelvic floor morphology measured using ultrasound imaging (USI) and/or LAM force measured using IVD and 2) to investigate the relationship between changes in levator plate length and bladder neck height seen on dynamic transperineal USI and maximal vaginal closure force measured using IVD, in supine and standing positions. Study design, materials and methods This was a secondary analysis of data acquired through a previous cross-sectional, observational study, and received approval from the local institutional research ethics board and consent from research participants [2]. Thirty women (assigned female at birth) who had received previous instruction by a pelvic health physiotherapist on how to perform LAM contractions, and had performed home LAM exercise training for at least three weeks were recruited from local physiotherapy clinics. Potential participants were excluded if they were pregnant, <6 months post-partum, experienced dyspareunia, had a history of pelvic trauma, had pelvic organ prolapse (POP) beyond stage 2, or had previous gynaecologic surgery for incontinence or POP. Participants attended two visits in the research laboratory. At the first visit, three rest and three LAM maximum voluntary contraction (MVC) efforts were performed while force data were collected using a custom mechatronic IVD with the arms opened to a 35mm diameter. These tasks were performed in a supine then in a standing position. At the second visit, two-dimensional transperineal USI was performed while participants repeated the same rest and MVC tasks as the first visit. The USI video was captured while keeping the pubic symphysis, the bladder neck, and the anorectal angle clearly visible within the image frame throughout the three repetitions of the LAM MVC in both the supine and the standing positions. IVD outcomes included: force at rest, forces acquired before (baseline force) and during (peak force, relative peak force, and rate of force development) the three MVC tasks performed in each position. USI data were processed to identify the baseline morphology (from rest trials) and transient changes in levator plate length (LPL) and bladder neck height (BNH) relative to baseline observed during the three MVCs performed in each position. For all measures, the median value from the three trials was retained for analysis. The effect of testing position (supine vs. standing) was analysed for each outcome using paired-samples t-tests. Parametric tests were conducted with bootstrapping based on 1000 samples with replacement and bias corrected accelerated 95% confidence intervals. A Bonferroni correction was applied (α =.005). The associations between relative peak force measured using IVD and transient changes in pelvic morphology observed on USI in both supine and standing were assessed using multiple linear regression models with an uncorrected significance level (α =.05). Results Twenty-six females (mean +/- SD, age =42 +/- 2 years, height =1.66 +/- 0.01m, weight =70.40 +/- 2.38 kg, n =22 parous) participated. A summary of IVD and USI outcomes is presented in Figure 1. IVD baseline force was higher in standing compared to supine, while relative peak force and rate of force development were lower in standing compared to supine. Absolute peak force was not different between standing and supine. USI outcomes showed that baseline LPL and LPL at the peak of the LAM contraction were longer in standing than in supine. BNH was lower at baseline in standing and was lower at the peak of the LAM contraction. There was no difference in the extent of LPL shortening or BN elevation observed during the LAM MVC between supine and standing. The regression models showed a significant negative relationship between relative peak force measured through IVD and change in LPL observed during LAM MVCs in both supine (adj. R-squared =.19, p =.05) and standing (adjusted R-squared =.49, p =.00) (Fig 2). Interpretation of results The findings that baseline force is higher and relative peak force measured using IVD is lower in standing compared to supine are consistent with previous reports [3]. The increased baseline force is likely the result of increased loading of the dynamometer arms by the weight of the abdominal/pelvic organs. These results highlight the importance of assessing LAM function in standing to reflect LAM force generating capacity in a functional position. While the results show that MVC force measured through dynamometry is linearly related to the extent of shortening of the LPL seen on USI in both supine and standing positions, the relationships are not strong, explaining less than 20% of the variance in the data for the supine position and approximately half of the variance in the model for the standing position. The lack of a significant relationship between change in the BNH and LAM force measured through IVD is not surprising. The position of the BNH within the pelvic cavity is defined in relation to a plane drawn between the pubic symphysis and the anorectal junction. As the levator ani muscles contract, the anorectal junction moves, changing the position and angle of the reference plane and impacting the measured BNH. Changes in BNH are not recommended as a reflection of LAM contractile force. Higher order measures, such as the velocity or acceleration of landmarks may show stronger relationships with IVD measures of force or power and should be considered in future work. Concluding message While baseline and peak forces achieved during MVC are higher when measured using IVD in standing compared to supine, the relative peak force is lower. LPL is longer and BNH is more caudal when measured using USI in standing compared to supine, both at rest and at the peak of the MVC. Separate normative data sets are therefore needed for recordings made in standing and supine. The relationship between LAM MVC force and the change in LPL observed during MVC was significant in both standing and supine positions, but, at best, only half of the variance in the data was explained by the model. It is not recommended to use the extent of change in the BNH or LPL observed on USI during LAM MVC as a reflection of force generated by the LAMs, either in research or in clinical practice. References: 1. Thibault-Gagnon S, Auchincloss C, Graham R, McLean L. The temporal relationship between activity of the pelvic floor muscles and motion of selected urogenital landmarks in healthy nulliparous women. J Electromyo. Kinesiol. 38 (2018) 126-135. 2. Czyrnyj CS, Berube M-E, Brooks K, Varette K, McLean L. Reliability and validity of a mobile home pelvic floor muscle trainer: The Elvie Trainer. Neurourol. Urodyn. 39 (2020) 1717-1731. 3. Bø K, Finckenhagen HB. Is there any difference in measurement of pelvic floor muscle strength in supine and standing position? Acta Obstet. Gynecol. Scand. 82 (2003) 1120-1124.

HYPOTHESIS / AIMS OF STUDY Urinary incontinence (UI) is a common healthcare problem that is recognized as a worldwide concern, having a substantial medical and economic burden on healthcare systems. Primary care providers (PCPs) are in a perfect position to uncover, triage and/or initiate first-line therapy for females living with UI. However, it has been suggested that UI in females remains under-diagnosed and under-treated in primary care settings. Objectives: To 1) describe PCPs practices for the evaluation and management of females with UI, and 2) compare and appraise PCP UI practices against recommendations made in high-quality clinical practice guidelines. STUDY DESIGN, MATERIALS AND METHODS A systematic review was conducted, guided by Cochrane methods and PRISMA reporting guidelines (Protocol registered on PROSPERO). Four databases (Medline, EMBASE, CINAHL, Web of Science) were searched from their respective inception dates to March 6, 2023. All studies published in English and French describing PCPs evaluation and management practices for female patients reporting UI were eligible for inclusion (e.g., history taking, objective assessment, interventions, referrals, and follow-ups). Studies were excluded if they: 1) were focused on other healthcare providers (e.g., gynecologists, urologists, physiotherapists), 2) looked at subtypes of UI other than stress, urgency or mixed, and 3) included male, children, or pregnant female. Two reviewers independently selected studies, assessed their quality (Mixed Methods Appraisal Tool), and extracted data. Reported practices were narratively synthesized. Reported evaluation and management practices were then compared to recommendations that were consistent among four recent high-quality (≥70% in five domains using Agree-II) UI guidelines (AUA-SUFU, EAU, ICI and NICE). Consistent recommendations for initial evaluation and treatment are as follows: focused history taking, pelvic and abdominal examination, pelvic floor muscle assessment, bladder diary and urinalysis to diagnose UI and conservative strategies as first-line treatment such as pelvic floor muscle training, bladder training and lifestyle modifications. Topical estrogen is also recommended, if needed, to treat vaginal atrophy. Adherence to guideline recommendations was appraised using a cut-off of poor: 0-33% of providers, moderate: 34-66% and high: 67-100%. Pharmacotherapy, referrals and follow-ups were reported descriptively only. RESULTS 3475 articles were retrieved and underwent abstract screening inclusion, while 31 were retained after full text review. Among the included studies, 27 used quantitative methods, three used qualitative methods, and one used mixed methods (Figure 1). Nine articles were published before or in 2000, eleven were published between 2001-2010, and eleven were published between 2011-2022. Included studies assessed the practice patterns of PCPs in the United States (n=9), the Netherlands (n=5), the United Kingdom (n=5), Norway (n=3), Canada (n=3), Australia (n=1) Denmark (n=1), France (n=1), Germany (n=1) and internationally (n=1; France, Germany, Spain and UK). The majority of studies reported a poor to moderate adherence to performing a pelvic examination (6 of 8 studies reporting on this practice; percent range of all included studies: 23-76%), abdominal examination (2 of 3; 0-87%), pelvic floor muscle assessment (2 of 2; 9-36%) and bladder diary (8 of 9; 0-92%) while a high adherence to urinalysis was reported in a majority (5 of 9; 40-97%). For the conservative management of UI, studies revealed a poor to moderate adherence to pelvic floor muscle training (7 of 9; 13-82%), bladder training (8 of 8; 2-53%) and lifestyle interventions (5 of 6; 1-71%) (Figure 2). In terms of pharmacotherapy, PCPs mostly prescribed antimuscarinics (2-46%; n=9 studies reporting on this practice) while there was a wider variation for estrogen therapy (2-77%; n=7). PCPs referred to medical specialists (5-37%; n=14), more specifically to urologists (2-27%; n=2), to gynecologists (19-25%; n=2) and urogynecologists (10-12%; n=2). Referrals to medical specialists were generally made less than 30 days following UI initial assessment. From the studies that looked at referral preferences, urologists were the most sought out professional for UI consultations. Finally, there was high variability in PCPs practice patterns around scheduling follow-up appointments (3-79%; n=4). Regarding the quality assessment of included studies, the representative sample of the target population and the appropriate measurement criteria were rated mostly as having an unclear risk of bias across studies. The nonresponse criterion was an unclear or high risk of bias most of the time. For the qualitative studies, the most relevant bias noted was that the approaches chosen were not necessarily appropriate for answering the research question, making the overall coherence of each study unclear. INTERPRETATION OF RESULTS This review revealed a high variability in PCP adherence to guideline recommendations for the assessment and management of UI in female. However, some trends were observed, including: 1) most studies reported poor or moderate adherence to important objective assessments that allow for a proper diagnosis of UI (abdominal and pelvic exam, bladder diary), 2) an under-use of recommended conservative therapies as first-line treatment, 3) an overreliance on anticholinergic medication and 3) a dependence on medical specialists (based on less than 30 days referrals). Nevertheless, it was found that most PCPs tend to complete a detailed and focused history with their patients. Accounting for the variation in research methodology and clinical practices, our findings lead to the following discussion points. First, a high number of included studies were survey-based (cross-sectional) with a low response rate, thus affecting the generalizability of reported results. Nevertheless, a trend of low to moderate adherence to most guideline recommendations was observed. Second, regarding the methodological quality of the studies included in this review, it is mostly unclear if measurements (surveys, interview questions, etc.) were appropriate to collect data. Most questionnaires and interviews were not validated, and in most studies, it is unclear if they were pilot tested before use. This could lead to unknown measurement errors, with a risk of drawing inaccurate conclusions. Third, only six studies reported on management strategies used per UI subtype. Treatment recommendations for urgency and stress UI differ and, based on our findings, it is unclear if PCPs use the appropriate treatment per UI type, which could lead to false or biased conclusions. Fourth, time and geography could be potential confounders to the findings of this review. We included studies regardless of publication year; and it could reasonably be expected that PCPs studied in older publications may not follow the recommendations included in recent guidelines even though most assessment and treatment recommendations have not changed in two decades. Variation in study results could also stem from differences in geography, which include, but are not limited to the country and the region where data were collected. Each country has their own healthcare system, that could hinder or facilitate some practices. CONCLUDING MESSAGE The findings of this review reveal that PCPs report poor to moderate adherence to most clinical guideline’s recommendations that have been disseminated to them for decades. Despite that these findings are prone to high variability in reporting and may be limited in terms of generalizability, the key message is consistent: patient care for UI needs to be improved considerably. Researchers and audit experts should focus on collecting representative objective data with the use of validated UI quality of care indicators. A collaborative effort should also be made to reflect on the complexity of behavior/practice changes within the PCP community looking specifically at UI; all with the aim to find the best ways to optimize the provision of evidence-informed care for female with UI.

Questions: Do women with stress urinary incontinence (SUI) who receive instruction to perform the knack maneuver as part of a 12-week pelvic floor muscle training (PFMT) program perform it during voluntary coughing without specific instruction to do so, and are subjective and objective outcomes better among those who do than among those who do not demonstrate the knack during voluntary coughing? Design: Secondary analysis of a prospective interventional cohort. Participants: Women with SUI. Intervention: 12-week PFMT intervention including instruction to perform the knack. Outcome measures: Performance of the knack before a voluntary cough as confirmed through ultrasound imaging. SUI severity determined subjectively (International Consultation on Incontinence Modular Questionnaire-Female Lower Urinary Tract Symptoms [ICIQ-FLUTS] overall score, ICIQ-FLUTS UI subscale score, 3-day bladder diary) and objectively (30-min pad test). Results: Outcome data were available from 69 participants. At baseline, no participants performed the knack when asked to cough. At follow-up, more participants performed the knack during a voluntary cough [18/69 (26%), 95% confidence interval [CI] 15%-35%] than at baseline. The extent of improvement in SUI symptoms was not different between participants who did and did not demonstrate the knack during a voluntary cough [FLUTS-UI subscale score (d = 0.31, 95% CI -0.78 to 2.77, n = 69), FLUTS overall score (d = 0.26, 95% CI -1.52-4.23, n = 69), 30-min pad test (d = 0.03, 95% CI -9.35 to 10.32, n = 69), 3-day bladder diary (d = 0.03, 95% CI -4.07 to 3.60, n = 51)]. Conclusion: Approximately one in four women appear to adopt the knack as a motor response to a cough command, however, adopting the knack was not independently associated with greater improvements in SUI.