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

Relationship between pelvic floor muscle and hormone levels in polycystic ovary syndrome

AIMS

To evaluate the electrical activity of the pelvic floor muscles (PFM) in women with polycystic ovary syndrome.

METHODS

Forty-two women with polycystic ovary syndrome (PCOS group) and 13 premenopausal women (control group) were recruited in this cross-sectional study. Total testosterone and estradiol were measured and muscle tone and maximum voluntary contraction (MVC) of PFM were determined by surface electromyography.

RESULTS

There was a difference in muscle tone (PCOS = 59.9 µV and Control group = 25.5 µV; P < 0.0001) and MVC (PCOS = 159.7 µV and Control group = 63.7 µV; P < 0.0002) between groups. The concentration of estradiol and testosterone showed a strong correlation with tone (r = 0.9, r = 0.8 respectively) and MVC (r = 0.9, r = 0.9 respectively) in women with PCOS. The control group exhibited a strong correlation between testosterone and muscle tone (r = 0.9) and MVC (r = 0.9).

CONCLUSION

Women with PCOS display higher electromyographic values than those in premenopause. Moreover, electrical activity showed a positive relation with estradiol and testosterone concentrations. Although PCOS is a heterogeneous disorder affecting young women, it is suggested that the hyperandrogenic state associated with PCOS is a protective factor for PFM. Neurourol. Urodynam. 35:780-785, 2016. © 2015 Wiley Periodicals, Inc.

The effect of parity on pelvic floor muscle strength and quality of life in women with urinary incontinence: a cross sectional study

[Purpose] The purpose of this study was to analyze the pelvic floor muscle (PFM) activity after vaginal birth, and the effect of parity on PFM strength and quality of life (QoL) in women with urinary incontinence. [Subjects and Methods] Patients (n=241) who gave birth vaginally and experienced urinary incontinence were divided into three groups: group 1 consisted of women having 1–3 children, group 2 consisted of women having 4–6 children, and group 3 consisted of women having more than 6 children. All patients underwent detailed examination of the PFM. The Turkish version of the self-administered Incontinence Quality of Life Instrument (I-QoL) questionnaire was used to evaluate the effects of stress urinary incontinence on participants’ QoL. [Results] Comparison of PFM strengths showed a significant intergroup difference. Group 1 showed significantly higher PFM strength scores than those of groups 2 and 3. I-QoL scores related to stress incontinence showed a significant intergroup difference. As number of deliveries increased, quality of life decreased. Comparison of PFM strengths and I-QoL scores related to stress incontinence showed a significant intergroup difference. [Conclusion] Increasing the awareness of PFM training in women will reduce potential postpartum incontinence due to a weak PFM strength; and will increase quality of life.

Pelvic floor muscle displacement during voluntary and involuntary activation in continent and incontinent women: a systematic review

INTRODUCTION

Investigations of the dynamic function of female pelvic floor muscles (PFM) help us to understand the pathophysiology of stress urinary incontinence (SUI). Displacement measurements of PFM give insight into muscle activation and thus help to improve rehabilitation strategies. This systematic review (PROSPERO 2013: CRD42013006409) was performed to summarise the current evidence for PFM displacement during voluntary and involuntary activation in continent and incontinent women.

METHODS

MEDLINE, EMBASE, Cochrane and SPORTDiscus databases were searched using selected terminology reflecting the PICO approach. Screening of Google Scholar and congress abstracts added to further information. Original articles investigating PFM displacement were included if they reported on at least one of the aims of the review, e.g., method, test position, test activity, direction and quantification of displacement, as well as the comparison between continent and incontinent women. Titles and abstracts were screened by two reviewers. The papers included were reviewed by two individuals to ascertain whether they fulfilled the inclusion criteria and data were extracted on outcome parameters.

RESULTS

Forty-two predominantly observational studies fulfilled the inclusion criteria. A variety of measurement methods and calculations of displacement was presented. The sample was heterogeneous concerning age, parity and continence status. Test positions and test activities varied among the studies.

CONCLUSIONS

The findings summarise the present knowledge of PFM displacement, but still lack deeper comprehension of the SUI pathomechanism of involuntary, reflexive activation during functional activities. We therefore propose that future investigations focus on PFM dynamics during fast and stressful impact tasks.

A strong pelvic floor is associated with higher rates of sexual activity in women with pelvic floor disorders

INTRODUCTION AND HYPOTHESIS

We evaluated the associations between pelvic floor muscle strength and tone with sexual activity and sexual function in women with pelvic floor disorders.

METHODS

This was a secondary analysis of a multicenter study of women with pelvic floor disorders from the USA and UK performed to validate the Pelvic Organ Prolapse/Incontinence Sexual Questionnaire, IUGA-Revised (PISQ-IR). Participants were surveyed about whether they were sexually active and completed the PISQ-IR and the Female Sexual Function Index (FSFI) questionnaires to assess sexual function. Physical examinations included assessment of pelvic floor strength by the Oxford Grading Scale, and assessment of pelvic floor tone as per ICS guidelines.

RESULTS

The cohort of 585 women was middle-aged (mean age 54.9 ± 12.1) with 395 (67.5 %) reporting sexual activity. Women with a strong pelvic floor (n = 275) were more likely to report sexual activity than women with weak strength (n = 280; 75.3 vs 61.8 %, p < 0.001), but normal or hypoactive pelvic floor tone was not associated with sexual activity (68.8 vs 60.2 %, normal vs hypoactive, p = 0.08). After multivariable analysis, a strong pelvic floor remained predictive of sexual activity (OR 1.89, CI 1.18-3.03, p < 0.01). Among sexually active women (n = 370), a strong pelvic floor was associated with higher scores on the PISQ-IR domain of condition impact (parameter estimate 0.20± 0.09, p = 0.04), and the FSFI orgasm domain (PE 0.51 ± 0.17, p = 0.004).

CONCLUSION

A strong pelvic floor is associated with higher rates of sexual activity as well as higher sexual function scores on the condition impact domain of the PISQ-IR and the orgasm domain of the FSFI.

Reliability of pelvic floor muscle strength assessment in healthy continent women

BACKGROUND

The aim of this study was to compare pelvic floor muscle (PFM) strength using transvaginal digital palpation in healthy continent women in different age groups, and to compare the inter- and intra-rater reliability of examiners performing anterior and posterior vaginal assessments.

METHODS

We prospectively studied 150 healthy multiparous women. They were distributed into four different groups, according to age range: G1 (n = 37), 30-40 years-old; G2 (n = 39), 41-50 years-old; G3 (n = 39), 51-60 years-old; and G4 (n = 35), older than 60 years-old. PFM strength was evaluated using transvaginal digital palpation in the anterior and posterior areas, by 3 different examiners, and graded using a 5-point Amaro's scale.

RESULTS

There was no statistical difference among the different age ranges, for each grade of PFM strength. There was good intra-rater concordance between anterior and posterior PFM assessment, being 64.7%, 63.3%, and 66.7% for examiners A, B, and C, respectively. The intra-rater concordance level was good for each examiner. However, the inter-rater reliability for two examiners varied from moderate to good.

CONCLUSIONS

Age has no effect on PFM strength profiles, in multiparous continent women. There is good concordance between anterior and posterior vaginal PFM strength assessments, but only moderate to good inter-rater reliability of the measurements between two examiners.

Impact of different body positions on bioelectrical activity of the pelvic floor muscles in nulliparous continent women

We examined pelvic floor muscles (PFM) activity (%MVC) in twenty nulliparous women by body position during exercise as well as the activation of abdominal muscles and the gluteus maximus during voluntary contractions of the PFMs. Pelvic floor muscle activity was recorded using a vaginal probe during five experimental trials. Activation of transversus abdominis, rectus abdominis, and gluteus maximus during voluntary PFM contractions was also assessed. Significant differences in mean normalized amplitudes of baseline PFM activity were revealed between standing and lying (P < 0.00024) and lying and ball-sitting positions (P < 0.0053). Average peak, average time before peak, and average time after peak did not differ significantly during the voluntary contractions of the PFMs. Baseline PFM activity seemed to depend on the body position and was the highest in standing. Pelvic floor muscles activity during voluntary contractions did not differ by position in continent women. Statistically significant differences between the supine lying and sitting positions were only observed during a sustained 60-second contraction of the PFMs.

Pelvic floor health: a concept analysis

AIM

To report an analysis of the concept 'pelvic floor health'.

BACKGROUND

'Pelvic floor health' is a term used by multiple healthcare disciplines, yet as a concept is not well defined.

DESIGN

Rodger's evolutionary view was used to guide this analysis.

DATA SOURCES

Academic literature databases and public domain websites viewed via the Internet search engine Google.

REVIEW METHODS

Literature in English, published 1946-July 2014 was reviewed. Websites were accessed in May 2014, then analysed of presentation for relevance and content until data saturation. Thematic analysis identified attributes, antecedents and consequences of the concept.

RESULTS

Based on the defining attributes identified in the analysis, a contemporary definition is offered. 'Pelvic floor health' is the physical and functional integrity of the pelvic floor unit through the life stages of an individual (male or female), permitting an optimal quality of life through its multifunctional role, where the individual possesses or has access to knowledge, which empowers the ability to prevent or manage dysfunction.

CONCLUSION

This analysis provides a definition of 'pelvic floor health' that is based on a current shared meaning and distinguishes the term from medical and lay terms in a complex, multifaceted and often under-reported area of healthcare knowledge. This definition provides a basis for theory development in future research, by focusing on health rather than disorders or dysfunction. Further development of the meaning is required in an individual's social context, to ensure a contemporaneous understanding in a dynamic system of healthcare provision.

How well can levator ani muscle morphology on 3D pelvic floor ultrasound predict the levator ani muscle function?

INTRODUCTION AND HYPOTHESIS

The aim of our study was to assess the performance of levator ani muscle deficiency (LAD) evaluated by 3D endovaginal ultrasound (EVUS) to detect pelvic floor muscle function as assessed by digital examination.

METHODS

This cross-sectional study was conducted among 77 patients referred to our urogynecology clinic for pelvic floor dysfunction symptoms. Patients underwent physical examinations including digital pelvic muscle strength assessment using the Modified Oxford scale (MOS). EVUS volumes were evaluated and levator ani muscles were scored according to a validated LAD scoring system. MOS scores were categorized as nonfunctional (scores 0-1) and functional (scores 2-5).

RESULTS

Mean age of participants was 56 (SD ± 12.5) and 71% were menopausal. Overall, 32.5% had nonfunctional muscle strength and 44.2% were classified as having significant LAD. LAD identified by ultrasound had a sensitivity of 60% (95% CI 41 -79%) for detecting nonfunctional muscle and a specificity of 63% (95% CI 50 -77%) for detecting functional muscle. Overall, LAD demonstrated fair ability to discriminate between patients with and those without poor muscle function (area under the ROC curve = 0.70 [95% CI 0.58-0.83]). Among patients with an LAD score of 16-18, representing almost total muscle avulsion, 70% had nonfunctional MOS scores, whereas in patients with normal/minimal LAD (scores of 0-4), 89.5% had functional MOS scores.

CONCLUSIONS

Levator ani deficiency and MOS scales were moderately negatively correlated. Among patients with normal morphology or the most severe muscle deficiency, LAD scores can identify the majority of patients with functional or nonfunctional MOS scores respectively.

Active encouragement of older women with urinary incontinence in primary care to undergo diagnosis and treatment: a matched-pair cluster randomized controlled trial

OBJECTIVES

The URINO trial investigated the effect of offering treatment to older women with urinary incontinence in the general population, who had not sought help on their own initiative.

STUDY DESIGN

In a cluster randomized trial, 14 general practitioners were matched into pairs and randomly allocated to an intervention or a control group. Women aged ≥ 55 years registered in the participating practices were asked about urinary incontinence via a postal questionnaire. Patients in the intervention group were assessed and treated whereas patients in the control group received standard care.

MAIN OUTCOME MEASURES

Primary outcome was improvement (yes or no) of the severity of symptoms at 12-month follow-up measured with the Incontinence Severity Index. Secondary outcomes were the number of incontinence episodes per day and quality of life. The primary analysis was on an intention-to-treat basis with multiple imputation of missing data. A logistic regression model with correction for cluster randomization was fitted to estimate odds ratios (ORs).

RESULTS

At 12 months, the severity of symptoms had improved in more patients in the intervention group (n166) than in the controls (n184) (OR 1.9; 95% CI 1.1-3.3). Also, the number of patients with fewer episodes of incontinence had increased (OR 2.5; 95% CI 1.5-4.1). No between-group differences in changes in quality of life were apparent (p0.14).

CONCLUSIONS

It is recommended to encourage women in the general population aged ≥ 55 years with urinary incontinence to undergo diagnosis and treatment.

Effect of pelvic floor muscle training compared with watchful waiting in older women with symptomatic mild pelvic organ prolapse: randomised controlled trial in primary care

OBJECTIVE

To compare the effects of pelvic floor muscle training and watchful waiting on pelvic floor symptoms in a primary care population of women aged 55 years and over with symptomatic mild pelvic organ prolapse.

DESIGN

Randomised controlled trial.

SETTING

Dutch primary care.

PARTICIPANTS

Women aged 55 years or over with symptomatic mild prolapse (leading edge above the hymen) were identified by screening. Exclusion criteria were current prolapse treatment or treatment in the previous year, malignancy of pelvic organs, current treatment for another gynaecological disorder, severe/terminal illness, impaired mobility, cognitive impairment, and insufficient command of the Dutch language.

INTERVENTIONS

Pelvic floor muscle training versus watchful waiting.

MAIN OUTCOME MEASURES

The primary outcome was change in bladder, bowel, and pelvic floor symptoms measured with the Pelvic Floor Distress Inventory-20 (PFDI-20), three months after the start of treatment. Secondary outcomes were changes in condition specific and general quality of life, sexual function, degree of prolapse, pelvic floor muscle function, and patients' perceived change in symptoms.

RESULTS

Of the 287 women who were randomised to pelvic floor muscle training (n=145) or watchful waiting (n=142), 250 (87%) completed follow-up. Participants in the intervention group improved by (on average) 9.1 (95% confidence interval 2.8 to 15.4) points more on the PFDI-20 than did participants in the watchful waiting group (P=0.005). Of women in the pelvic floor muscle training group, 57% (82/145) reported an improvement in overall symptoms from the start of the study compared with 13% (18/142) in the watchful waiting group (P<0.001). Other secondary outcomes showed no significant difference between the groups.

CONCLUSIONS

Although pelvic floor muscle training led to a significantly greater improvement in PFDI-20 score, the difference between the groups was below the presumed level of clinical relevance (15 points). Nevertheless, 57% of the participants in the intervention group reported an improvement of overall symptoms. More studies are needed to identify factors related to success of pelvic floor muscle training and to investigate long term effects.Trial registration Dutch Trial Register (www.trialregister.nl) identifier: NTR2047.

Female patient-specific finite element modeling of pelvic organ prolapse (POP)

Pelvic organ prolapse (POP) occurs only in women and becomes more common as women age. However, the surgical practices remain poorly evaluated. The realization of a simulator of the dynamic behavior of the pelvic organs is then identified as a need. It allows the surgeon to estimate the functional impact of his actions before his implementation. In this work, the simulation will be based on a patient-specific approach in which each geometrical model will be carried out starting from magnetic resonance image (MRI) acquisition of pelvic organs of one patient. To determine the strain and stress in the soft biological tissues, hyperelastic constitutive laws are used in the context of finite element analysis. The Yeoh model has been implemented into an in-house finite element code FER to model these organ tissues taking into account large deformations with multiple contacts. The 2D and 3D models are considered in this preliminary study and the results show that our method can help to improve the understanding of different forms of POP.

[Pelvic floor muscle contraction and maximum urethral closure pressure]

OBJECTIVES

The aim of this study was to precise the relationship between the pelvic floor muscle (PFM) contraction and the maximum urethral closure pressure (MUCP) at rest and during a containing effort.

MATERIALS

Longitudinal study, observational, single-center retrospective performed in successively 358 women addressed for urodynamics. MUCP at rest and during a containing effort, gain of MUCP, functional urethral length (FUL), scores USP and ICQ-SF, cervico-urethral mobility (CUM) according to POP-Q classification and leak point pressure were analyzed according to the PFM contraction.

RESULTS

One hundred and seventy-three had genuine stress urinary incontinence, 25 urge urinary incontinence, 148 mixed incontinence and 12 had no urinary incontinence. PFM contraction was not associated with a hysterectomy, age, parity, BMI, CUM, FUL, MUCP at rest, the severity of the incontinence assessed by ICIQ-SF score and leak point pressure. There was a proportional relationship between PFM contraction and the value of MUCP measured during this contraction (P<0.0001) on the one hand, and the gain of MUCP (P<0.0001) on the other. MUCP at rest was independent from the MUCP during the containing effort and the gain of MUCP.

CONCLUSIONS

The strength of contraction of the PFM is not correlated with MUCP at rest but proportional to the augmentation of the MUCP during the containing effort.

A finite element model validates an external mechanism for opening the urethral tube prior to micturition in the female

PURPOSE

Existing theories for micturition in the female mandate total relaxation of the pelvic floor while detrusor pressure pushes the urethra open. However, video X-ray and electromyogram data indicate that micturition is preceded by active outwards opening of the outflow tract by backward-/downward-acting muscle vectors. If the detrusor pressure alone is enough to expand the tube, why does the active opening take place? The aim was to model the urethral tube in detail to assess the relative importance of the active opening mechanism and detrusor pressure.

METHODS

Finite element methods were used to model the urethral tube in detail. Nonlinear-elastic properties similar to urethral component tissues were taken from the literature. The boundary conditions applied to the tube model included internal pressure due to detrusor contraction (60 cm H2O) and various displacements and constraints such as pubourethral and pubovesical ligament attachments.

RESULTS

In order to achieve opening dimensions similar to those in the lateral X-ray under the action of detrusor pressure alone, the pressure had to be increased by two orders of magnitude above normal levels.

CONCLUSIONS

Normal detrusor pressure alone is not sufficient to achieve opening of the urethra against the elasticity of the constituent tissues, suggesting that normal micturition requires an active mechanism provided by backward-/downward-acting pelvic floor muscles, as predicted by the integral theory.

Pelvic floor muscle function is an independent predictor of outcome after retrourethral transobturator male sling procedure

PURPOSE

To evaluate the impact of the retrourethral transobturator sling (RTS) on pelvic floor muscle function (PFMF) and whether preoperative PFMF is associated with RTS outcome.

METHODS

Between May 2008 and December 2010, 59 consecutive men with postprostatectomy stress urinary incontinence (PSUI) underwent PFMF assessment before RTS and 6 months thereafter in a prospective cohort study. The assessments included demographic and clinical characteristics, and quality of life (QoL) questionnaires. PFMF was evaluated by digital rectal examination on the modified 6-point Oxford scale and by surface electromyography. The primary outcome measurement was success after RTS defined as PSUI cure with use of no or one dry "security" pad. For secondary outcome, PFMF, 1-h pad test, and impact of PSUI on QoL were evaluated. Uni- and multivariate analyses were performed.

RESULTS

After 6-month follow-up, the cure, improvement (>50 % pad reduction) and failure rates were 50 % (29/58 patients), 24 % (14/58 patients) and 26 % (15/58 patients), respectively. Significant improvement of QoL, clinical and PFMF parameters occurred after RTS. On multivariate analysis, weak PFMF (OR 86.29) and greater muscle fatigue (OR 3.31) were significant independent predictors of RTS failure. The final model demonstrated good calibration (p = 0.882) and excellent discriminative ability (0.942, 95 % CI 0.883-1.0) to predict success after RTS.

CONCLUSIONS

PFMF improved significantly after RTS procedure. Higher muscle fatigue and weak PFMF were independent predictors of RTS failure. Digital rectal evaluation of PFMF is a simple and reliable clinical tool, which can be used by urologists in daily routine to predict the RTS outcome.

Physical examination of the female internal and external genitalia with and without pelvic organ prolapse: A review

Pelvic organ prolapse, a herniation of pelvic organs through the vagina, is a common condition in older women. Pelvic organ prolapse distorts vaginal anatomy making pelvic examination difficult. A clinician must accurately identify anatomic landmarks both in women presenting with symptoms of prolapse and in women noted to have coincidental prolapse during routine gynecologic examination. We present a systematic approach to the female pelvic examination including anatomic landmarks of the external genitalia, vagina, and uterus in women with normal support as well as changes that occur with pelvic organ prolapse. Knowledge and awareness of normal anatomic landmarks will improve a clinician's ability to identify defects in pelvic support and allow for better diagnosis and treatment of pelvic organ prolapse.

Pelvic floor muscle variables and levator hiatus dimensions: a 3/4D transperineal ultrasound cross-sectional study on 300 nulliparous pregnant women

INTRODUCTION AND HYPOTHESIS

The aims of the present study were to investigate the correlation among vaginal resting pressure and pelvic floor muscle (PFM) strength and endurance, and the correlation between the same variables and levator hiatus (LH) dimensions in nulliparous pregnant women.

METHODS

This was a cross-sectional study of 300 nulliparous pregnant women, mean age 28.7 years (SD 4.3) and pre-pregnancy BMI 23.9 kg/m(2) (SD 3.9), assessed at mean gestational week 20.8 (±1.4). Vaginal resting pressure and PFM strength and endurance were measured using a high precision pressure transducer connected to a vaginal balloon. LH dimensions (transverse and anterior-posterior diameters_ and LH area were assessed using 3/4D transperineal ultrasound in the axial plane of minimal hiatal dimensions using render mode. The Pearson correlation was used to analyze correlations among vaginal resting pressure and PFM strength and endurance, and between PFM variables and LH dimensions. Level of significance was set at 0.05.

RESULTS

Pelvic floor muscle strength and vaginal resting pressure were significantly, but weakly correlated (r = 0.198, p < 0.001). PFM strength and endurance showed a strong correlation (r = 0.929, p < 0.001). High vaginal resting pressure was moderately correlated with a small LH area at rest (r = -0.451, p < 0.001), but there was no significant correlation neither between PFM strength and LH area at rest (r = -0.012, p = 0.84) nor between muscle endurance and LH area at rest (r = -0.014, p = 0.81). A strong PFM contraction correlated moderately with reduction of the LH area (r = -0.367, p < 0.001).

CONCLUSIONS

Pelvic floor muscle strength and endurance are strongly correlated, butdo not correlate with a smaller LH area at rest.

Diagnostic value of pelvic floor surface electromyography in functional anorectal pain

AIM: To assess the diagnostic value of pelvic floor surface electromyography (sEMG) in functional anorectal pain (FARP) using receiver operating characteristic (ROC) curve analysis.

METHODS: The parameters of pelvic floor sEMG in 118 patients with FARP and 103 normal controls were measured according to the Glazer protocol. Parameters included amplitude (AVG), coefficient of variance (CV), onset time and median frequency (MF). The ROC curve was plotted to assess the diagnostic value of pelvic floor sEMG.

RESULTS: Compared with the control group, the FARP group had a lower AVG (23.81 ± 13.75 vs 30.55 ± 16.14, P < 0.05) and a higher CV (0.43 ± 0.12 vs 0.30 ± 0.07, P < 0.05) during the tonic phase and a higher CV during the endurance phase (0.40 ± 0.15 vs 0.28 ± 0.09, P < 0.05). The critical value of CV during the tonic and endurance phases were 0.35 and 0.31, respectively, and the areas under ROC curve were 0.813 and 0.761.

CONCLUSION: CV during the tonic and endurance phases has better diagnostic value in FARP.

Pelvic floor muscle dysfunctions are prevalent in female chronic pelvic pain: a cross-sectional population-based study

BACKGROUND

No current standardized set of pelvic floor muscle (PFM) outcome measures have been specifically tested for their applicability in a general female chronic pelvic pain (CPP) population. We aimed to compare PFM function between a randomly selected population-based sample of women with CPP and age-matched pain-free controls using multiple standardized intravaginal examination measures recommended by the International Continence Society.

METHODS

This was a cross-sectional, population-based and controlled study with randomly selected participants among women in Denmark. We reported blinded findings from a set of standardized vaginal PFM examination manoeuvres in 50 female participants (24 with CPP, 26 pain free). A preliminary pilot study ensured the intra- and intertester reliability of the test procedure. PFM outcomes were resting tone, relaxation capacity, strength, surface electromyographic activity and mechanosensitivity. Statistical analyses included unpaired t-tests, Fisher's exact tests and Mann-Whitney tests.

RESULTS

The examination protocol was a reliable and predictable clinical measurement of associated PFM dysfunction in female CPP. Women with CPP had higher PFM resting tone and decreased maximal PFM strength and relaxation capacity compared with pain-free controls. Enhanced PFM pressure-pain sensitivity measured by palpometry during examination was also associated to CPP.

CONCLUSION

This controlled, single-blinded study with randomly selected participants provides new population-based information regarding associated PFM dysfunction in women with CPP using multiple intravaginal examination methods. However, to identify women with CPP who will benefit from a physiotherapeutic specialized intervention, future prospective randomized controlled trials using these reliable and predictive outcomes are needed.

[Pelvic floor muscles training, electrical stimulation, bladder training and lifestyle interventions to manage lower urinary tract dysfunction in multiple sclerosis: a systematic review]

AIM

To assess the effectiveness of conservative therapeutic approaches in a multiple sclerosis population.

MATERIAL

Review was performed in PubMed, PEDro, Scopus and Cochrane Library using combinations of the following keywords: multiple sclerosis; bladder dysfunction; overactive bladder; detrusor hyperreflexia; urge incontinence; urgency; stress incontinence; pelvic floor muscle; biofeedback; PTNS; tibial nerve; bladder training; physical therapy; physiotherapy; conservative treatment and behavioral therapy.

RESULTS

Six randomized articles including 289 patients were selected. Four papers exhibited strong scores for the methodological quality assessment. The parameters always significantly improved concerned: number of incontinence episodes (decreased from 64% to 86% after treatment versus before treatment), quality of life (P≤0.001), severity of irritative symptoms (decreased by more than 50% after treatment versus before treatment), and nocturia (P=0.035 to P<0.001). Activities and participation, maximum flow rate, mean voided volume and daytime frequency were not significantly improved in all trials.

CONCLUSIONS

The physical therapy techniques could be effective for the treatment of urinary disorders in multiple sclerosis populations with mild disability. However, the analyses are based on six studies within only four showed good methodological quality. No strong conclusions regarding treatment approaches can be drawn from this review.

The pharmacology of the human female orgasm - its biological and physiological backgrounds

The female orgasm has been examined over the years by numerous scientific disciplines yet it still has many secrets to be disclosed. Because its physiology, especially its neurophysiology, is sparingly understood its pharmacology is necessarily limited based mainly on the side effects of drugs. Few published studies have used a placebo group as controls. The paucity of focussed studies is well illustrated by the fact that there still is no approved medication to treat female orgasmic dysfunction. The present brief overview examines the most important aspects of its biology and especially its physiology highlighting the many questions that need answering if we are to have a comprehensive pharmacology of the female orgasm.

Ethnic differences in pelvic floor muscle strength and endurance in South African women

INTRODUCTION AND HYPOTHESIS

Limited knowledge exists about pelvic floor muscle (PFM) function in ethnic groups. The aim of this study was to compare PFM strength and endurance in a group of black, white and mixed-race women.

METHODS

This was a cross-sectional study. Maximum voluntary contraction (MVC) and endurance were measured with a perineometer and vaginal balloon sensor. Two sets of three MVC of the PFM were recorded; resting phase was 5 min. Demographic variables and factors associated with PFM strength were assessed.

RESULTS

A total of 122 nulliparous black (n = 44), white (n = 44) and mixed-race (n = 34) students participated. PFM of black women were stronger than that of white (p = 0.02) or mixed-race (p < 0.01) women. The MVC of PFM in black women decreased (p = 0.02) between the first and second set of contractions.

CONCLUSIONS

Ethnic differences were found. Further clinical studies are needed to confirm an association between PFM function and pelvic floor disorders.

Pelvic floor muscle activity, quality of life, and sexual function in peri- and recently postmenopausal women with and without dyspareunia: a cross-sectional study

Pelvic floor alterations during menopausal years, resulting from aging and hormonal decline, may lead to several forms of sexual dysfunction. Dyspareunia-pain during sexual intercourse-is among the most frequent. Nevertheless, few studies so far have evaluated pelvic floor muscle function in postmenopausal women with dyspareunia. The authors thus carried out a cross-sectional study to assess myoelectric activity in pelvic floor muscles in peri- and postmenopausal women with and without dyspareunia receiving routine care at an outpatient clinic. In addition, sexual function (using the Female Sexual Function Index) and quality of life (using the Cervantes Scale) were assessed. Fifty-one peri- and postmenopausal women between 45 to 60 years of age (M = 52.1, SD = 4.9) were evaluated, 27 with and 24 without dyspareunia. There were no statistically significant differences in resting muscle activity, maximal voluntary contraction, and sustained contraction between women with and without dyspareunia. There were statistically significant between-group differences on the Cervantes Scale (p =.009) and in all Female Sexual Function Index domains except desire and satisfaction (arousal, p =.019; lubrication, p =.030; orgasm, p =.032; pain, p <.001; desire, p =.061; satisfaction, p =.081), indicating that women with dyspareunia experience worse quality of life and less satisfactory sexual function as compared with women without dyspareunia.

[Urinary incontinence in older multimorbid female patients. Screening and assessment]

Symptoms of urinary incontinence are a common problem in elderly, multimorbid female patients. The first step in establishing optimal management is to screen patients routinely and address this pathology directly. Urinary incontinence is considered to be a geriatric syndrome. It develops as a consequence of many complex underlying and potentially synergistic factors related to ageing and disease. A multidimensional clinically based assessment of urinary incontinence should be performed using a defined multimodal method including geriatric assessment, medical history, targeted physical investigation, urinalysis, and measurement of post-void residual urine volume. The aim is to identify as many of the underlying factors and pathologies, followed by step-by-step treatment to alleviate or eliminate incontinence. With this approach, excellent therapeutic results can be achieved in practice, even in elderly patients.

Pelvic floor muscle function in women with pelvic floor dysfunction: a retrospective chart review, 1992-2008

INTRODUCTION AND HYPOTHESIS

The objectives of this study were to investigate the level of pelvic floor muscle (PFM) function in women with pelvic floor dysfunction (PFD) referred by gynaecologists and urologists for in-hospital pelvic floor muscle training (PFMT), and to identity associated factors for a low level of PFM function.

METHODS

Data of women with PFD referred to a PFMT programme were included in a retrospective chart review. Measurement of PFM function performed by digital vaginal palpation included: voluntary PFM contraction, PFM strength (Modified Oxford Grading Scale) and PFM static endurance.

RESULTS

Data of 998 women, mean age 56 (SD 13) years, with PFD (urinary incontinence, n = 757, anal incontinence, n = 36, pelvic organ prolapse, n = 111, other PFD, n = 94) were analysed. In all, 690 women (70%) were, at baseline, unable to perform correct voluntary PFM contraction, mean PFM strength was 1.5 (SD 1.0) points, mean PFM static endurance was 16.7 (SD 16.1) seconds. Age ≥ 65 years and year of referral > 2000 were significantly (p < 0.01) associated with the ability to perform correct PFM contraction. Likewise, year of referral was significantly associated with high PFM strength (p < 0.01).

CONCLUSIONS

The majority of the women were unable to perform correct voluntary PFM contraction and almost all had low PFM strength. The most important factor associated with a low level of PFM function was age.

Pelvic floor muscle training versus watchful waiting or pessary treatment for pelvic organ prolapse (POPPS): design and participant baseline characteristics of two parallel pragmatic randomized controlled trials in primary care

Pelvic floor muscle training (PFMT) and pessaries are commonly used in the conservative treatment of pelvic organ prolapse (POP). Because there is a lack of evidence regarding the optimal choice between these two interventions, we designed the "Pelvic Organ prolapse in primary care: effects of Pelvic floor muscle training and Pessary treatment Study" (POPPS). POPPS consists of two parallel open label randomized controlled trials performed in primary care, in women aged ≥55 years, recruited through a postal questionnaire. In POPPS trial 1, women with mild POP receive either PFMT or watchful waiting. In POPPS trial 2, women with advanced POP receive either PFMT or pessary treatment. Patient recruitment started in 2009 and was finished in December 2012. Primary outcome of both POPPS trials is improvement in POP-related symptoms. Secondary outcomes are quality of life, sexual function, POP-Q stage, pelvic floor muscle function, post-void residual volume, patients' perception of improvement, and costs. All outcomes are measured 3, 12, and 24 months after the start of treatment. Cost-effectiveness will be calculated based on societal costs, using the PFDI-20 and the EQ-5D as outcomes. In this paper the POPPS design, the encountered challenges and our solutions, and participant baseline characteristics are presented. For both trials the target numbers of patients in each treatment group are achieved, giving this study sufficient power to lead to promising results.

The effects of multidisciplinary rehabilitation: RePCa-a randomised study among primary prostate cancer patients

BACKGROUND

The objective of this study is the effectiveness of multidisciplinary rehabilitation on treatment-related adverse effects after completed radiotherapy in patients with prostate cancer (PCa).

METHODS

In a single-centre oncology unit in Odense, Denmark, 161 PCa patients treated with radiotherapy and androgen deprivation therapy were randomly assigned to either a programme of two nursing counselling sessions and two instructive sessions with a physical therapist (n=79) or to usual care (n=82). Primary outcome was Expanded Prostate Cancer Index Composite (EPIC-26) urinary irritative sum-score. Before radiotherapy, pre-intervention 4 weeks after radiotherapy, and after a 20-week intervention, measurements included self-reported disease-specific quality of life (QoL; EPIC-26, including urinary, bowel, sexual, and hormonal symptoms), general QoL (Short-form-12, SF-12), pelvic floor muscle strength (Modified Oxford Scale), and pelvic floor electromyography. Intension-to-treat analyses were made with adjusted linear regression.

RESULTS

The intervention improved, as compared with controls, urinary irritative sum-score 5.8 point (Cohen's d=0.40; P=0.011), urinary sum-score (d=0.34; P=0.023), hormonal sum-score (d=0.19; P=0.018), and the SF-12 Physical Component Summary, d=0.35; P=0.002. Patients with more severe impairment gained most. Pelvic floor muscle strength measured by electromyography declined in both groups, P=0.0001.

CONCLUSION

Multidisciplinary rehabilitation in irradiated PCa patients improved urinary and hormonal symptoms, and SF-12 physical QoL.

Dutch guidelines for physiotherapy in patients with stress urinary incontinence: an update

Introduction and hypothesis

Stress urinary incontinence (SUI) is the most common form of incontinence impacting on quality of life (QOL) and is associated with high financial, social, and emotional costs. The purpose of this study was to provide an update existing Dutch evidence-based clinical practice guidelines (CPGs) for physiotherapy management of patients with stress urinary incontinence (SUI) in order to support physiotherapists in decision making and improving efficacy and uniformity of care.

Materials and methods

A computerized literature search of relevant databases was performed to search for information regarding etiology, prognosis, and physiotherapy assessment and management in patients with SUI. Where no evidence was available, recommendations were based on consensus. Clinical application of CPGs and feasibility were reviewed. The diagnostic process consists of systematic history taking and physical examination supported by reliable and valid assessment tools to determine physiological potential for recovery. Therapy is related to different problem categories. SUI treatment is generally based on pelvic floor muscle exercises combined with patient education and counseling. An important strategy is to reduce prevalent SUI by reducing influencing risk factors.

Results

Scientific evidence supporting assessment and management of SUI is strong.

Conclusions

The CPGs reflect the current state of knowledge of effective and tailor-made intervention in SUI patients.

The effect of pelvic physiotherapy on reduction of functional constipation in children: design of a multicentre randomised controlled trial

Background

Functional constipation is a common disorder worldwide and is found in all paediatric age groups. Functional constipation can be caused by delayed colonic transit or dysfunction of the pelvic floor muscles. Standard medical care in paediatric practice is often based on clinical experience and mainly consists of a behavioural approach and toilet training, along with the prescription of laxatives. Evidence to evaluate the effectiveness of pelvic physiotherapy for this complaint is lacking.

Methods/design

A two-armed multicentre randomised controlled trial has been designed. We hypothesise that the combination of pelvic physiotherapy and standard medical care will be more effective than standard medical care alone for constipated children, aged 5 to 17 years. Children with functional constipation according to the Rome III will be included. Web-based baseline and follow-up measurements, scheduled at 3 and 6 months after inclusion, consist of the numeric rating scale in relation to the perceived severity of the problem, the Strength and Difficulties Questionnaire and subjective improvement post-intervention (global perceived effect). Examination of the pelvic floor muscle functions, including digital testing and biofeedback, will take place during baseline and follow-up measurements at the physiotherapist. The control group will only receive standard medical care, involving at least three contacts during five months, whereas the experimental group will receive standard medical care plus pelvic physiotherapy, with a maximum of six contacts. The physiotherapy intervention will include standard medical care, pelvic floor muscle training, attention to breathing, relaxation and awareness of body and posture. The study duration will be six months from randomisation, with a three-year recruitment period. The primary outcome is the absence of functional constipation according to the Rome III criteria.

Discussion

This section discusses the relevance of publishing the study design and the development of the presented physiotherapy protocol. It also addresses difficulties when interpreting the literature with regard to the effectiveness of biofeedback, potential confounding, and future research indications. To our knowledge, this article is the first to describe the design of a randomised controlled trial among children with constipation to assess the effect of pelvic physiotherapy as an add-on to standard medical care.

Trial registration

Current Controlled Trials NL30551.068.09

Electrical stimulation with non-implanted electrodes for urinary incontinence in men

BACKGROUND

Electrical stimulation with non-implanted devices is used for patients with different types of urinary incontinence and symptoms of urgency, frequency and nocturia. The current review focused on electrical stimulation with non-implanted devices for the treatment of urinary incontinence in men.

OBJECTIVES

To determine the effectiveness of electrical stimulation with non-implanted devices for men with stress, urgency or mixed urinary incontinence in comparison with no treatment, placebo treatment, or any other 'single' treatment. Additionally, the effectiveness of electrical stimulation with non-implanted devices in combination with another intervention was compared with the other intervention alone. Finally, the effectiveness of one method of electrical stimulation with non-implanted devices was compared with another method.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Trials Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PreMEDLINE, and handsearching of journals and conference proceedings (searched 21 January 2012). We also searched other electronic and non-electronic bibliographic databases and the reference lists of the included studies as well as contacting researchers in the field to identify other relevant trials.

SELECTION CRITERIA

Randomized and quasi-randomized controlled trials.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed all the identified trials for eligibility. Risk of bias was assessed using the Cochrane tool for determining bias. Disagreements were resolved by discussion, and a third review author was involved in the case of no consensus. Data were analysed using Cochrane methods.

MAIN RESULTS

Six randomized controlled trials (five full papers and one abstract) were included. There was considerable variation in the interventions used, study protocols, types of electrical stimulation parameters and devices, study populations and outcome measures. In total 544 men were included, of whom 305 received some form of electrical stimulation, and 239 a control or comparator treatment. The trials were mostly small and generally there was not sufficient information to assess risk of bias; only two trials used secure methods of randomization.There was some evidence that electrical stimulation (ES) had a short-term effect in reducing incontinence compared with sham treatment (for example risk ratio (RR) at six months 0.38, 95% CI 0.16 to 0.87) but not at 12 months. Four trials evaluated the effect of adding PFMT to ES versus pelvic floor muscle training (PFMT) alone or with biofeedback. There was no evidence of a statistically significant difference in the number of men with urinary incontinence at three months (146/239, 61% for combined treatment versus 98/156, 63% with PFMT alone; RR 0.93, 95% CI 0.82 to 1.06). However, there were more adverse effects with combined treatment (23/139, 17% versus 2/99, 2% with PFMT alone; RR 7.04, 95% CI 1.51 to 32.94) and quality of life also seemed better with PFMT alone. One small trial did not detect statistically significant differences between two methods of administration of transcutaneous electrical stimulation (anal versus perineal) but the quality of life score was lower (better) in the anal stimulation group.

AUTHORS' CONCLUSIONS

There was some evidence that electrical stimulation enhanced the effect of PFMT in the short term but not after six months. There were, however, more adverse effects (pain or discomfort) with electrical stimulation.

Short-term outcomes after rehabilitation treatment in patients selected by a novel rehabilitation score system (Brusciano score) with or without previous stapled transanal rectal resection (STARR) for rectal outlet obstruction

PURPOSE

The purpose of this study was to examine short-term outcomes of rehabilitation treatment in patients with or without previous stapled transanal resection (STARR) for rectal outlet obstruction by using a novel rehabilitation score system (Brusciano score).

METHODS

This is a retrospective cohort study conducted at a single tertiary referral institution including all patients with chronic functional constipation admitted to the outpatient unit from 2004 to 2009.

RESULTS

Among 330 consecutive patients, 247 (74.8 %) (204 females and 43 males) showing a significantly higher rehabilitation score (mean of 15.7 ± 1.8; range, 7-25) than healthy controls (mean, 3.2 ± 1.2; range 2-6) (p < .0001) were selected for rehabilitation. Of the 247 patients evaluated, group A (no previous surgery) consisted of 170 patients (53 males; mean age, 44.8 ± 12.9 years; range, 19-80) of which 38 presented mixed constipation, whereas group B (previous surgery) consisted of 77 patients (18 males; mean age, 47.0 ± 11.2 years; range, 22-81). The Brusciano score, Agachan-Wexner score and quality of life improved in both groups of patients after treatment. Better improvements of Brusciano and Agachan-Wexner scores were observed in patients with previous STARR (group B).

CONCLUSIONS

The rehabilitation score system employed in this study seems to be a useful tool in selecting and assessing the outcome of patients who might benefit from rehabilitation treatment. Constipation and quality of life were significantly improved by the rehabilitation treatment. Further studies are needed to clarify either the impact of rehabilitation treatment on long-term outcome of patients treated for rectal outlet obstruction or its role in those who develop problems over time.

Cerebral palsy, neurogenic bladder, and outcomes of lifetime care

AIM

To determine the prevalence of symptomatic neurogenic bladder (SNB) and social and functional variables in a large sample of people with cerebral palsy (CP).

METHOD

The medical records of 214 individuals (96 females, 118 males) with CP between the years 1990 and 2000 were retrospectively reviewed. Individuals with frequency, urgency, or incontinence were assigned Gross Motor Function Classification System levels and underwent cystometrogram/electromyelogram studies. Neurogenic bladders were classified according to the nomenclature of the International Continence Society.

RESULTS

Fifty-two patients had hemiplegia, 42 diplegia, 117 quadriplegia, and three dyskinesia. Educational levels ranged from full special education to those with graduate degrees. Thirty-five individuals in our group aged 5 to 66 years had SNB with a prevalence of 16.4%. The median age for the entire population was 9 years 7 months and for those with SNB 12 years 4 months (range 5-57y). Over 80% of individuals who underwent investigation were found to have spastic hyper-reflexic type bladders. Ninety-one percent obtained total continence or major improvement with conservative care. SNB was documented across the lifespan, educational spectrum, and functional level. Upper urinary tract pathology was infrequent.

INTERPRETATION

SNB is a common finding in individuals with CP. In most patients it is readily diagnosed and treated with conservative interventions.