Conference Paper

How does pelvic floor muscle training lead to improvement of stress urinary incontinence symptoms in females?

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Abstract

Background: The role of levator ani muscle (LAM) dysfunction in female stress urinary incontinence (SUI) is not known. Purpose: To determine whether LAM function is associated with SUI severity, and whether changes in LAM function induced through pelvic floor muscle training (PFMT) are associated with improvements in SUI in females. Methods: Females with SUI were recruited from urogynaecology and physiotherapy clinics. LAM function was evaluated using ultrasound imaging (USI) and manual palpation (PERFECT-Scheme) before and after participants underwent a 12-week PFMT program. SUI severity was assessed using the ICIQ-FLUTS-UI and a 30-minute pad test(30MPT). Results: At baseline (n=97), lower 30MPT was weakly associated with higher bladder neck position(ρs=-0.209,p=0.044) yet with lower PERFECT-Scheme outcomes(overall ρs=0.206, repeated maximum voluntary contractions (MVCs):ρs=0.203, power/motor control ρs=0.214,p<0.05) except perineal lift during coughing was associated with lower ICIQ-FLUTS-UI. All measures of SUI and LAM function were significantly improved after the PFMT intervention (p<0.05). Greater improvements in ICIQ-FLUTS-UI were associated with greater reductions in levator plate length during MVC (ρs=0.238,p=0.041) yet with less improvement in the ability to repeat MVCs(ρs=0.303,p=0.009). Greater improvements in the 30MPT were associated with more bladder neck elevation(ρs=-0.261,p=0.027) and greater reductions in levator plate length(ρs=0.292,p=0.016) during MVC. Conclusion: Improvements in bladder neck support and elevation during MVC show weak associations with improvement in SUI signs and symptoms. Implications: While associations are weak, improved bladder neck support and elevation during MVC may play a role in improving continence function among females with SUI. The PERFECT-Scheme provides limited information on LAM function relevant to SUI or PFMT outcomes.

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Objective To assess age‐related changes in the pelvic floor muscular hiatus and their association with symptoms of pelvic organ prolapse, urinary and fecal incontinence, and sexual function. Methods In this pilot study we performed 3D endovaginal ultrasonography in two age groups of nulliparous women: 18 to 40 years and 52 to 85 years. Anterior‐posterior (AP) diameter, left‐right (LR) diameter, and the Minimal Levator Hiatus area were measured. The AP/LR ratio was calculated to compare the shape of the pelvic floor muscles between participants (oval vs circular). Other measurements included length of the urethra, and levator plate lift. Participants were assessed for (1) distress symptoms of pelvic floor prolapse, urinary, and fecal symptoms by the Pelvic Floor Distress Inventory‐20, (2) quality of life via the pelvic floor impact inventory‐7, and (3) sexual function by the female sexual function inventory (FSFI‐19). Results A total of 12 women into the younger group and 10 to the older group were recruited. Older women had higher AP/LR ratio and longer distance levator plate lift while performing the squeeze maneuver ( P = 0.017 and 0.038, respectively). Older women had worse urinary and pelvic organ prolapse symptoms ( P = 0.002 and 0.004, respectively). Fewer women in the older group were sexually active (60% vs 92%) and their quality of sexual life was lower based on their FSFI‐19 results. Conclusion Levator ani muscle hiatus changes to a more oval form in older nulliparous postmenopausal women and this change in shape is associated with increased pelvic floor symptoms.
Article
Aims: The purpose of this study was to investigate the relationship between pelvic floor muscle (PFM) electromyographic (EMG) activation and urogenital landmark motion measured using 2D transperineal ultrasound (US) imaging. Methods: Eight healthy, nulliparous women performed maximum voluntary PFM contractions while EMG and transperineal US images were acquired simultaneously. Changes in the levator plate length (LPL), bladder neck (BN) position and urethral position were determined by visual inspection. The relative timing of EMG onset and the onset of landmark motion, and the correlation coefficients between EMG activation and landmark motion were computed. Comparisons between the correlation coefficients and onset latencies of each landmark motion were made using one-way analysis of variance models. Results: Despite generally good reliability metrics for the onset of EMG and the onset of landmark motion, the relative timing of EMG onset and the onset of landmark motion demonstrated no systematic patterns of activation onset. That said, the overall motion of the different urogenital landmarks throughout the MVC task was highly correlated with the PFM EMG data; correlation coefficients were generally good (>0.90) and highly significant (p < .001). The correlation between PFM EMG and LPL motion was significantly better than the correlation between PFM EMG and motion of the other landmarks. The relevance of one outlier is discussed. Conclusions: The motion of all urogenital landmarks seen on US imaging is highly correlated with PFM EMG activation during maximum voluntary PFM contractions and may therefore be of value in the context of biofeedback training to infer that PFM activation has occurred. The motion of the BN, however, may require more cautious interpretation than the reduction of LPL. The timing of the onset of urogenital landmark motion on transperineal US imaging does not precede nor follow the timing of PFM activation, while the high variance of relative onset timing makes the onset of landmark motion of questionable value when training or evaluating co-ordination or motor control.
Article
Aims: The purposes of this study were: (i) to evaluate the reliability of vaginal palpation, vaginal manometry, vaginal dynamometry; and surface (transperineal) electromyography (sEMG), when evaluating pelvic floor muscle (PFM) strength and/or activation; and (ii) to determine the associations among PFM strength measured using these assessments. Methods: One hundred and fifty women with pelvic floor disorders participated on one occasion, and 20 women returned for the same investigations by two different raters on 3 different days. At each session, PFM strength was assessed using palpation (both the modified Oxford Grading Scale and the Levator ani testing), manometry, and dynamometry; and PFM activation was assessed using sEMG. Results: The interrater reliability of manometry, dynamometry, and sEMG (both root-mean-square [RMS] and integral average) was high (Lin's Concordance Correlation Coefficient [CCC] = 0.95, 0.93, 0.91, 0.86, respectively), whereas the interrater reliability of both palpation grading scales was low (Cohen's Kappa [k] = 0.27-0.38). The intrarater reliability of manometry (CCC = 0.96), and dynamometry (CCC = 0.96) were high, whereas intrarater reliability of both palpation scales (k = 0.78 for both), and of sEMG (CCC = 0.79 vs 0.80 for RMS vs integral average) was moderate. The Bland-Altman plot showed good inter and intrarater agreement, with little random variability for all instruments. The correlations among palpation, manometry, and dynamometry were moderate (coefficient of determination [r(2) ] ranged from 0.52 to 0.75), however, transperineal sEMG amplitude was only weakly correlated with all measures of strength (r(2) = 0.23-0.30). Conclusions: Manometry and dynamometry are more reliable tools than vaginal palpation for the assessment of PFM strength in women with pelvic floor disorders, especially when different raters are involved. The different PFM strength measures used clinically are moderately correlated; whereas, PFM activation recorded using transperineal sEMG is only weakly correlated with PFM strength. Results from perineal sEMG should not be interpreted in the context of reporting PFM strength.
Article
Pelvic floor muscle training (PFMT) is the first step of treatment for stress urinary incontinence (SUI). Patients must perform self-retraining exercises of the perineal muscles at home in order to maintain the benefit of the physiotherapy. The aim of this study is to assess the benefit of a perineal electro-stimulator, using three-dimensional ultrasound, during this home-care phase. A longitudinal prospective study was conducted between May 2012 and May 2013. All patients with de novo SUI benefited from PFMT followed by a self-maintenance of perineal rehabilitation at home with the Keat(®) Pro system. The primary endpoint was the biometric of the levator ani and it was assessed by three-dimensional perineal ultrasound at inclusion, after conventional rehabilitation and at the end of the study after self-rehabilitation. Ten patients were included. All patients (100%) showed a clinical improvement of SUI. The quality of life was significantly improved after PFMT vs. inclusion (P=0.014) and after self-rehabilitation vs. after PFMT (P=0.033). Levator ani muscles were significantly thicker after conventional rehabilitation than at baseline (P=0.004) and significantly thicker after self-rehabilitation than after PFMT (P=0.009). Conducting self-rehabilitation in addition to conventional PFMT objectively improves the perineal muscle building achieved after conventional rehabilitation. Copyright © 2015 Elsevier Masson SAS. All rights reserved.
Article
Objective To assess the association between clinical and sonographic measures of pelvic floor muscle (PFM) function and symptoms of urinary and anal incontinence (AI).MethodsA retrospective study of women seen at a tertiary urogynecological unit. All women had undergone a standardized interview, clinical examination including modified Oxford Scale grading (MOS), urodynamic testing and 4D translabial ultrasound (TLUS). Cranioventral shift of the bladder neck (BN) and reduction of the hiatal anteroposterior (AP) diameter were measured using US volumes acquired on maximal PFM contraction, blinded against all clinical data.ResultsData from 726 women with a mean age of 56 (SD 13.7; range 18–88) years and a mean BMI of 29 (SD 6.11; range 17–55) kg/m2 were analyzed. Stress (SI) and urge (UI) urinary incontinence were reported by 73% and 72% respectively. Thirteen percent had anal incontinence (AI). Mean MOS was 2.4 (SD 1.1, range 0–5). Mean cranioventral BN shift on imaging was 7.1 (SD 4.36; range 0.3-25.3) mm; mean reduction of AP hiatal diameter was 8.6 (SD 4.8; range 0.3-31.3) mm. On univariate analysis neither MOS nor US measures were strongly associated with symptoms of urinary or anal incontinence (P values were all non-significant except for BN/SI (7.32 vs. 6.51 mm; P = 0.03), AP/AI (9.55 vs. 8.49 mm; P = 0.047) and MOS/SI (2.42 vs. 2.19; P = 0.013)).Conclusions In this large retrospective study we did not find any strong associations between sonographic or palpatory measures of pelvic floor muscle function and symptoms of urinary or anal incontinence.
Article
Aims of study1.To develop a digital technique to assess pelvic floor muscles (PFM).2.To validate the technique and test for validity and reliability.3.To translate the assessment into an exercise-based regimen.Method and ResultsPERFECT is an acronym with P representing power (or pressure, a measure of strength using a manometric perineometer), E = endurance, R = repetitions, F = fast contractions, and finally ECT = every contraction timed. The scheme was developed to simplify and clarify PFM assessment. The pressure (referred to hereafter as power, although actually a surrogate measure of muscular strength) of a contraction was validated by examining perineal lift and perineometric pressure during a maximum voluntary contraction (MVC). Data analysis demonstrated significant positive correlations between power and both lift (r = 0.864; p = 0.031) and perineometric pressure (r = 0.786; p = 0.001); digitally assessed endurance correlated with the area under the pressure curve of a sophisticated perineometer (r = 0.549; p = 0.001). A study of inter-examiner reliability demonstrated highly significant positive correlations between two examiners for power (r = 0.947; p < 0.001), endurance (r = 0.946; p < 0.001), repetitions (r = 0.730; p < 0.005) and number of fast contractions (r = 0.909; p < 0.001). Scatter diagrams confirmed a lack of systematic bias between examiners.Test-retest reliability produced highly significant correlations (p < 0.001) between power (r = 0.929) and endurance values (r = 0.988) recorded on two different occasions, with no convincing evidence of significant discrepancies between the pair of assessments.ConclusionsThe PERFECT scheme has demonstrated reliability and validity as an assessment tool. Furthermore, it is proposed that this scheme provides guidelines for the planning of patient-specific exercise programmes which satisfy the principles of muscle training.
Article
This article reviews progress made in understanding the causes of stress urinary incontinence. Over the last century, several hypotheses have been proposed to explain stress urinary incontinence. These theories are based on clinical observations and focus primarily on the causative role of urethral support loss and an open vesical neck. Recently these hypotheses have been tested by comparing measurements of urethral support and function in women with primary stress urinary incontinence to asymptomatic volunteers who were recruited to be similar in age, race, and parity. Maximal urethral closure pressure is the parameter that differs the most between groups being 43% lower in women with stress incontinence than similar asymptomatic women having as effect size of 1.6. Measures of urethral support effect sizes range from 0.5 to 0.6. Because any one objective measure of support may not capture the full picture of urethrovesical mobility, review of blinded ultrasounds of movements during cough were reviewed by an expert panel. The panel was able to identify women with stress incontinence correctly 57% of the time; just 7% above the 50% that would be expected by chance alone, confirming that urethrovesical mobility is not strongly associated with stress incontinence. Although operations that provide differential support to the urethra are effective, urethral support is not the predominant cause of stress incontinence. Improving our understanding of factors affecting urethral closure may lead to novel treatments targeting the urethra and improved understanding of the small but persistent failure rate of current surgery.
Article
A prospective longitudinal study. Diastasis recti abdominis (DRA) is defined as an increase in the inter-recti distance (IRD), or width of the linea alba. It is a common occurrence in women postpartum. Little information exists on the short- and long-term recovery of IRD and the relationship between changes in IRD and the functional performance of the abdominal muscles. To investigate the natural recovery of IRD and abdominal muscle strength and endurance in women between 7 weeks and 6 months postpartum, and to examine the relationship between IRD and abdominal muscle function. Forty postpartum (25-37 years of age) and 20 age-matched, nulliparous females participated. IRD was measured at 4 locations (upper and lower margin of the umbilical ring, and 2.5 cm above and below the umbilical ring) with a 7.5-MHz linear ultrasound transducer. Trunk flexion and rotation strength and endurance were measured with manual muscle testing and curl-ups. Evaluation was conducted at 4 to 8 weeks and 6 to 8 months after childbirth in postpartum women, and only once for the nulliparous female controls. During follow-up, the IRD at 2.5 cm above the umbilical ring and at the upper margin of the umbilical ring decreased (P = .013 and P = .002, respectively). The strength and static endurance of the abdominal muscles improved over time (P<.05). A negative correlation between IRD and abdominal muscle function at 7 weeks and 6 months postpartum was found (r = 0.34 to 0.51; P<.05, except for trunk flexion strength at 6 months postpartum [P = .064]). In addition, IRD changes between 7 weeks and 6 months postpartum were correlated with improvement in trunk flexion strength (Spearman rho = 0.38, P = .040). At 6 months after childbirth, postpartum women had greater mean ? SD IRDs at all 4 locations (from cranial to caudal: 1.80 ± 0.72, 2.13 ± 0.65, 1.81 ± 0.62, and 1.16 ± 0.58 cm) than those of nulliparous females (0.85 ± 0.26, 0.99 ± 0.31, 0.65 ± 0.23, and 0.43 ± 0.17 cm) (all P<.001). All abdominal strength and endurance measurements were less than those of nulliparous females (all P<.001). The IRD and abdominal muscle function of postpartum women improved but had not returned to normal values at 6 months after childbirth. Future research is essential to explore the need for intervention and, if needed, the effectiveness of specific intervention to reduce the size of IRD in postpartum women.
Article
This study compared the patterns of pelvic floor muscle (PFM) activity during coughing between women with stress urinary incontinence (SUI) and continent women, using surface electromyography (EMG) and posterior vaginal wall (PVW) pressure. Twenty-four women participated: eight continent, eight with mild SUI and eight with severe SUI. Volunteers performed three maximum coughs in supine and standing. Maximum PFM EMG and PVW pressure amplitudes and the timing of the EMG peak relative to the PVW pressure peak were determined. Ensemble average PVW pressure versus EMG curves were created. There were no significant differences among the groups in the maximum EMG or PVW pressure amplitudes. The EMG and PVW pressure peaked simultaneously in both positions in the continent group. In the mild SUI group, the EMG and PVW pressure peaked simultaneously in supine, but the EMG peaked before the PVW pressure in standing. In the severe SUI group, the EMG peaked before the PVW pressure in both positions. The shapes of the PVW pressure versus EMG curves were similar among the groups and positions, however the SUI groups displayed higher EMG-intercepts than the continent women. Conclusion: These findings suggest that urine leakage during coughing in women with SUI may be related to delays in force generation rather than PFM weakness.
Article
To analyze the sensitivity and specificity of the 1-hour pad test, as suggested by the International Continence Society, in the diagnosis of female urinary incontinence. 158 female patients, with or without urinary incontinence, underwent a 1-hour pad test. The pad test was assessed as positive or negative and pad weight was recorded. Uni- and multivariate analysis investigated correlation with age, body mass index (BMI), symptoms, prolapse grade, urinary incontinence grade and type, number of pads daily, urodynamic variables and Urogenital Distress Inventory and Incontinence Impact Quality of Life questionnaires. A positive 1-hour pad test was significantly associated with urinary incontinence grade, with a positive stress test, with detrusor overactivity (DO), urine leakage and a positive Valsalva leak point pressure at urodynamics. The association between presence/absence of incontinence and DO, stress test, urine leakage and pad weight had 83% sensitivity and 89% specificity in predicting urinary incontinence. When the 1-hour pad test result was added to stress test and urine leakage versus presence/absence of incontinence, the sensitivity was 90%, and specificity 65%. Our data seem to confirm the 1-hour pad test has poor predictive value in the diagnosis of female urinary incontinence when associated to stress test and urine leakage.
Article
Stress urinary incontinence results from specific damage to the muscles, fascial structures, and nerves of the pelvic floor. Scientific data are accumulating about the nature of each of these injuries. As we begin to define the damage occurring in each element of the continence mechanism, we should be able to precisely select treatment plans on the basis of the abnormality found in individual patients. For example, a woman who has lost all neural control of her pelvic muscles could be saved the useless frustration of attempting pelvic muscle strengthening, whereas a woman with intact but weak muscles can be made continent with exercise. Before these advances can be realized, we must change our current empiric approach that assigns women to treatment because they have stress urinary incontinence to one that asks about the status of each part of the continence mechanism.
Article
Several randomized controlled trials have demonstrated that pelvic floor muscle training is effective to treat stress urinary incontinence. The aim of the present study was to compare muscle strength increase and maximal strength in responders and non-responders to pelvic floor muscle training. Fifty-two women with urodynamically proven stress incontinence who had participated in a six months randomized controlled trial on pelvic floor muscle training, mean age 45.4 years (range 24-64), participated in the study. The women were classified as responders and non-responders based on a combination of five effect variables covering urodynamic measurement, pad test with standardized bladder volume, and self-reports. Pelvic floor muscle strength was measured with a vaginal balloon connected to a fiber optic micro tip transducer (Camtech AS, Sandvika, Norway). There was a positive correlation between improvement in PFM maximal strength and improvement measured by leakage index (r = 0.34, P < 0.01), and reduction in urinary leakage measured by the pad test (r = 0.23, P = 0.05). The total sample of 52 women comprised 21 responders, 18 unclassifiable, and 13 non-responders. There was a statistically significant difference in maximal strength after the training period between responders and non-responders; 24.0 cm H2O (95% CI:18.1-29.9) versus 12.7 cm H2O (95% CI: 6.8-18.6) P < 0.001), and strength increase; 14.8 cm H2O (95% CI: 8.9-20.7) versus 5.0 cm H2O (95% CI: 2.6-12.6), respectively (P = 0.03). There was a positive relation between both pelvic floor muscle strength increase and maximal strength, and improvement of stress urinary incontinence.
Article
To analyze the relation between urethral hypermobility and urethral incompetence, and to summarize the interdependence between maximum urethral closure pressure (MUCP), urethral hypermobility, and urethral incompetence. A group of 255 patients was selected from a large bank of cases. Inclusion criteria were age 20 years or above, no neurological disease, stable bladder, and no previous incontinence surgery or hysterectomy. The degree of hypermobility (cysto-urethrocele) and the degree of urethral incompetence (abdominal leak point pressure (ALPP)) were determined. Statistical analyses between urethral hypermobility and incompetence were performed with Spearman's correlation and the Jonckherre-Terpstra test. The Spearman's rank correlation test showed a statistically significant relation between urethral hypermobility and the degree of urethral incompetence (P = 0.0049). The statistically significant relation between urethral incompetence and hypermobility suggests that urethral incompetence will increase as the degree of urethral hypermobility does. Optimal conditions for urinary continence include a high maximum urethral closure pressure, absence of hypermobility, and a low degree of urethral incompetence. This last factor is assured by a strong support underneath the urethra permitting compression of the latter during straining. Failure of the urethral closure mechanism is highly probable with a diminished maximum closure pressure accompanied by urethral hypermobility often associated with a high degree of urethral incompetence. Clinically significant urinary incontinence may appear in many intermediate circumstances between these two extreme states, but stress urinary incontinence is essentially an activity-related phenomenon.
Article
To study the relation between maximum urethral closure pressure (MUCP) at rest and the degree of urethral incompetence in the female. Two hundred fifty five patients aged 20 years or older, with stable bladders on multichannel urodynamics, without known neurological pathology, and with no previous history of pelvic or anti-incontinence surgery were included in the study. Resting urethral pressure profile (UPP) and the grade of urethral incompetence was registered. Mean age of the group was 45.6+/-12.7 years; mean MUCP was 62.7+/-28.5 cm of water. There was a statistically significant difference in the MUCP when the different grades of urethral incompetence were compared to each other, the higher grades being associated with a lower maximal closure pressure. This study demonstrates that there is a highly significant relationship between MUCP and between all grades of urethral incompetence. This supports previous observations that MUCP decreases when abdominal leak point pressure (ALPP) is low and that this might be secondary to some mechanical failure in the pressure transmission from the abdominal cavity to the urethra. Studies should never compare continent to incontinent cohorts without considering their ALPP because in doing so they are comparing groups that are functionally heterogeneous.
Article
Until recently, magnetic resonance was the only imaging method capable of assessing the levator ani in vivo. Three-dimensional (3D) ultrasound has recently been shown to be able to demonstrate the pubovisceral muscle. The aim of this study was to define the anatomy of the levator hiatus in young nulliparous women with the help of 3D ultrasound. In a prospective observational study, 52 nulligravid female Caucasian volunteers (aged 18-24 years) were assessed by two-dimensional (2D) and 3D translabial ultrasound after voiding whilst supine. Pelvic organ descent was assessed on Valsalva maneuver. Volumes were acquired at rest and on Valsalva maneuver, and biometric indices of the pubovisceral muscle and levator hiatus were determined in the axial and coronal planes. In the axial plane, average diameters of the pubovisceral muscle were 0.4-1.1 cm (mean 0.73 cm). Average area measurements were 7.59 (range, 3.96-11.9) cm2. The levator hiatus at rest varied from 3.26 to 5.84 (mean 4.5) cm in the sagittal direction, and from 2.76 to 4.8 (mean 3.75) cm in the coronal plane. The hiatus area at rest ranged from 6.34 to 18.06 (mean 11.25) cm2 increasing to 14.05 (6.67-35.01) cm(2) on Valsalva maneuver (P = 0.009). There were significant correlations between pelvic organ mobility and hiatus area at rest (P = 0.018 to P < 0.001) and on Valsalva maneuver (all P < 0.001). Biometric indices of the pubovisceral muscle and levator hiatus can be determined by 3D ultrasound. Significant correlations exist between hiatal area and pelvic organ descent. These data provide support for the hypothesis that levator ani anatomy plays an independent role in determining pelvic organ support.
Article
Vaginal sEMG biofeedback and pelvic floor physical therapists' manual techniques are being increasingly included in the treatment of vulvar vestibulitis syndrome (VVS). Successful treatment outcomes have generated hypotheses concerning the role of pelvic floor pathology in the etiology of VVS. However, no data on pelvic floor functioning in women with VVS compared to controls are available. Twenty-nine women with VVS were matched to 29 women with no pain with intercourse. Two independent, structured pelvic floor examinations were carried out by physical therapists blind to the diagnostic status of the participants. Results indicated that therapists reached almost perfect agreement in their diagnosis of pelvic floor pathology. A series of significant correlations demonstrated the reliability of assessment results across muscle palpation sites. Women with VVS demonstrated significantly more vaginal hypertonicity, lack of vaginal muscle strength, and restriction of the vaginal opening, compared to women with no pain with intercourse. Anal palpation could not confirm generalized hypertonicity of the pelvic floor. We suggest that pelvic floor pathology in women with VVS is reactive in nature and elicited with palpations that result in VVS-type pain. Treatment interventions need to recognize the critical importance of addressing the conditioned, protective muscle guarding response in women with VVS.
Article
While morphological abnormalities of the pubovisceral muscle have been described on magnetic resonance imaging (MRI), their relevance remains unclear. This study was designed to define prevalence and clinical significance of such abnormalities in urogynaecological patients. Prospective observational study. Tertiary urogynaecological clinic. Three hundred and thirty-eight consecutive women referred for urodynamic assessment. Participants underwent a clinical assessment, multichannel urodynamics and imaging with 3D translabial ultrasound. Blinded offline analysis was performed with the software 4D View (GE Kretztechnik, Zipf, Austria). Major morphological abnormalities of the pubovisceral muscle. Defects of the pubovisceral muscle were found in 15.4% of parous women. They were exclusively anteromedial (uni- or bilateral), only occurred among women who had delivered vaginally and were associated with anterior and central compartment prolapse (all P<0.001). There was no association with symptoms of bladder dysfunction or urodynamic findings. Major morphological abnormalities of the pubovisceral muscle are common in parous urogynaecological patients. They are associated with prolapse of the anterior and central compartment, but not with symptoms of bladder dysfunction or urodynamic findings.
Article
To assess the impact of pelvic floor muscle training (PFMT) on bladder neck mobility in a prospective observational study, and to correlate any observed changes with objective, standardized outcome measures of the severity of stress urinary incontinence (SUI). Women with the symptom of SUI were recruited prospectively over a 3-year period from a tertiary referral urogynaecology clinic in a teaching hospital. A group of 97 treatment-naive women complaining of SUI and confirmed as having urodynamic SUI on video-urodynamic assessment agreed to participate. Bladder neck mobility on perineal ultrasonography was assessed immediately before and on completing a 14-week programme of 'PFM rehabilitation'. Treatment outcome was assessed using a standardized pad-test and a condition-specific, validated quality-of-life questionnaire (King's Health Questionnaire). Changes in functional anatomy were quantified using transperineal ultrasonography to measure the bladder neck position at rest, maximum PFM contraction and maximum Valsalva manoeuvre. Bladder neck rotational mobility from rest to maximum incursion and maximum excursion was calculated. Treatment with an intensive package of PFMT and behavioural modification resulted in significant elevation of the bladder neck position at all three measured positions. Displacement of the bladder neck on Valsalva (rotational excursion) was reduced after treatment, suggesting increased levator 'stiffness'. These changes in functional anatomy were associated with a statistically and clinically significant reduction in urine loss and improvement in condition-specific quality of life. The present results show that PFMT is an effective treatment for SUI and provide an important new insight into how dynamic pelvic floor anatomy can be modified by this widely used intervention.
Article
The aim of this study was to determine whether postural activity of the pelvic floor (PF) and abdominal muscles differs between continent and incontinent women during rapid arm movements that present a postural challenge to the trunk. A further aim was to study the effect of bladder filling. Electromyographic activity (EMG) of the PF, abdominal, erector spinae (ES), and deltoid muscles was recorded with surface electrodes. During rapid shoulder flexion and extension, PF EMG increased before that of the deltoid in continent women, but after the deltoid in incontinent women (p = 0.002). In many incontinent women, PF EMG decreased before the postural activation. Although delayed, postural PF EMG amplitude was greater in women with incontinence (p = 0.010). In both groups, PF EMG decreased and abdominal and ES EMG increased when the bladder was moderately full. These findings would be expected to have negative consequences for continence and lumbopelvic stability in women with incontinence.
Article
The anatomic structures in the female that prevent incontinence and genital organ prolapse on increases in abdominal pressure during daily activities include sphincteric and supportive systems. In the urethra, the action of the vesical neck and urethral sphincteric mechanisms maintains urethral closure pressure above bladder pressure. Decreases in the number of striated muscle fibers of the sphincter occur with age and parity. A supportive hammock under the urethra and vesical neck provides a firm backstop against which the urethra is compressed during increases in abdominal pressure to maintain urethral closure pressures above the rapidly increasing bladder pressure. This supporting layer consists of the anterior vaginal wall and the connective tissue that attaches it to the pelvic bones through the pubovaginal portion of the levator ani muscle, and the uterosacral and cardinal ligaments comprising the tendinous arch of the pelvic fascia. At rest the levator ani maintains closure of the urogenital hiatus. They are additionally recruited to maintain hiatal closure in the face of inertial loads related to visceral accelerations as well as abdominal pressurization in daily activities involving recruitment of the abdominal wall musculature and diaphragm. Vaginal birth is associated with an increased risk of levator ani defects, as well as genital organ prolapse and urinary incontinence. Computer models indicate that vaginal birth places the levator ani under tissue stretch ratios of up to 3.3 and the pudendal nerve under strains of up to 33%, respectively. Research is needed to better identify the pathomechanics of these conditions.
Article
To estimate the risk of prolapse associated with levator avulsion injury among a urogynaecological clinic population. Retrospective observational study. Tertiary urogynaecological unit. A total of 934 women seen for interview, examination using the pelvic organ prolapse quantification (POP-Q) staging system and imaging of the levator ani muscle by four-dimensional translabial ultrasound. Retrospective review of charts and stored imaging data. Pelvic organ prolapse stage II and higher and presence of defects of the levator ani muscle. After exclusion of 137 women with a history of anti-incontinence or prolapse surgery, and a further exclusion of 16 women in whom either examination or imaging was impossible, we compared prolapse and imaging data in 781 women. Mean age was 53 years (range 15-89 years), and median parity was 2 (range 0-12). Women reported stress incontinence (76%), urge incontinence (69%), frequency (47%), nocturia (49%) and symptoms of prolapse (38%). Significant prolapse (stage II or higher) was diagnosed in 415 (53%) women, and 181 (23%) women were found to have levator avulsion defects. Prolapse was seen in 150/181 (83%) women with avulsion and in 265/600 (44%) women without avulsion, giving a relative risk (RR) of 1.9 (95% CI 1.7-2.1). The association was strongest for cystocele (RR 2.3, 95% CI 2.0-2.7) and uterine prolapse (RR 4.0, 95% CI 2.5-6.5). Women with levator avulsion defects were about twice as likely to show pelvic organ prolapse of stage II or higher than those without. This effect is mainly due to an increased risk of cystocele and uterine prolapse.
Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women
  • C Dumoulin
  • L P Cacciari
  • Ejc Hay-Smith
Dumoulin C, Cacciari LP, Hay-Smith EJC. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database Syst Rev. 2018;35(1):15-20. https://doi.org/10.1002/nau.22677.
Effects of three interventions in facilitating voluntary pelvic floor muscle contraction in women: a randomized controlled trial
  • Ecl Mateus-Vasconcelos
  • Lgo Brito
  • P Driusso
  • T D Silva
  • F I Antônio
  • Chj Ferreira
Mateus-Vasconcelos ECL, Brito LGO, Driusso P, Silva TD, Antônio FI, Ferreira CHJ. Effects of three interventions in facilitating voluntary pelvic floor muscle contraction in women: a randomized controlled trial. Braz J Phys Ther. 2018;22(5):391-9. Available from: https://linkinghub.elsevier.com/retrieve/pii/ S1413355517303118.
A pelvic muscle Precontraction can reduce cough-related urine loss in selected women with mild SUI
  • J M Miller
  • J A Ashton-Miller
  • Jol Delancey
Miller JM, Ashton-Miller JA, DeLancey JOL. A pelvic muscle Precontraction can reduce cough-related urine loss in selected women with mild SUI. J Am Geriatr Soc. 1998;46(7):870-4. https://doi.org/10.1111/j.1532-5415.1998.tb02721.x.
Assessment of the effect of pelvic floor exercises on pelvic floor muscle strength using ultrasonography in patients with urinary incontinence: a prospective randomized controlled trial
  • O C Tosun
  • U Solmaz
  • A Ekin
  • G Tosun
  • C Gezer
  • A M Ergenoglu
Tosun OC, Solmaz U, Ekin A, Tosun G, Gezer C, Ergenoglu AM, et al. Assessment of the effect of pelvic floor exercises on pelvic floor muscle strength using ultrasonography in patients with urinary incontinence: a prospective randomized controlled trial. J Phys Ther Sci. 2016;28(2):360-5. Available from: https://www.jstage.jst.go. jp/article/jpts/28/2/28_jpts-2015-709/_article.
Reliability and validity of a mobile home pelvic floor muscle trainer: the Elvie Trainer
  • C S Czyrnyj
  • M Bérubé
  • K Brooks
  • K Varette
  • L Mclean
Czyrnyj CS, Bérubé M, Brooks K, Varette K, McLean L. Reliability and validity of a mobile home pelvic floor muscle trainer: the Elvie Trainer. Neurourol Urodyn. 2020;39(6):1717-31. https://doi.org/10.1002/nau.24439s.