Standardization of terminology of pelvic floor muscle function and dysfunction: report from the pelvic floor clinical assessment group of the International Continence Society

Treatment of urinary incontinence in women with chronic obstructive pulmonary disease-a randomised controlled study

BACKGROUND

Little is known regarding treatment of urinary incontinence (UI) in women with chronic obstructive pulmonary disease (COPD). The aim of the study was to explore the efficacy of pelvic floor muscle training (PFMT) or cough-suppression techniques (CST) on UI in women with COPD.

METHODS

A three-armed, two-centred, single-blinded, randomised controlled study was performed. Subjects were randomised to (a) PFMT for 16 weeks, (b) 2-3 educational sessions in CST, or (c) written information only. All participants completed questionnaires about UI, cough symptoms, and health status and underwent clinical examinations to evaluate the strength of the pelvic floor muscles and exercise capacity. Daily physical activity levels were measured using an activity monitor and lung function with spirometry. With a significance level of 5% and an 80% chance of detecting a significant difference between groups of 2.5 points on the ICIQ UI SF score, our sample size calculation showed that a total of 78 women, 26 in each group, was required to complete the study.

RESULTS

During the period 2016 to 2018, 95 women were invited to the study. A total of 42 were recruited, three were excluded and 10 (24%) dropped out during the follow-up period. Mean ICIQ-UI SF total baseline score was 9.6 (range: 1-17) and 7.0 (range: 0-16) at follow-up. Changes in subjective UI as measured with the ICIQ-UI SF questionnaire were seen in the PFMT group and control group, but not in the CST group.

CONCLUSION

Due to the low number of available participants and recruitment difficulties including practical issues such as travel distance, lack of interest, poor state of health, and high number of comorbidities, our results are inconclusive. However, reduced subjective UI was observed in the PFMT and control groups with a trend towards best effect in the PFMT group. Screening for UI is advisable in all women with COPD to be able to identify and treat these women to reduce symptom burden and improve quality of life. Future studies should focus on barriers to recruitment as well as randomised controlled studies with larger sample sizes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02614105. 25th November 2015.

Absolute and Relative Reliability of the Assessment of the Muscle Mechanical Properties of Pelvic Floor Muscles in Women with and without Urinary Incontinence

An analysis of the muscle mechanical properties (MMPs) of the pelvic floor muscles (PFMs) is relevant for understanding the physiopathology of urinary incontinence (UI). However, there is no objective and reliable methodology currently available for quantifying the MMPs of PFMs. Thus, the objective was to determine the intra-rater and inter-rater reliability of the MMPs of PFM assessment with a hand-held tonometer device, called the MyotonPRO, in young women with and without UI. Sociodemographic and pelvic floor questionnaires, plus MMPs of PFMs were assessed in 38 nulliparous women with UI and 40 matched healthy women by two trained physiotherapists on two different occasions, 48-72 h apart. Good to excellent absolute reliability was found for tone, stiffness, and decrement of both intra- and inter-rater analyses in both study groups (Intraclass Correlation Coefficient ranged from 0.75 to 0.92), with a trend of lower values for relaxation and creep. The standard error of measurement (SEM) did not achieve 10% of the mean values for any MMPs. The minimum detectable change (MDC) values were also provided for clinical applications. In conclusion, the relative reliability of tone, stiffness, and the assessment of the decrement of PFMs with MyotonPRO is good to excellent for UI and healthy women. The SEM and MDC values were acceptable for their application in clinical settings.

Spanish Questionnaires for the Assessment of Pelvic Floor Dysfunctions in Women: A Systematic Review of the Structural Characteristics and Psychometric Properties

BACKGROUND

Pelvic floor dysfunctions affect a third of the adult female population, including a large number of clinical conditions, which can be evaluated through validated questionnaires that inform us of the status and perception of women both objectively and subjectively. The main objective of this study was to review and explain the topics of the validated questionnaires in Spanish on pelvic floor dysfunctions and to review their psychometric properties.

METHODS

A systematic review was carried out in the PUBMED and WOS databases. The keywords used were in PUBMED: (((((((("Fecal Incontinence" [Mesh]) OR "Urinary Incontinence" [Mesh]) OR "Pelvic Organ Prolapse" [Mesh]) OR "Pelvic Floor Disorders" [Mesh]) OR "Sexual Dysfunction, Physiological" [Mesh]) OR "Pelvic Girdle Pain" [Mesh]) OR "sexual function" [Title/Abstract]) OR "Prolapse" [Title/Abstract]) AND "Surveys and Questionnaires" [Mesh] AND "Validation" [Title/Abstract] combined with the Boolean operators "AND"/"OR". In contrast, in WOS, a segregated search was carried out with each of the terms of pelvic floor dysfunction together with "Validation" and "Surveys and Questionnaires". All articles published up to 19 November 2021 were considered. Methodological quality was assessed with the COSMIN scale.

RESULTS

A total of 687 articles were identified, of which 13 were included. The evaluated questionnaires and the structural characteristics and psychometric properties of each of them were collected.

CONCLUSION

The Spanish versions of the questionnaires show good basic structural and psychometric characteristics for the evaluation of patients with pelvic floor dysfunctions and that they resemble other versions of the same questionnaire published in other languages.

The effect of group or individualised pelvic floor exercises with or without ultrasonography guidance for urinary incontinence in elderly women - A pilot study

INTRODUCTION

Pelvic floor exercises combined with patient education has shown to be a promising intervention for women suffering from urinary incontinence. This pilot study investigated the effect of patient education combined with group or individualised pelvic floor exercises, or individualised pelvic floor exercises with ultrasonography guidance.

METHODS

Thirty-three elderly women with urinary incontinency completed a block-randomised, assessor-blinded study combining patient education with 12-weeks of pelvic floor exercises either group-based or individual with or without ultrasonography guidance. Urinary incontinence symptoms were assessed using the Incontinence Impact Questionnaire-7 (IQ-7) and Urogenital Distress Inventory-6 (UDI-6). Furthermore, daily fluid intake and number of bathroom visits were recorded. Pelvic floor muscle strength was assessed using a manual squeeze test (Oxford Scale, 6-point).

RESULTS

An increase in pelvic floor strength was observed after 12 weeks for both the individual (P = 0.038) and the individual ultrasonography-guided (P = 0.01) exercise groups. However, only the latter group maintained an increased strength at the 24-week follow-up (P = 0.008). Across all groups, the intervention led to a decrease in bathroom visits (P = 0.002) that was maintained at the 24-week follow-up (P < 0.001). The interventions led to a decrease in UDI-6 both after the 12-week intervention (P = 0.009) and at the 24-week follow-up (P = 0.032).

CONCLUSIONS

These findings indicate that pelvic floor exercises together with patient education can reduce urogenital distress and bathroom visits without change in fluid intake. Furthermore, when pelvic floor exercises were conducted individually, pelvic floor strength increased, but pelvic floor strength was maintained over time only for individualised pelvic floor exercises with ultrasonography guidance.

Evaluation of pelvic floor muscle function (PFMF) in cervical cancer patients with Querleu-Morrow type C hysterectomy: a multicenter study

INTRODUCTION

To evaluate the pelvic floor muscle function (PFMF) of cervical cancer patients after type QM-C hysterectomy and to explore the relationship between decreased PFMF and related factors.

METHODS

This was a multi-centered retrospective cohort study. 181 cervical cancer patients who underwent type QM-C hysterectomy were enrolled from 9 tertiary hospitals. Strength of PFMF were measured using neuromuscular apparatus (Phenix U8, French). Risk factors contributing to decreased PFMF were analyzed by univariate and multivariate ordinal polytomous logistic regression.

RESULTS

Totally 181 patients were investigated in this study. 0-3 level of type I muscle fibre strength (MFSI) was 52.6% (95/181), 0-3 level of type IIA muscle fibre strength (MFSIIA) was 50% (91/181). Subjective stress urinary incontinence was 46% (84/181), urinary retention was 27.3% (50/181), dyschezia was 41.5% (75/181), fecal incontinence was 9% (18/181). ① MFSI: Multivariate ordinal polytomous logistic regression shows that the follow-up time (p < 0.05), chemotherapy and radiotherapy (p = 0.038) are independent risk factors of MFSI's reduction after type QM-C hysterectomy. ② MFSIIA: multivariate ordinal polytomous logistic regression shows that the follow-up time (p < 0.05) are independent risk factors of MFSIIA's reduction after type QM-C hysterectomy. The pelvic floor muscle strength (PFMS) increased after 9 months than in 9 months after operation, which showed that the PFMS could be recovered after operation.

CONCLUSIONS

We advocate for more attention and emphasis on the PFMF of Chinese female patients with cervical cancer postoperation.

PEKING UNIVERSITY PEOPLE'S HOSPITAL

PFMF after QM-C hysterectomy has not been analyzed by current study. The contribution is that patients with radical hysterectomy should do pelvic floor rehabilitation exercises in 3 months after operation. Clinical Trails NCT number of this study is 02492542.

Basic versus biofeedback-mediated intensive pelvic floor muscle training for women with urinary incontinence: the OPAL RCT

BACKGROUND

Urinary incontinence affects one in three women worldwide. Pelvic floor muscle training is an effective treatment. Electromyography biofeedback (providing visual or auditory feedback of internal muscle movement) is an adjunct that may improve outcomes.

OBJECTIVES

To determine the clinical effectiveness and cost-effectiveness of biofeedback-mediated intensive pelvic floor muscle training (biofeedback pelvic floor muscle training) compared with basic pelvic floor muscle training for treating female stress urinary incontinence or mixed urinary incontinence.

DESIGN

A multicentre, parallel-group randomised controlled trial of the clinical effectiveness and cost-effectiveness of biofeedback pelvic floor muscle training compared with basic pelvic floor muscle training, with a mixed-methods process evaluation and a longitudinal qualitative case study. Group allocation was by web-based application, with minimisation by urinary incontinence type, centre, age and baseline urinary incontinence severity. Participants, therapy providers and researchers were not blinded to group allocation. Six-month pelvic floor muscle assessments were conducted by a blinded assessor.

SETTING

This trial was set in UK community and outpatient care settings.

PARTICIPANTS

Women aged ≥ 18 years, with new stress urinary incontinence or mixed urinary incontinence. The following women were excluded: those with urgency urinary incontinence alone, those who had received formal instruction in pelvic floor muscle training in the previous year, those unable to contract their pelvic floor muscles, those pregnant or < 6 months postnatal, those with prolapse greater than stage II, those currently having treatment for pelvic cancer, those with cognitive impairment affecting capacity to give informed consent, those with neurological disease, those with a known nickel allergy or sensitivity and those currently participating in other research relating to their urinary incontinence.

INTERVENTIONS

Both groups were offered six appointments over 16 weeks to receive biofeedback pelvic floor muscle training or basic pelvic floor muscle training. Home biofeedback units were provided to the biofeedback pelvic floor muscle training group. Behaviour change techniques were built in to both interventions.

MAIN OUTCOME MEASURES

The primary outcome was urinary incontinence severity at 24 months (measured using the International Consultation on Incontinence Questionnaire Urinary Incontinence Short Form score, range 0-21, with a higher score indicating greater severity). The secondary outcomes were urinary incontinence cure/improvement, other urinary and pelvic floor symptoms, urinary incontinence-specific quality of life, self-efficacy for pelvic floor muscle training, global impression of improvement in urinary incontinence, adherence to the exercise, uptake of other urinary incontinence treatment and pelvic floor muscle function. The primary health economic outcome was incremental cost per quality-adjusted-life-year gained at 24 months.

RESULTS

A total of 300 participants were randomised per group. The primary analysis included 225 and 235 participants (biofeedback and basic pelvic floor muscle training, respectively). The mean 24-month International Consultation on Incontinence Questionnaire Urinary Incontinence Short Form score was 8.2 (standard deviation 5.1) for biofeedback pelvic floor muscle training and 8.5 (standard deviation 4.9) for basic pelvic floor muscle training (adjusted mean difference -0.09, 95% confidence interval -0.92 to 0.75; p = 0.84). A total of 48 participants had a non-serious adverse event (34 in the biofeedback pelvic floor muscle training group and 14 in the basic pelvic floor muscle training group), of whom 23 (21 in the biofeedback pelvic floor muscle training group and 2 in the basic pelvic floor muscle training group) had an event related/possibly related to the interventions. In addition, there were eight serious adverse events (six in the biofeedback pelvic floor muscle training group and two in the basic pelvic floor muscle training group), all unrelated to the interventions. At 24 months, biofeedback pelvic floor muscle training was not significantly more expensive than basic pelvic floor muscle training, but neither was it associated with significantly more quality-adjusted life-years. The probability that biofeedback pelvic floor muscle training would be cost-effective was 48% at a £20,000 willingness to pay for a quality-adjusted life-year threshold. The process evaluation confirmed that the biofeedback pelvic floor muscle training group received an intensified intervention and both groups received basic pelvic floor muscle training core components. Women were positive about both interventions, adherence to both interventions was similar and both interventions were facilitated by desire to improve their urinary incontinence and hindered by lack of time.

LIMITATIONS

Women unable to contract their muscles were excluded, as biofeedback is recommended for these women.

CONCLUSIONS

There was no evidence of a difference between biofeedback pelvic floor muscle training and basic pelvic floor muscle training.

FUTURE WORK

Research should investigate other ways to intensify pelvic floor muscle training to improve continence outcomes.

TRIAL REGISTRATION

Current Controlled Trial ISRCTN57746448.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 70. See the NIHR Journals Library website for further project information.

Pelvic-floor function, dysfunction, and treatment

The pelvic floor functions as a holistic entity. The organs, bladder, bowel, smooth and striated muscles, nerves, ligaments and other connective tissues are directed cortically and reflexly from various levels of the nervous system. Such holistic integration is essential for the system's multiple functions, for example, pelvic girdle stability, continence, voiding/defecation, and sexuality. Pelvic floor dysfunction (PFD) is related to a variety of pelvic pain syndromes and organ problems of continence and evacuation. Prior to treatment, it is necessary to understand which part(s) of the system may be causing the dysfunction (s) of Chronic Pelvic Pain Syndrome (CPPS), pelvic girdle pain, sexual problems, Lower Urinary Tract Symptoms (LUTS), dysfunctional voiding, constipation, prolapse and incontinence. The interpretation of pelvic floor biomechanics is complex and involves multiple theories. Non-surgical treatment of PFD requires correct diagnosis and correctly supervised pelvic floor training. The aims of this review are to analyze pelvic function and dysfunction. Because it is a holistic and entirely anatomically based system, we have accorded significant weight to the Integral Theory's explanations of function and dysfunction.

Clinical assessment of pelvic floor and abdominal muscles 3 months post partum: an inter-rater reliability study

OBJECTIVES

Evaluation of the inter-rater reliability of clinical assessment methods for pelvic floor muscles and diastasis recti abdominis post partum.

DESIGN

A multicentre inter-rater reliability study.

SETTING

Three primary care rehabilitation centres in Sweden.

PARTICIPANTS

A total of 222 participants were recruited via advertising at Swedish maternity care units and social media. Eligibility for participation included female gender, ≥18 years, at maximum 3 months after childbirth. Exclusion criteria were chronic pelvic girdle pain and/or low back pain and/or pelvic floor tear grade III/IV. At each centre, 2 physiotherapists, with training and experience in pelvic floor assessment, assessed the 222 women according to a standardised protocol in random order.

OUTCOME MEASURES

Inter-rater reliability of the assessment of pelvic floor muscle function (involuntary and voluntary contraction and voluntary relaxation) and diastasis recti abdominis (width, depth and bulging).

RESULTS

Vaginal palpation of maximal voluntary contraction revealed a kappa value of 0.69 (95% CI 0.62 to 0.76). Assessments of involuntary contraction and voluntary relaxation yielded inconsistent results, with slight-to-moderate weighted kappa values ranging from 0.10 to 0.51. After 2 months of training in applying this method, diastasis recti abdominis width measured at the umbilicus by calliper yielded an intraclass correlation coefficient value of 0.83 (95% CI 0.76 to 0.87). Assessments of diastasis recti abdominis depth and bulging showed moderate kappa values, with reservation for some inconsistency between the centres.

CONCLUSIONS

Vaginal palpation of pelvic floor muscle strength is a reliable method for the postpartum muscle assessment. Additional research is needed to identify reliable assessment method for other pelvic floor muscle functions like involuntary contraction and voluntary relaxation. With some training, a calliper is a reliable instrument for measuring the postpartum diastasis recti abdominis width. This study provides novel thoughts about how to measure diastasis recti abdominis depth and bulging.

TRIAL REGISTRATION NUMBER

NCT03703804.

The innervation of the bladder, the pelvic floor, and emotion: A review

The innervation of the pelvic region is complex and includes extensive neurologic pathways. The higher centres' organisation determining the pelvic floor and organs' function remains a challenge understanding the physiological and pain mechanisms. Psychological and emotional factors have a profound influence on the pelvic floor and organ dysfunction such as LUTS. LUTS are associated with stress, depression, and anxiety. Neuroception is a subconscious neuronal system for detecting threats and safety and might explain the permanent disturbance of higher brain centres maintaining functional urological and gastrointestinal disorders and sphincter dysfunction.

Reliability of Pelvic Floor Muscle Assessment with Transabdominal Ultrasound in Young Nulliparous Women

The aim of this study was to assess the reliability of pelvic floor muscles evaluation via transabdominal ultrasonography in young nulliparous women and to present the methodology for quantitative assessment of the ultrasound image of the pelvic floor muscles visible as displacement of the posterior wall of the bladder, caused by action of the pelvic floor muscles. The study comprised 30 young, Caucasian, nulliparous women (age 22-27; 168.6 ± 5.1 cm; 57.1 ± 11.8 kg) without pelvic floor muscle dysfunctions. The intra-rater, test-retest and inter-rater reliability of pelvic floor muscles evaluation was performed using transabdominal ultrasound at rest and during voluntary contraction. The reliability was assessed at three points of the image (at the middle, on the right and left side). The reliability of the three-point measurement of the pelvic floor muscles transabdominal ultrasound is excellent in the case of intra-rater assessments, both at rest (ICC = 0.98-0.99) and during contraction (ICC = 0.97-0.98); moderate at rest (ICC = 0.54-0.62) and poor during contraction (ICC = 0.22-0.50) in the case of test-retest assessment; excellent at rest (ICC = 0.95-0.96), and good during contraction (ICC = 0.81-0.87) in the case of inter-rater assessment. Transabdominal ultrasound is a reliable method of pelvic floor muscle evaluation. The three-points of assessment used in our study allowed for broader and more comprehensive imaging of the pelvic floor muscle, e.g., for quantitative detection contractility imbalances between the left and right side Due to the fact that understanding mechanisms of pelvic floor muscle functioning is crucial in the therapy of pelvic floor dysfunctions, therefore, reliable, valid tests and instruments are important.

Four-Dimensional Introital Ultrasound in Assessing Perioperative Pelvic Floor Muscle Functions of Women with Cystoceles

PURPOSE

 Research on the use of ultrasound to explore the pelvic floor in women is rarely done with introital ultrasound. This study aimed to investigate the performance of four-dimensional (4D) introital ultrasound in the perioperative assessment of pelvic floor muscle (PFM) function in women with cystocele.

MATERIALS AND METHODS

 The reliability and agreement of ultrasound measurements were determined by intraclass correlation coefficients (ICC) with 95 % confidence interval and Bland-Altman analysis in 20 women. The validity of ultrasound parameters was assessed by correlating squeezing ultrasound measurements with the modified Oxford scale (MOS) in 317 women. 4D introital ultrasound data of 241 women with (n = 29) and without (n = 212) postoperative cystocele at the 12-month postoperative assessment were retrospectively analyzed. Levator avulsion was diagnosed using tomographic ultrasound imaging. Involuntary and voluntary PFM functions were explored by dynamic changes in the bladder neck and genital hiatus, respectively, upon coughing and squeezing on 4D introital ultrasound.

RESULTS

 The ICC for the reliability of all tested ultrasound parameters was good to very good. The changes and change ratios of most ultrasound measurements from resting to squeezing were fairly correlated with MOS. Women with postoperative cystocele demonstrated more rates of complete levator avulsion [41.3 % vs. 4.7 %, P < 0.001, odds ratio (OR) 14.26, 95 % confidence interval (CI) 4.88-42.42] and fewer rates of capable voluntary PFM contraction (65.5 % vs. 92.5 %, P < 0.001, OR 0.16, 95 % CI 0.06-0.43) than those without postoperative cystocele postoperatively.

CONCLUSION

 4D introital ultrasound is feasible to assess perioperative PFM function in women with cystocele.

Is there agreement between the preference of examiner and women for unidigital and bidigital vaginal palpation? A qualitative study

INTRODUCTION AND HYPOTHESIS

The International Continence Society recommends vaginal palpation as a method for assessing pelvic floor muscle (PFM) function. Our aim was to analyze the agreement between preferences of examiner and participants according to unidigital and bidigital vaginal palpation during PFM assessment. The second aim was to investigate qualitatively women's perception of vaginal palpation.

METHODS

Maximal voluntary contractions (MVCs) were requested during both types of vaginal palpation and were classified by the Modified Oxford Scale (MOS). Examiner and participants answered if they had preferences regarding vaginal palpation. Women answered qualitatively what they felt during the assessment. Cohen's linear kappa (κ) evaluated the agreement after allocation of the women with a weaker and stronger MVC and qualitative analysis was performed by transcription considering age range (18-35; 36-59; ≥60 years).

RESULTS

Agreement was almost zero for women with weaker and stronger MVC at unidigital (κ = 0.06 and κ = -0.12) and bidigital vaginal palpation (κ = 0.008 and κ = 0.005). Participants associated bidigital palpation with more perception and an easier way of contracting the PFMs. Women between 36 and 59 years associated unidigital palpation with a harder but comfortable way of contracting the PFMs. Subjects aged ≥60 years associated bidigital palpation with an uncomfortable, harder way of contracting PFM, with less space into the vagina.

CONCLUSIONS

Agreement between preferences was almost zero neither between women with a weaker and stronger PFM contraction, nor between the types of vaginal palpation. Bidigital palpation increased women's perception, made the contraction easier, and was associated with less space in the vaginal canal and less comfort.

Tradução para a língua portuguesa do artigo original em inglês “ The International Continence Society (ICS) report on the terminology for adult male lower urinary tract and pelvic floor symptoms and dysfunction”

Introdução

No desenvolvimento da terminologia do trato urinário inferior, devido à sua crescente complexidade, a terminologia para os sintomas e a disfunção do trato urinário inferior masculino e assoalho pélvico precisa ser atualizada, utilizando abordagem específica masculina e por meio de um relatório de consenso clinicamente embasado.

Métodos

Este relatório combina a contribuição de membros do Standardisation Committee da International Continence Society em um Grupo de Trabalho com especialistas reconhecidos no campo, assistido por muitos julgadores externos. Categorias clínicas centrais apropriadas e uma subclassificação foram desenvolvidas para fornecer uma codificação numérica para cada definição. Um extenso processo de 22 rodadas de revisão interna e externa foi desenvolvido para examinar exaustivamente cada definição, com tomada de decisão por opinião coletiva (consenso).

Resultados

Um relatório de terminologia para os sintomas e a disfunção do trato urinário inferior e do assoalho pélvico foi desenvolvido, abrangendo cerca de 390 definições/descritores separados. É clinicamente embasado nos diagnósticos mais comuns definidos. A clareza e a facilidade de uso foram os principais objetivos para torná-lo interpretável por profissionais e estagiários em todos os diferentes grupos de especialidades envolvidos na disfunção do trato urinário inferior e do assoalho pélvico masculino. Imagens específicas para homens (ultrassonografia, radiologia, tomografia computadorizada e ressonância magnética) foram um adicional importante, enquanto figuras apropriadas foram incluídas para complementar e ajudar a esclarecer o texto.

Conclusões

Um relatório de terminologia com base em consenso para sintomas e disfunção do trato urinário inferior e do assoalho pélvico masculino foi produzido visando ser um auxílio significativo para a prática clínica e um estímulo para a pesquisa.

Effects of Biofeedback Combined With Pilates Training on Post-prostatectomy Incontinence

OBJECTIVE

To verify the effect of Pilates training combined with biofeedback training, Kegel training combined with biofeedback training, and Kegel training alone on post-prostatectomy incontinence in male patients.

MATERIAL AND METHODS

Forty-two patients were randomly divided into 3 groups. The changes occurring to the 3 groups before and after treatment and the differences between the 3 groups were assessed using a 1-hour pad test, number of incontinent episodes, the ICIQ questionnaire, and the Oxford Grading Scale. The 3 groups were required to undergo daily training for an 8-week period.

RESULTS

At 8 weeks, groups A, B and C experienced a 34.3%, 61.9%, and 67% improvement in the 1-hour pad test, respectively, and 32.1%, 52.9%, and 58.8% reduction in the number of urinary incontinence episodes, respectively, and a 29.4%, 50%, and 64.7% reduction in the ICIQ Scale, respectively, and a 33.3%, 50%, and 50% in Oxford Grading Scale improvement, respectively. The graph results showed that the effect was noted after 3 weeks of treatment and a significant effect occurred by the eighth week of treatment.

CONCLUSION

Three methods were shown to optimize urinary continence and pelvic floor muscle strength of patients with post-prostatectomy incontinence. The treatment effect of group C was better than group B, but there was no statistically significant difference in the 1-hour pad tests. It is particularly important to understand the time sensitivity for patient training.

[Diagnostic testing of female urinary incontinence: dos and dont's]

Urinary incontinence causes significant limitations in quality of life and reduces mental and physical health. It is a widespread and chronic disease. About 200 million people are affected by urinary incontinence worldwide. Females are more often affected than males. For the therapy of female urinary incontinence various conservative and surgical treatment measures are available. A comprehensive diagnostic work-up is crucial for effective and successful use of those therapeutical measures. The current paper gives a review of diagnostic options for female urinary incontinence: from non-invasive up to invasive investigations. It presents potential pitfalls and possibilities for improving the diagnostic work-up.

Proposal of a protocol for pelvic floor muscle evaluation and training to provide care to women with urinary incontinence

OBJECTIVE

To present a proposal of a protocol for pelvic floor muscle evaluation and training to provide care to women with urinary incontinence.

METHOD

Professional experience report, conducted in an outpatient facility for voiding dysfunctions in the Brazilian Unified Health System, conducted by an enterostomal therapist nurse.

RESULTS

Elaboration of a proposal of care protocol in nursing consultations based on a directed physical examination, nursing diagnoses of the International Classification for Nursing Practice, and the adaptation of a muscle training protocol as prescription. Steps: static observation, dynamic observation, and palpation to verify the tension and evaluation of strength, sustentation, relaxation, and muscle coordination, followed by prescriptions for relaxation, proprioception, training for strength, sustentation, abdominal and pelvic coordination, and maintenance, as per diagnosis.

CONCLUSION

This protocol proposal intends to support the evaluation of the pelvic muscles of women with urinary incontinence or at risk for developing this condition by nurses of all levels of healthcare, especially as part of nursing consultations in primary care.

Relationship between the types of urinary incontinence, handgrip strength, and pelvic floor muscle strength in adult women

AIM

To investigate the relationship between handgrip strength with types of urinary incontinence (UI) and pelvic floor muscle strength (PFMS) in women.

METHODS

Ninety-two women, who presented to the geriatric and urology outpatient clinics complaining of UI between July 2019 and February 2020 and had indicated to undergo urodynamic assessment after basic neurourological evaluation, were included in this cross-sectional study. The presence and types of UI were identified by clinical examination and urodynamic studies. Demographic parameters, anthropometric data, comorbidities and medications were recorded. The International Consultation on Incontinence Questionnaire-Short Form was applied. Handgrip strength (HGS) was measured by a hand dynamometer. The PFMS was subjectively assessed via vaginal digital palpation and measured quantitatively by the vaginal probe of the perineometer.

RESULTS

Thirty-eight urodynamic stress, 28 detrusor overactivity, 26 urodynamic mixed UI patients were reported. Perineometer measurements were significantly lower in the urodynamic stress UI group compared to the other two groups (p = 0.020). There was no relationship between the types of urinary incontinence and HGS. However, a positive correlation was found between PFMS and HGS (p = 0.045, r = 0.298).

CONCLUSION

The positive correlation between HGS and PFMS indicates that low HGS may be a marker for PFMS weakness. Furthermore, the association between sarcopenia and UI may be explained by this condition.

Using Preoperative Pelvic Floor Assessment to Predict Early Return of Continence after Robotic Radical Prostatectomy

OBJECTIVE

To evaluate whether pre-operative pelvic floor physical therapy (PFPT) parameters may predict early return of urinary continence after RP. While long-term urinary continence is eventually achieved in most patients who undergo radical prostatectomy (RP), predicting when patients will become continent is challenging. Prior studies aiming to predict return of post-operative continence have not evaluated patient-specific pelvic floor strength parameters.

METHODS

We reviewed a prospectively maintained database of patients undergoing RP who underwent pre-operative PFPT consultation and completed 3-month patient-reported quality of life evaluation. Trained therapists documented pelvic strength parameters. Urinary continence was defined as using 0 or 1 pad per day. We evaluated the association of PFPT parameters with urinary continence at 3 months, adjusting for other factors that could affect continence.

RESULTS

144 men met inclusion criteria. The majority of patients underwent nerve-sparing procedures and had intermediate- or high-risk prostate cancer. At 3 months, 90 of 144 (62.5%) were continent, while 54 of 144 (37.5%) were not. On multivariable analysis, prostate volume (OR 0.98, 95% CI 0.96-1.00) and pelvic floor endurance (OR 2.71, 95% CI 1.23-6.17) were significantly associated with being continent at 3 months. 56 of 76 (74%) men with good pelvic floor endurance were continent at 3 months, while only 34 of 68 (50%) men with poor endurance were continent (P = .006).

CONCLUSION

Pre-operative assessment of pelvic floor endurance is an objective measure that may allow more accurate prediction of early continence after radical prostatectomy. Improved patient counseling could positively impact patient satisfaction and quality of life and reduce decision regret.

Epistles of dyspareunia: storying Christian women's experiences of painful sex

Dyspareunia is painful attempted or completed vaginal-penile intercourse, and vaginal pain from other forms of touch. Because there is a persistent underlying message of shame and taboo surrounding female sexual pleasure in some Christian-informed cultural contexts, we sought to examine how self-identified Christian women in the Midsouthern USA conceptualise and experience dyspareunia. Data were collected through initial surveys and semi-structured interviews and analysed using incident-to-incident and in-vivo coding. Creative Analytic Practice was used to create composite character narratives from the data, storying five aspects of participants' experiences: (1) ignorance and abstinence at home, church, and school; (2) socially-informed expectations of sex and painful realities; (3) making sense of, coping with, and seeking help for painful sex; (4) validation, diagnosis, and treatment; and (5) sex mis-education and desire for a different future. Findings suggest that participants' understandings of and coping with their sexuality and the accompanying painful sex are shaped by implicit and explicit religious messages they encountered in their family upbringing, schooling, social and religious circles, and interactions with healthcare providers. Health professionals are urged to pre-screen women for symptoms of dyspareunia and include sexual wellness checks as routine procedure, and subsequently refer patients to pelvic health physical therapy when appropriate.

An International Continence Society (ICS) report on the terminology for pelvic floor muscle assessment

INTRODUCTION

The terminology for female and male pelvic floor muscle (PFM) assessment has expanded considerably since the first PFM function and dysfunction standardization of terminology document in 2005. New terms have entered assessment reports, and new investigations to measure PFM function and dysfunction have been developed. An update of this terminology was required to comprehensively document the terms and their definitions, and to describe the assessment method and interpretation of the finding, to standardize assessment procedures and aid diagnostic decision making.

METHODS

This report combines the input of members of the Standardisation Committee of the International Continence Society (ICS) Working Group 16, with contributions from recognized experts in the field and external referees. A logical, sequential, clinically directed assessment framework was created against which the assessment process was mapped. Within categories and subclassifications, each term was assigned a numeric coding. A transparent process of 12 rounds of full working group and external review was undertaken to exhaustively examine each definition, plus additional extensive internal development, with decision making by collective opinion (consensus).

RESULTS

A Terminology Report for the symptoms, signs, investigations, and diagnoses associated with PFM function and dysfunction, encompassing 185 separate definitions/descriptors, has been developed. It is clinically based with the most common assessment processes defined. Clarity and user-friendliness have been key aims to make it interpretable by clinicians and researchers of different disciplines.

CONCLUSION

A consensus-based Terminology Report for assessment of PFM function and dysfunction has been produced to aid clinical practice and be a stimulus for research.

International Society for the Study of Women's Sexual Health (ISSWSH) Review of Epidemiology and Pathophysiology, and a Consensus Nomenclature and Process of Care for the Management of Persistent Genital Arousal Disorder/Genito-Pelvic Dysesthesia (PGAD/GPD)

BACKGROUND

Persistent genital arousal disorder (PGAD), a condition of unwanted, unremitting sensations of genital arousal, is associated with a significant, negative psychosocial impact that may include emotional lability, catastrophization, and suicidal ideation. Despite being first reported in 2001, PGAD remains poorly understood.

AIM

To characterize this complex condition more accurately, review the epidemiology and pathophysiology, and provide new nomenclature and guidance for evidence-based management.

METHODS

A panel of experts reviewed pertinent literature, discussed research and clinical experience, and used a modified Delphi method to reach consensus concerning nomenclature, etiology, and associated factors. Levels of evidence and grades of recommendation were assigned for diagnosis and treatment.

OUTCOMES

The nomenclature of PGAD was broadened to include genito-pelvic dysesthesia (GPD), and a new biopsychosocial diagnostic and treatment algorithm for PGAD/GPD was developed.

RESULTS

The panel recognized that the term PGAD does not fully characterize the constellation of GPD symptoms experienced by patients. Therefore, the more inclusive term PGAD/GPD was adopted, which maintains the primacy of the distressing arousal symptoms and acknowledges associated bothersome GPD. While there are diverse biopsychosocial contributors, there is a common underlying neurologic basis attributable to spontaneous intense activity of the genito-pelvic region represented in the somatosensory cortex and its projections. A process of care diagnostic and treatment strategy was developed to guide the clinician, whenever possible, by localizing the symptoms as originating in any of five regions: (i) end organ, (ii) pelvis/perineum, (iii) cauda equina, (iv) spinal cord, and (v) brain. Psychological treatment strategies were considered critical and should be performed in conjunction with medical strategies. Pharmaceutical interventions may be used based on their site and mechanism of action to reduce patients' symptoms and the associated bother and distress.

CLINICAL IMPLICATIONS

The process of care for PGAD/GPD uses a personalized, biopsychosocial approach for diagnosis and treatment.

STRENGTHS AND LIMITATIONS

Strengths and Limitations: Strengths include characterization of the condition by consensus, analysis, and recommendation of a new nomenclature and a rational basis for diagnosis and treatment. Future investigations into etiology and treatment outcomes are recommended. The main limitations are the dearth of knowledge concerning this condition and that the current literature consists primarily of case reports and expert opinion.

CONCLUSION

We provide, for the first time, an expert consensus review of the epidemiology and pathophysiology and the development of a new nomenclature and rational algorithm for management of this extremely distressing sexual health condition that may be more prevalent than previously recognized. Goldstein I, Komisaruk BR, Pukall CF, et al. International Society for the Study of Women's Sexual Health (ISSWSH) Review of Epidemiology and Pathophysiology, and a Consensus Nomenclature and Process of Care for the Management of Persistent Genital Arousal Disorder/Genito-Pelvic Dysesthesia (PGAD/GPD). J Sex Med 2021;18:665-697.

Symptoms of voiding dysfunction and other coexisting pelvic floor dysfunctions: the impact of transvaginal, mesh-augmented sacrospinous ligament fixation

INTRODUCTION AND HYPOTHESIS

The objective was to investigate the prevalence for voiding dysfunction and if symptom improvement can be achieved by adequate pelvic floor surgery.

METHODS

We evaluated the Propel Study data from 281 women with pelvic organ prolapse (POP) stage 2-4. Bother caused by obstructive micturition, voiding dysfunction, and coexisting pelvic floor symptoms were assessed using the Pelvic Floor Distress Inventory (PFDI) preoperatively and 6, 12, and 24 months after vaginal prolapse repair. Successful reconstruction (Pelvic Organ Prolapse Quantification [POP-Q] stage 0-I throughout the 2-year follow-up at all compartments, "responders"), was compared with all others ("non-responders").

RESULTS

Prevalence of voiding dysfunction was significantly reduced after surgery for all patients with "moderate" to "quite a bit" of bother ("R2") regarding all examined PFDI questions. Defects of the posterior/apical compartment and lower stage defects were found to cause obstructive micturition, which improved significantly after POP surgery. Six months after surgery, the prevalence of R2 for voiding dysfunction symptoms was reduced significantly for responders compared with non-responders. Significant reduction of R2 in patients with rectoceles could be shown for some PFDI questions, whereas the rate was lower in patients with cystoceles. Other pelvic floor symptoms often coexisted in patients with voiding dysfunction symptoms and improved significantly after surgery as well.

CONCLUSIONS

Symptoms of voiding dysfunction are frequent in female patients with POP and can significantly improve after vaginal mesh-augmented prolapse repair even for posterior and minor defects. Before counseling patients to undergo POP surgery because of their obstructive symptoms, other causes of voiding dysfunction must first have been ruled out.

Are visual inspection and digital palpation reliable methods to assess ability to perform a pelvic floor muscle contraction? An intra-rater study

AIMS

To investigate the intrarater reliability of visual inspection and digital palpation to classify women's ability to perform a voluntary pelvic floor muscle (PFM) contraction and the association between the two methods.

METHODS

This was a test-retest clinical study including 44 women. The ability to perform a PFM voluntary contraction was evaluated two times in all participants using visual inspection and digital palpation. All analyzed participants were assessed with a 7-day interval between the two assessments and by the same examiner. Kappa's agreement coefficient was used to estimate the intrarater reliability, and Fisher's exact test was used to analyze association between the two methods.

RESULTS

This study found a substantial intrarater reliability of visual inspection (k = 0.73; p < .001) and digital palpation (k = 0.74; p < .001). A significant association between visual inspection and digital palpation was found at both time points (p < .001).

CONCLUSION

Both visual inspection and digital palpation have substantial intrarater reliability and visual inspection can be recommended when vaginal palpation is not tolerated.

Verbal instruction to obtain voluntary pelvic floor muscle contraction: Acceptability, and understanding

PURPOSE

The aim of this study was to describe verbal instructions used to obtain a voluntary pelvic floor muscle contraction and to evaluate their understanding and acceptability.

METHODS

This prospective study led in two phases. A questionnaire was submitted to experts to collect the most frequently used instructions to obtain a PFMC. Then a questionnaire was submitted to subjects in order to: estimate the pelvic floor anatomical knowledge; estimate understanding and acceptability of these instructions; select the best instruction.

RESULTS

First phase: 46 experts proposed 356 instructions. Forty-four percent were functional instructions ("hold a gas"), 40% anatomical ("squeeze your anus") and 16% allied both. Fifteen instructions for the women and 11 for the men were selected. Second phase: 33 subjects completed the questionnaire. More than 75% had correct answers for anatomical knowledge. The instructions judged by the subjects as the most adapted to obtain a PFMC were: "contract the anus", "do as if you wanted to hold a strong desire to void". The items including "perineum" or "vagina" were less understood.

CONCLUSIONS

The more understandable and acceptable instruction to assess the PFMC is the association of two simple instructions: one anatomical and one functional.

LEVEL OF EVIDENCE

4.

Reliability of the PERFECT scheme assessed by unidigital and bidigital vaginal palpation

INTRODUCTION AND HYPOTHESIS

The aim of the present study was to evaluate the inter- and intra-rater reliability of the PERFECT scheme assessed by uni- and bidigital vaginal palpation in young nulligravid women.

METHODS

Forty healthy women [median age 22 (19-34) years] were evaluated by unidigital vaginal palpation by both Examiners A and C, while the other 40 participants [median age 23.5 (19-35) years] were assessed by Examiners B and C by bidigital vaginal palpation. Inter- and intra-rater reliability of all items of the PERFECT scheme were evaluated: P = power (Modified Oxford Scale); E = endurance; R = repetitions; F = fast contractions. Cohen's linear weighted kappa (κw) was used to assess the reliability of the power, while the intraclass correlation coefficient (ICC) was applied for the other items. A priori sample size calculation found that 40 participants would be adequate.

RESULTS

Inter-rater reliability of unidigital palpation was considered fair for power (κw = 0.34) and poor for other items (ICC < 0.50); bidigital inter-rater reliability was considered moderate (power: κw = 0.57; endurance: ICC = 0.53; fast contractions: ICC = 0.65, respectively) and low (repetitions: ICC = 0.27). Intra-rater reliability was substantial for power (κw = 0.73 and 0.62), moderate for fast contractions (ICC = 0.63 and 0.51) and poor for repetitions (ICC < 0.50), respectively, for uni- and bidigital palpation. Endurance showed poor (ICC < 0.50) and moderate (ICC = 0.61) reliability for uni- and bidigital palpation.

CONCLUSIONS

The PERFECT scheme carried out by bidigital vaginal palpation presents higher reliability when two examiners carry out the physical examination. When one examiner is responsible for PFM assessment, both types of palpation are recommended for evaluation of power and fast contraction; endurance should be evaluated using bidigital palpation. Examiners should be careful during the assessment of repetition of sustained contractions because inter- and intra-reliabilities for both types of palpation were classified as poor.

Inter- and intrarater reliability of unidigital and bidigital vaginal palpation to evaluation of maximal voluntary contraction of pelvic floor muscles considering risk factors and dysfunctions

AIMS

To evaluate inter- and intrarater reliability of unidigital and bidigital vaginal palpation of pelvic floor muscle (PFM) maximal voluntary contraction (MVC) according to PFM risk factors and dysfunctions.

METHODS

A total of 187 women were recruited and evaluated by two examiners. Both performed the evaluation of MVC with unidigital and bidigital palpation, graded by Modified Oxford Scale. After 7-10 days, one examiner repeated the assessment. To analyze reliability by Cohen's linear Kappa (κw), participants were allocated into different groups according to: body mass index (BMI), menopause, parity, type of delivery and PFM dysfunctions, as pelvic organ prolapse (POP), constipation, urgency, urgency urinary incontinence, pelvic pain, and stress urinary incontinence.

RESULTS

Inter-rater reliability of unidigital palpation was considered fair (κw = 0.21-0.40) to moderate (κw = 0.41-0.60) according to BMI, postmenopausal status, parity, type of delivery, and PFM dysfunctions. Inter-rater reliability of bidigital palpation varied from none (κw = 0.00-0.20) to moderate for all risk factors and PFM dysfunctions. Intra-rater reliability of unidigital palpation was considered fair only for women with POP (κw = 0.37) and moderate to substantial (κw = 0.61-0.80) to all other variables. Intra-rater reliability of bidigital palpation ranged from moderate to almost perfect (κw = 0.81-1.00).

CONCLUSIONS

When performing vaginal palpation, physiotherapists must consider the way that is performing the evaluation, as some PFM risk factors and dysfunctions could influence the inter- and intrarater reliability of unidigital and bidigital palpation.

Pelvic floor dysfunctions and associated factors in female CrossFit practitioners: a cross-sectional study

INTRODUCTION AND HYPOTHESIS

It is known that high-impact exercises can cause an increase in intra-abdominal pressure and provide overload in the pelvic floor structures. We hypothesized that female CrossFit practitioners would report symptoms of pelvic floor dysfunction (PFD) and that there will be factors associated with these dysfunctions.

METHODS

The study design is an online cross-sectional survey. Demographic and anthropometric data, the characterization of CrossFit activity, the description of PFD and previous obstetric history were collected through a structured web-based questionnaire. Associations between PFD and the clinical and CrossFit-related independent variables were tested using logistic regression analysis.

RESULTS

A total of 828 female CrossFit practitioners answered the questionnaire. The most prevalent symptom was anal incontinence (AI) (52.7%), with flatus incontinence (FI) being the most reported (93.3%). Women who reported constipation are 1.7 times more likely to have FI, and women who practice CrossFit more than five times a week are 3.0 times more likely to have FI. Urinary incontinence(UI) affected 36% of women, and 84.2% of participants reported urinary loss during CrossFit practice. The occurrence of dyspareunia was reported by 48.7% and showed an inverse association with age and body mass index. POP was reported by only 1.4% of the sample.

CONCLUSION

There is a high prevalence of PFD in female CrossFit practitioners, with AI being the most reported symptom, especially FI. In addition, constipation and weekly training frequency were significantly associated with FI. UI occurred primarily in CrossFit exercises, and dyspareunia was the most prevalent sexual symptom.

Effectiveness of pelvic floor muscle training with and without electromyographic biofeedback for urinary incontinence in women: multicentre randomised controlled trial

OBJECTIVE

To assess the effectiveness of pelvic floor muscle training (PFMT) plus electromyographic biofeedback or PFMT alone for stress or mixed urinary incontinence in women.

DESIGN

Parallel group randomised controlled trial.

SETTING

23 community and secondary care centres providing continence care in Scotland and England.

PARTICIPANTS

600 women aged 18 and older, newly presenting with stress or mixed urinary incontinence between February 2014 and July 2016: 300 were randomised to PFMT plus electromyographic biofeedback and 300 to PFMT alone.

INTERVENTIONS

Participants in both groups were offered six appointments with a continence therapist over 16 weeks. Participants in the biofeedback PFMT group received supervised PFMT and a home PFMT programme, incorporating electromyographic biofeedback during clinic appointments and at home. The PFMT group received supervised PFMT and a home PFMT programme. PFMT programmes were progressed over the appointments.

MAIN OUTCOME MEASURES

The primary outcome was self-reported severity of urinary incontinence (International Consultation on Incontinence Questionnaire-urinary incontinence short form (ICIQ-UI SF), range 0 to 21, higher scores indicating greater severity) at 24 months. Secondary outcomes were cure or improvement, other pelvic floor symptoms, condition specific quality of life, women's perception of improvement, pelvic floor muscle function, uptake of other urinary incontinence treatment, PFMT self-efficacy, adherence, intervention costs, and quality adjusted life years.

RESULTS

Mean ICIQ-UI SF scores at 24 months were 8.2 (SD 5.1, n=225) in the biofeedback PFMT group and 8.5 (SD 4.9, n=235) in the PFMT group (mean difference -0.09, 95% confidence interval -0.92 to 0.75, P=0.84). Biofeedback PFMT had similar costs (mean difference £121 ($154; €133), -£409 to £651, P=0.64) and quality adjusted life years (-0.04, -0.12 to 0.04, P=0.28) to PFMT. 48 participants reported an adverse event: for 23 this was related or possibly related to the interventions.

CONCLUSIONS

At 24 months no evidence was found of any important difference in severity of urinary incontinence between PFMT plus electromyographic biofeedback and PFMT alone groups. Routine use of electromyographic biofeedback with PFMT should not be recommended. Other ways of maximising the effects of PFMT should be investigated.

TRIAL REGISTRATION

ISRCTN57756448.

Analysis of conventional versus advanced pelvic floor muscle training in the management of urinary incontinence after radical prostatectomy: a systematic review and meta-analysis of randomized controlled trials

Background

The underutilization of additional supportive muscles is one of the potential reasons for suboptimal efficacy of conventional pelvic floor muscle training (CPFMT). The present study concentrates on any advantage of advanced pelvic floor muscle training (APFMT) in patients with urinary incontinence (UI) after radical prostatectomy (RP).

Methods

Literature search was conducted on PubMed, Embase, Cochrane Library and Web of Science from database inception to February 2020. The data analysis was performed by the Cochrane Collaboration's software RevMan 5.3.

Results

Both APFMT and CPFMT groups indicates superiority over baseline in terms of pad number, the International Consultation on Incontinence Questionnaire—Short Form (ICIQ-SF) score, pad weight at short-term follow-up, and PFME and PFMS at intermediate-term follow-up. No adverse events were reported in all included studies. Patients receiving APFMT had a similar attrition rate to those receiving CPFMT (18/236 vs. 22/282, P=0.61). Compared to CPFMT group, APFMT group provided intermediate-term advantages in terms of pad number (MD: −0.75, 95% CI: −1.36 to −0.14; P=0.02), ICIQ-SF score (MD: −3.79, 95% CI: −5.89 to −1.69; P=0.0004), PFME (MD: 1.93, 95% CI: 0.99 to 2.87; P<0.0001) and pad weight (MD: −1.40, 95% CI: −1.70 to −1.00; P<0.00001).

Conclusions

Current evidence indicated that APFMT might facilitate the recovery of UI after RP according to intermediate-term advantages over CPFMT in terms of pad number, ICIQ-SF score, PFME and pad weight. Further standardized, physiotherapist-guided and well-designed clinical trials conducted by large multicenter and experienced multidisciplinary clinicians are still warranted.

Pelvic floor dysfunction distress is correlated with quality of life, but not with muscle function

OBJECTIVE

To analyze the relationship between the symptoms of pelvic floor dysfunction (PFD) and quality of life (QoL), as well as the function of the pelvic floor muscle (PFM) in women with urinary incontinence (UI).

METHODS

A cross-sectional study conducted in two centers in Brazil (Northeast and Southeast regions) with women with stress urinary incontinence (SUI) and mixed urinary incontinence (MUI). Data on pelvic floor symptoms, discomfort and impact on QoL were collected using the Pelvic Floor Distress Inventory-short form (PFDI-SF-20) and the Pelvic Floor Impact Questionnaire (PFIQ-7) instruments. PFM function was assessed by palpation (PERFECT scale) and manometry. Pearson's correlation test, analysis of variance (ANOVA) and the Student's t test were used to discriminate the differences, adopting a significance level of 5%.

RESULTS

A total of 72 women participated in the study (mean age 51.7 ± 11.9 years). The presence and discomfort of pelvic floor symptoms (PFDI-SF-20) were correlated with QoL (PFIQ-7) (r = 0.52, p < 0.001). Deficits in PFM function (power and pressure) were observed, however, there was no correlation between these with the presence and discomfort of the pelvic floor symptoms (PFDI-SF-20).

CONCLUSION

Greater discomfort due to PFD symptoms were correlated with a worse QoL. However, the relationship between symptoms and PFM function was not significant. These results reinforce the need to assess the aspects of activity and participation which compose functionality and QoL, and not only the PFM functions in women with UI.

Linking Pelvic Floor Muscle Function Terminology to the International Classification of Functioning, Disability and Health

OBJECTIVE

A previous systematic review on pelvic floor muscle function (PFMF) identified a miscellaneity of terms. The lack of consensual terminology might have come from the complexity of neuromusculoskeletal function itself. This study sought to link the previously identified PFMF terms to the International Classification of Functioning, Disability and Health (ICF) terminology.

METHODS

In this secondary analysis study, 10 linkage rules were applied to link 196 previously identified PFMF terms to the ICF. Two researchers performed the linking process independently. Disagreements were solved by open dialogue with a third researcher. Percentage agreement was computed for main outcome.

RESULTS

A total of 184 (93.9%) PFMF terms were subsumed into the following 6 ICF terms: tone, involuntary movement reaction, control, coordination, strength, and endurance. The most frequently investigated PFMF was strength (25.5%), followed by involuntary movement reaction (22.9%), endurance (17.2%), control (14.1%), coordination (9.9%), and tone (4.2%). Only 6.2% PFMF could not be linked to ICF terminology. A wide variation of instruments/methods was used to measure PFMF. Vaginal palpation was the only method employed to measure all 6 PFMF. Percentage agreement between raters was 100%.

CONCLUSIONS

Linking PFMF terminology to the ICF was feasible and valid. It allowed the identification of the most investigated PFMF and their measuring methods. ICF terminology to describe PFMF should be used since it may improve communication, data gathering, and the advance in scientific knowledge.

IMPACT

Standardized terminology anchored in a theoretical framework is crucial to data gathering, communication, and dissemination of evidence-based practice. PFMF terminology based on ICF can be used to improve data pooling and communication.

Efficacy of biofeedback, repetitive transcranial magnetic stimulation and pelvic floor muscle training for female neurogenic bladder dysfunction after spinal cord injury: a study protocol for a randomised controlled trial

INTRODUCTION

Neurogenic bladder dysfunction is prevalent in female patients with spinal cord injury (SCI), and previous guidelines have recommended pelvic floor muscle training (PFMT) for first-line conservative treatment. However, the actual regimen of PFMT varies widely and the single treatment does not satisfy the need of some patients. Therefore, this study aims to provide a detailed rationale and methodology for comparing the effectiveness of PFMT, biofeedback and repetitive transcranial magnetic stimulation (rTMS) as adjunct treatments for neurogenic bladder dysfunction.

METHODS AND ANALYSIS

This trial is a single-centre randomised controlled trial for female patients with urinary incontinence (UI) in phase of chronic SCI. Eligible participants will be randomised to one of four arms: (1) PFMT, (2) PFMT with biofeedback, (3) PFMT and rTMS and (4) PFMT with biofeedback and rTMS. There will be 44 participants in each arm and all the subjects will undergo 20 treatment sessions, five times a week for 4 weeks. The outcomes will be evaluated at 4 weeks, 3 months and 6 months after randomisation. The primary outcome is the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form, and the secondary outcomes include bladder diary, pelvic floor muscle function and the International Spinal Cord Injury Quality of Life Basic Data Set.

ETHICS AND DISSEMINATION

The Clinical Research and Biomedical Ethics Committee of the West China Hospital, Sichuan University has approved this trial and the approval number is 2019-885. All participants will be provided written informed consent after verification of the eligibility criteria. The results of this study will be accessible in peer-reviewed publications and be presented at academic conferences.

TRIAL REGISTRATION NUMBER

Chinese Clinical Trial Registry (ChiCTR1900026126).

Ability to contract the pelvic floor muscles and association with muscle function in incontinent women

INTRODUCTION AND HYPOTHESIS

Many women with pelvic floor dysfunction are unable to perform pelvic floor muscle (PFM) contraction. We aimed to assess the ability to contract the PFM and to evaluate the association with muscle function in Brazilian women with urinary incontinence.

METHODS

We conducted a retrospective cross-sectional study including incontinent women over the age of 18. The assessment of PFM contraction was carried out by bidigital palpation via the PERFECT scheme. We categorized our population as: group absent: women not able to contract the PFM with verbal instructions; group 1 (1st command): women able to contract their PFM after verbal instructions; group 2 (2nd command): women who needed additional training on PFM anatomy and functioning to contract them. We compared the groups regarding their PFM functionality. We used ANOVA for demographic data and Mann-Whitney test for association analyses and P value < 0.05 for statistical significance.

RESULTS

Among 139 women included, 21 (15.1%) were not able to perform the contraction of the PFM. Sixty-five (46.7%) contracted their PFM voluntarily at the first command and 53 (38.1%) at the second command. There was a significant reduction in the PFM function in group 2 in terms of power (p < 0.001), endurance (p < 0.001) and fast contraction (p < 0.001) compared to group 1.

CONCLUSION

A high percentage (53.2%) of women were not able to contract their PFM voluntarily without training in PFM anatomy and functioning. Those women had impaired muscle function compared to women able to perform PFM after receiving exclusively oral instructions.

The Overactive Pelvic Floor (OPF) and Sexual Dysfunction. Part 2: Evaluation and Treatment of Sexual Dysfunction in OPF Patients

INTRODUCTION

The assessment of pelvic floor muscle (PFM) overactivity is part of a comprehensive evaluation including a detailed history (medical, gynecological history/antecedent), appraisal of the psychosocial contexts of the patient, as well as a musculoskeletal and a neurological examination.

OBJECTIVES

The aims of this article are to review (i) the assessment modalities evaluating pelvic floor function in women and men with disorders associated with an overactive pelvic floor (OPF), and (ii) therapeutic approaches to address OPF, with particular emphases on sexual pain and function.

METHODS

We outline assessment tools that evaluate psychological and cognitive states. We then review the assessment techniques to evaluate PFM involvement including digital palpation, electromyography, manometry, ultrasonography, and dynamometry, including an overview of the indications, efficacy, advantages, and limitations of each instrument. We consider each instrument's utility in research and in clinical settings. We next review the evidence for medical, physiotherapy, and psychological interventions for OPF-related conditions.

RESULTS

Research using these assessment techniques consistently points to findings of high PFM tone among women and men reporting disorders associated with OPF. While higher levels of evidence are needed, options for medical treatment include diazepam suppositories, botulinum toxin A, and other muscle relaxants. Effective psychological therapies include cognitive behavioral therapy, couple therapy, mindfulness, and educational interventions. Effective physiotherapy approaches include PFM exercise with biofeedback, electrotherapy, manual therapy, and the use of dilators. Multimodal approaches have demonstrated efficacy in reducing pain, normalizing PFM tone, and improving sexual function. Multidisciplinary interventions and an integrative approach to the assessment and management of OPF using a biopsychosocial framework are discussed.

CONCLUSION

Although the efficacy of various intervention approaches has been demonstrated, further studies are needed to personalize interventions according to a thorough assessment and determine the optimal combination of psychological, physical, and behavioral modalities. Padoa A, McLean, L, Morin M, et al. The Overactive Pelvic Floor (OPF) and Sexual Dysfunction. Part 2: Evaluation and Treatment of Sexual Dysfunction in OPF Patients. Sex Med 2021;9:76-92.

Pre-Licensure Inter-Professional Perspectives: Pelvic Health Physiotherapy

Purpose: In this study, we examined knowledge and perspectives pertaining to pelvic health physiotherapy among medical, midwifery, nursing, and physician assistant students at McMaster University. Moreover, we identified opportunities to improve knowledge translation to facilitate inter-professional education in urogynecological care. Method: A cross-sectional design was created to distribute an online survey to participants using a modified Dillman approach. The survey assessed areas of clinical interest in, knowledge of the scope of practice of, and regulations governing pelvic health physiotherapy in specific, in addition to clinical applications. Fisher's exact and Kruskal-Wallis tests were used to assess statistical significance. Results: A total of 90% of the participants incorrectly indicated that internal digital exams could be delegated to physiotherapy assistants, and 50% believed that Kegel exercises were appropriate for all presentations of pelvic floor dysfunction. Moreover, when prompted to select conditions that could be treated by pelvic health physiotherapists, only 2% of the participants selected the correct conditions. Conclusions: Knowledge in all four programmes about the scope of practice, authorized activities, and application of pelvic health physiotherapy is inadequate. To foster the optimal integration of urogynecology into the relevant health science curriculums, enhanced inter-professional education, inclusive of pelvic health physiotherapy knowledge, appears to be needed.

Valsalva urethral profile (VUP): A urodynamic measure to assess stress urinary incontinence in women

AIMS

We aimed to assess the value of the Valsalva urethral profile (VUP) in case of stress urinary incontinence (SUI).

METHODS

Six hundred and ninety-four women without pelvic organ prolapse were included in this prospective monocentric study. SUI was diagnosed from symptoms using the International Continence Society definition, and severity using two validated questionnaires (USP and ICIQ-SF). The urodynamic parameters studied were maximal urethral closure pressure (MUCP) and functional length (FL). Both were performed at rest, during a Valsalva maneuver (v-MUCP and v-FL) and again at rest. Correlation analyses and ROC curves were used to assess the value of the clinical and urodynamic measurements.

RESULTS

In our population, based on the questionnaires, 172 (24.8%) women were diagnosed with pure SUI on symptoms, 71 (10.2%) with urgency urinary incontinence and 392 (56.5%) with mixed urinary incontinence; 59 (8.5%) women were continent. The v-MUCP was the most correlated parameter to the severity of SUI (ρ: -0.63) and the most predictive of SUI risk, with a threshold value of 35 cm H₂ O (Se = 0.82, Sp = 0.86). The v-FL was significantly shortened in case of SUI.

CONCLUSIONS

The v-MUCP and v-FL are global measurements of urethral resistance during stress. With a threshold value of 35 cm H₂ O, the v-MUCP was the most discriminating parameter for the diagnosis of SUI, with a good reliability.

Reliability of manometry for assessing pelvic floor muscle function in healthy men

Objectives

To the best of our knowledge, no study has examined the reliability of assessment methods for male pelvic floor muscle (PFM) function. Therefore, this study aimed to clarify the reliability of manometry with an anal sensor (Peritron cat 9300A) to assess PFM function in healthy men.

Methods

Healthy male subjects (n = 21) without urinary leakage underwent testing to assess PFM function, and intra‐ and interrater reliability tests among examiners were performed. The PFM function included maximal anorectal squeeze pressure, endurance, mean anorectal squeeze pressure, gradient, and area under the curve during PFM voluntary contraction.

Results

Participants had a median age of 38 years (range 26‐51), and a mean BMI of 23.2 ± 2.0 kg/m². Satisfactory intra‐ and interrater reliability scores were found for resting pressure, anorectal squeeze pressure, and endurance. The intra‐rater reliability of resting pressure, anorectal squeeze pressure, and endurance were 0.71, 0.89, and 0.75 for examiner 1 and 0.72, 0.89, and 0.87 for examiner 2. The interrater reliability for resting pressure, anorectal squeeze pressure, and endurance were 0.58, 0.93, and 0.61, respectively.

Conclusions

This is the first prospective study showing the favorable intra‐ and interrater reliability of manometry for PFM function in healthy men. Our findings demonstrated that manometry can provide both reliable and reproducible data regarding PFM function in continent men, suggesting Peritron cat 9300A can be used to evaluate the PFM function in men.

"The Overactive Pelvic Floor (OPF) and Sexual Dysfunction" Part 1: Pathophysiology of OPF and Its Impact on the Sexual Response

INTRODUCTION

Overactive pelvic floor (OPF) muscles are defined as muscles that do not relax, or may even contract, when relaxation is needed, for example, during micturition or defecation. Conditions associated with OPF are multifactorial and include multiple possible etiologies and symptom complexes. The complex interplay between biological and psychosocial elements can lead to the persistence of OPF symptoms along with psychological and emotional distress.

OBJECTIVES

(1) To review and contextualize, from a pathophysiologic perspective, the evidence for OPF, (2) to provide an overview of common clinical presentations and comorbidities of OPF, and (3) to discuss the effect of OPF on sexual function in men and women.

METHODS

Review of the updated literature on the pathophysiology of OPF was carried out. OPF-associated conditions were overviewed, with special emphasis on the impact on sexual function in men and women.

RESULTS

Individuals with suspected OPF often present with a combination of gastrointestinal, gynecological, musculoskeletal, sexual, and urological comorbidities, mostly accompanied by psychoemotional distress. In both women and men, sexual function is significantly impaired by OPF and genitopelvic pain penetration disorders are often the primary manifestation of this condition. Women with OPF report less sexual desire, arousal, and satisfaction; more difficulty reaching orgasm; lower frequencies of intercourse; more negative attitudes toward sexuality; and more sexual distress than women without sexual pain. The most frequently reported sexual dysfunctions in men with OPF include erectile dysfunction, premature ejaculation, and ejaculatory pain.

CONCLUSION

The complex pathophysiology of OPF involving multisystemic comorbidities and psychosocial factors emphasize the importance of a biopsychosocial assessment for guiding effective and personalized management. Padoa A, McLean L, Morin M, et al. "The Overactive Pelvic Floor (OPF) and Sexual Dysfunction" Part 1: Pathophysiology of OPF and Its Impact on the Sexual Response. Sex Med 2021;9:64-75.

Assessment of pelvic floor muscles in sportswomen: Quality of life and related factors

OBJECTIVES

To evaluate Maximum Voluntary Contraction (MVC) of the Pelvic Floor Muscles (PFM) in sportswomen, to observe the urinary symptoms and their impact on the Quality of Life (QoL).

DESIGN

Observational cross-sectional study.

SETTING

Gyms and teams in the North of Portugal.

PARTICIPANTS

Sportswomen (n = 197).

MAIN OUTCOME MEASURES

The measurement was performed using a manometer. The sportswomen were instructed to perform 3 MVC of the perineum, held for 3 s. The Kings Health Questionnaire (KHQ) was used to evaluate urinary symptoms and the QoL of the sportswomen.

RESULTS

Age significantly influenced (p < 0.05) the QoL in all domains. An increase in BMI was also significantly associated with a decrease in the QoL. MVC values had a highly significant effect on the overall QoL and all domains, including a reduction in urinary symptoms. The weekly time of physical activity was associated with a better QoL in symptomatology. The practice of high-impact activities decreased the QoL (compared to low-impact activities). The vaginal resting pressure values ranged from 1.60 to 59.80 (24.34 ± 11.00).

CONCLUSIONS

Age, BMI and high-impact sports appear to be the leading factors that promote the onset of SUI, which in turn decrease the QoL in sportswomen. There was a positive association between MVC and weekly time of physical activity in the QoL.

Physiotherapy assessment for female urinary incontinence

INTRODUCTION AND HYPOTHESIS

As noted in the 6th International Consultation on Incontinence (ICI) chapter "Initial Management of Urinary Incontinence in Women" recommendations call for including physiotherapy as a first-line therapy.

METHODS

Building on this, checking available scientific evidence and using the International Classification of Functioning, Disabilities and Health, the following represents a holistic physiotherapist approach for initial evaluation of the health problem of urinary incontinence.

RESULTS

This paper proposes a teaching module for every relevant health care professional dealing with the assessment of adult female urinary incontinence, focusing on optimal patient selection and appropriate treatment choice.

CONCLUSION

The assessment stage involves the explicit decision as to whether "physiotherapy" is the treatment indicated for the patient, based on the findings of the physiotherapy assessment and supplemented by any medical information that accompanied the referral and evaluation.

Study protocol to investigate biomolecular muscle profile as predictors of long-term urinary incontinence in women with gestational diabetes mellitus

BACKGROUND

Pelvic floor muscles (PFM) and rectus abdominis muscles (RAM) of pregnant diabetic rats exhibit atrophy, co-localization of fast and slow fibers and an increased collagen type I/III ratio. However, the role of similar PFM or RAM hyperglycemic-related myopathy in women with gestational diabetes mellitus (GDM) remains poorly investigated. This study aims to assess the frequency of pelvic floor muscle disorders and pregnancy-specific urinary incontinence (PS-UI) 12 months after the Cesarean (C) section in women with GDM. Specifically, differences in PFM/RAM hyperglycemic myopathy will be evaluated.

METHODS

The Diamater is an ongoing cohort study of four groups of 59 pregnant women each from the Perinatal Diabetes Research Centre (PDRC), Botucatu Medical School (FMB)-UNESP (São Paulo State University), Brazil. Diagnosis of GDM and PS-UI will be made at 24-26 weeks, with a follow-up at 34-38 weeks of gestation. Inclusion in the study will occur at the time of C-section, and patients will be followed at 24-48 h, 6 weeks and 6 and 12 months postpartum. Study groups will be classified as (1) GDM plus PS-UI; (2) GDM without PS-UI; (3) Non-GDM plus PS-UI; and (4) Non-GDM without PS-UI. We will analyze relationships between GDM, PS-UI and hyperglycemic myopathy at 12 months after C-section. The mediator variables to be evaluated include digital palpation, vaginal squeeze pressure, 3D pelvic floor ultrasound, and 3D RAM ultrasound. RAM samples obtained during C-section will be analyzed for ex-vivo contractility, morphological, molecular and OMICS profiles to further characterize the hyperglycemic myopathy. Additional variables to be evaluated include maternal age, socioeconomic status, educational level, ethnicity, body mass index, weight gain during pregnancy, quality of glycemic control and insulin therapy.

DISCUSSION

To our knowledge, this will be the first study to provide data on the prevalence of PS-UI and RAM and PFM physical and biomolecular muscle profiles after C-section in mothers with GDM. The longitudinal design allows for the assessment of cause-effect relationships between GDM, PS-UI, and PFMs and RAMs myopathy. The findings may reveal previously undetermined consequences of GDM.

Are there differences in short-term pelvic floor muscle function after cesarean section or vaginal delivery in primiparous women? A systematic review with meta-analysis

INTRODUCTION AND HYPOTHESIS

The literature presents controversial results regarding the role of delivery mode in pelvic floor muscle (PFM) function after birth. Some studies showed a greater impairment of PFM function after vaginal delivery compared with cesarean section, while others have not identified a significant difference between these two modes of delivery. This study aimed to investigate whether there was a difference in short-term PFM function after childbirth in primiparous women who underwent cesarean section compared with those who underwent vaginal delivery.

METHODS

Up to December 2018, the PubMed-MEDLINE, CINAHL, Embase, Bireme, Scopus, Web of Science, and Science Direct databases were searched. Two independent reviewers performed the selection process based on titles, abstracts, and full-text reading. Observational studies comparing PFM function after cesarean section versus vaginal delivery in primiparous women were included. PRISMA guidelines and Cochrane recommendations were followed. Methodological quality of the primary studies was assessed through the checklist proposed by the Joanna Briggs Institute for cross-sectional studies. Random effects meta-analysis was performed to synthesize evidence regarding PFM strength in primiparous woman after vaginal delivery compared with cesarean section. The GRADE approach was applied to classify the quality of the evidence.

RESULTS

Eleven studies met the inclusion criteria and were included in this review. A total of 1726 primiparous women were analyzed after childbirth. Five studies were included in the meta-analysis. No difference in PFM strength after childbirth was identified when cesarean section was compared with vaginal delivery [standardized mean difference (SMD): -0.15, 95% confidence interval (CI): -0.85 to 0.56]. Differences in PFM strength were identified when patients who underwent cesarean section were compared with those with an episiotomy or instrumented vaginal delivery (SMD: -12.51, CI 95%: -24.57 to -0.44), favoring the cesarean section group. In both cases, the quality of evidence was classified as very low because of the observational design of the included studies and population heterogeneity.

CONCLUSION

There was no difference in short-term PFM strength after childbirth between primiparous women who underwent cesarean section or vaginal delivery, as assessed through vaginal manometry. However, we identified reduced PFM strength in women who underwent an episiotomy or instrumented vaginal delivery compared with those who underwent cesarean section. Nevertheless, this conclusion should be cautiously considered as the observational design of the primary studies and possible heterogeneity among the primiparous women included in the studies contributed to reducing the quality of the evidence synthesized. Future primary studies with longitudinal designs and long-term follow-up periods are needed to strengthen the quality of evidence and provide more conclusive evidence to guide clinical practice.

Pelvic floor muscle function and symptoms of dysfunctions in midwifes and nurses of reproductive age with and without pelvic floor dysfunction

OBJECTIVES

This study aims to compare pelvic floor muscle (PFM) functions in midwifes and nurses of reproductive age with and without pelvic floor dysfunction (PFD) and investigate the relationship between PFM function and the number, type and symptoms of PFDs.

MATERIALS AND METHODS

82 midwifes and nurses of reproductive age with (n = 51) and without PFD (n = 31) participated in the study. PFM function was assessed by digital palpation using PERFECT scale. Gynecological examination, ultrasonography, disease-specific questionnaires, questions and tests were used to assess symptoms of PFD. PFD was assessed in terms of risk factors, urinary incontinence, fecal incontinence, pelvic organ prolapse (POP), pelvic pain and sexual dysfunctions.

RESULTS

Power parameter of PERFECT scheme was significantly lower in subjects with PFD compared to Non-PFD group (p = 0.002). 41% of the subjects with Power 5 PFM strength in PFD group were diagnosed as stage 1 POP, 5.8% as stage 2 POP, 15.7% of urge incontinence, 23.3% of stress incontinence and 10.5% of mixed incontinence. Both urinary incontinence and POP were detected in 15.7% of them. Among all subjects, incontinence symptoms decreased whereas POP and sexual function did not change as PFM increased. PFM strength was negatively correlated with the number of PFD (p = 0.002, r = -0.34). The type of dysfunction did not correlate with PFM strength (p > 0.05).

CONCLUSION

PFM strength only affects of urinary incontinence sypmtoms among all PFDs in midwifes and nurses of reproductive age. PFM strength may not be the main factor in the occurrence of PFDs as pelvic floor does not consist solely of muscle structure. However, it strongly affects the number of dysfunctions. Therefore, PFM training should be performed to prevent the occurrence of extra dysfunctions in addition to the existing ones even if it does not alter the symptoms.

Volume at First Leak Is Associated With Sling Failure Among Women With Stress Urinary Incontinence

INTRODUCTION

Stress urinary incontinence at a low bladder volume is a clinically observed phenomenon that is not well studied with regard to treatment outcomes. The primary aim of our study was to determine if the volume at first leak is associated with sling outcome.

METHODS

This is a retrospective cohort study evaluating whether urodynamic stress urinary incontinence observed at low volumes is associated with sling failure using the Synthetic Derivative database. Sling failure was defined as (1) undergoing a subsequent surgery for stress incontinence (eg, urethral bulking agent, repeat sling) or (2) leakage that was subjectively worse or unchanged from baseline. Sling success was defined as subjective improvement in incontinence or being dry. Intrinsic sphincter deficiency was defined as maximum urethral closure pressure 20 cm H20 or less or abdominal leak point pressure less than 60 cm H20.

RESULTS

Outcome data were available for 168 of 206 women who underwent a sling after urodynamic testing from 2006 to 2014. Of the 168 women, 80 were transobturator, 79 were retropubic, 8 lacked data regarding the approach to the midurethral sling, and 1 was an autologous pubovaginal sling. Similar failure rates were seen for transobturator (10%) and retropubic slings (7.6%). Preoperative urodynamic parameters, such as cystometric capacity and intrinsic sphincter deficiency, were similar among failed and successful slings. For every additional 50 mL in bladder volume at first leak (SUIvol), there was a 1.6 increased odds of having a successful sling (odds ratio, 1.576; 95% confidence interval, 1.014-2.450; P = 0.04). There was no statistically significant association between maximum urethral closure pressure, abdominal leak point pressure, body mass index, age, sling type, or whether a prior anti-incontinence procedure had been performed and sling success.

CONCLUSIONS

Bladder volume at first leak is a strong predictor of sling failure.

Ultrasound assessment of pelvic floor muscle contraction: reliability and development of an ultrasound-based contraction scale

OBJECTIVES

To determine intra- and interrater reliability and agreement for ultrasound measurements of pelvic floor muscle contraction and to assess the correlation between ultrasound and vaginal palpation. We also aimed to develop an ultrasound scale for assessment of pelvic floor muscle contraction.

METHODS

This was a cross-sectional study of 195 women scheduled for stress urinary incontinence (n = 65) or prolapse (n = 65) surgery or who were primigravid (n = 65). Pelvic floor muscle contraction was assessed by vaginal palpation using the Modified Oxford Scale (MOS) and by two- and three-dimensional (2D/3D) transperineal ultrasound. Proportional change in 2D and 3D levator hiatal anteroposterior (AP) diameter and 3D levator hiatal area between rest and contraction were used as measures of pelvic floor muscle contraction. One rater repeated all ultrasound measurements on stored volumes, which were used for intrarater reliability and agreement analysis, and three independent raters analyzed 60 ultrasound volumes for interrater reliability and agreement analysis. Reliability was assessed using the intraclass correlation coefficient (ICC) and agreement using Bland-Altman analysis. Tomographic ultrasound was used to identify women with major levator injury. Spearman's rank correlation coefficient (r_S ) was used to assess the correlation between ultrasound measurements of pelvic floor muscle contraction and MOS score. The proportion of women allocated to each category of muscle contraction (absent, weak, moderate or strong) by palpation was used to determine the cut-offs for the ultrasound scale.

RESULTS

Intrarater ICC was 0.81 (95% CI, 0.74-0.85) for proportional change in 2D levator hiatal AP diameter. Interrater ICC was 0.82 (95% CI, 0.72-0.89) for proportional change in 2D AP diameter, 0.80 (95% CI, 0.69-0.88) for proportional change in 3D AP diameter and 0.72 (95% CI, 0.56-0.83) for proportional change in hiatal area. The prevalence of major levator injury was 22.6%. The strength of correlation (r_S ) between ultrasound measurements and MOS score was 0.52 for 2D AP diameter, 0.62 for 3D AP diameter and 0.47 for hiatal area (P < 0.001 for all). On the ultrasound contraction scale, proportional change in 2D levator hiatal AP diameter of < 1% corresponds to absent, 2-14% to weak, 15-29% to normal and > 30% to strong contraction.

CONCLUSIONS

Ultrasound seems to be an objective and reliable method for evaluation of pelvic floor muscle contraction. Proportional change in 2D levator hiatal AP diameter had the highest ICC and moderate correlation with MOS score assessed by vaginal palpation, and we constructed an ultrasound scale for assessment of pelvic floor muscle contraction based on this measure. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.