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

Perineal ultrasound evaluation of dysfunctional voiding in women with recurrent urinary tract infections

PURPOSE

We used urodynamics and perineal ultrasound to assess the function and morphology of the urethral sphincter and detrusor muscle in the evaluation of dysfunctional voiding in female patients with recurrent urinary tract infections.

MATERIALS AND METHODS

Patients selected for study purposes completed the American Urological Association Symptom Index and underwent multichannel video urodynamics and perineal ultrasound to evaluate urethral sphincter volume and detrusor thickness.

RESULTS

Of the 337 patients referred to our institution for recurrent urinary tract infections 166 were finally evaluated, including group 1-65 women with recurrent urinary tract infections and dysfunctional voiding, group 2-77 with recurrent urinary tract infections without dysfunctional voiding and group 3-24 healthy controls. Storage and emptying symptoms were recorded in 87.6% and 84.6% of group 1 patients, respectively. Opening and maximum flow detrusor pressure significantly correlated with urethral sphincter volume, and mean and maximum urethral closure pressure and detrusor thickness correlated with urethral sphincter volume. Dysfunctional voiding could be diagnosed by ultrasound when an increase in detrusor thickness and striated sphincter volume were observed. A threshold sphincter volume of 1.96 cm3 had 100% sensitivity and 63.2% specificity, and a threshold detrusor thickness of 4.95 mm had 100% sensitivity and 85.4% specificity for identifying patients with dysfunctional voiding.

CONCLUSIONS

We think that perineal ultrasound is useful in the evaluation of dysfunctional voiding in women with recurrent urinary tract infections.

Qualidade de vida e estratégias de enfrentamento em idosos com incontinência fecal: uma revisão da literatura

RESUMO O objetivo desta revisão foi apreciar criticamente a literatura sobre a avaliação da qualidade de vida (QV) e das estratégias de enfrentamento em idosos com incontinência fecal (IF), tendo como referencial o envelhecimento populacional brasileiro e o aumento da incidência de doenças crônicas que comprometem o bem-estar dos idosos. Foi realizada pesquisa nas principais bases de dados e a qualidade metodológica das publicações foi avaliada. A perda involuntária de fezes gera conseqüências físicas, sociais, emocionais e econômicas, sendo mais prevalente em idosos e mulheres. Recentemente, a avaliação de medidas centradas no paciente, incluindo a QV e as estratégias de enfrentamento foram apontadas como fundamentais. A qualidade de vida de idosos com IF pode ser avaliada através de instrumentos genéricos, como o WHOQOL e de instrumentos específicos, como o FIQL e o GIQLI. Alguns estudos têm indicado variáveis que podem se associar a um maior ou menor comprometimento da QV, mas ainda há escassez de trabalhos com idosos incontinentes. Embora já existam instrumentos de avaliação genérica das estratégias de enfrentamento disponíveis para uso no Brasil, nesta revisão, não foram encontradas pesquisas sobre a forma de enfrentamento da IF na população em geral ou entre os idosos. Esta revisão confirma a necessidade de mais estudos sobre como a IF afeta os idosos e como os mesmos lidam com essa disfunção.

Evaluation of pelvic floor muscle function in a random group of adult women in Austria

Despite an increasing clinical interest in female pelvic floor function, there is a lack of data with respect to the knowledge of average adult women about the physiological role of the pelvic floor and their ability to contract pelvic floor muscles (PFM) voluntarily. It was the aim of our study to evaluate the percentage of PFM dysfunction in adult women and the impact of risk factors, such as age, body mass index (BMI), number of children delivered, and the influence of previous PFM training. A total of 343 Austrian adult women (mean age, 41.2 +/- 14.6 years; range, 18-79 years), selected at random, were examined to test their ability to contract the PFM. The examination was carried out by three independent gynecologists during the course of a routine gynecological visit. The ability to contract the PFM voluntarily or involuntarily was assessed by digital intravaginal palpation with the patients in a supine position. The muscle strength was graded according to the Modified Oxford Grading Scale by Laycock. A high percentage (44.9%) of the women was not able to voluntarily perform a normal PFM contraction. In only 26.5%, an involuntary contraction of the pelvic floor was present before an increase in intra-abdominal pressure. The inability to contract the PFM did not correlate with women's age but revealed a weak relationship with the number of childbirths and the patient's BMI. A significant correlation was found between the Oxford Grading Scale rating and the patient's report about previous PFM training.

Management of dyspareunia and associated levator ani muscle overactivity

BACKGROUND AND PURPOSE

Musculoskeletal dysfunction is a known cause of dyspareunia and a reason for referral for physical therapist management. The purpose of this case report is to describe the physical therapist management of a patient with dyspareunia and overactivity of the pelvic-floor muscles with a limited number of visits and a focus on self-management strategies.

CASE DESCRIPTION

This case involved a 30-year-old married woman with levator ani muscle overactivity and dyspareunia that was 1 year in duration.

INTERVENTION

The therapist explained the anatomy and function of the pelvic-floor muscles during intercourse, instructed the patient on how to control the levator ani muscles, and instructed her on vaginal self-dilation techniques.

OUTCOMES

The patient attended 3 physical therapy sessions over a period of 9 weeks. She performed vaginal self-dilation at home. She rated pain during intercourse as 0/10 on a verbal rating scale and had no remaining tenderness in the levator ani muscles at discharge.

DISCUSSION

Some women with dyspareunia may improve with an intervention that emphasizes education and vaginal self-dilation techniques. Future research should compare home-based and clinic-based treatments.

Test–retest and intra-observer repeatability of two-, three- and four-dimensional perineal ultrasound of pelvic floor muscle anatomy and function

The aims of the present study were to evaluate test-retest intra-observer repeatability of ultrasound measurement of the morphology and function of the pelvic floor muscles (PFMs). Seventeen subjects were tested twice. Two-, three- and four- dimensional ultrasound recorded cough, huff, muscle morphology and PFM contraction, respectively. Analyses were conducted offline. Measurements of levator hiatal dimensions demonstrated intra-class correlation coefficient (ICC) values of 0.61, 0.72, 0.86 and 0.92, for the anterior-posterior dimension, transverse dimension, resting area and narrowing during contraction, respectively. Muscle thickness showed variable reliability. ICC values for measurement of the position of the bladder neck were 0.86 and 0.82 at rest, in the vertical and horizontal direction. Displacement of the bladder neck during contraction, huff and cough demonstrated ICC values of 0.56, 0.59 and 0.51, respectively. Perineal ultrasound is a reliable method for measuring most of the tested parameters of morphology and function of the PFMs.

Rehabilitation versus drug therapy for urge urinary incontinence: long-term outcomes

The objective of this study was to compare the residual effect of a 3-month rehabilitation treatment and a standard drug treatment for urge urinary incontinence (UUI) 21 months post intervention. Forty-four women (ages 27-68 years) who were diagnosed with overactive bladder (OAB) were divided into 2 treatment groups over 3 months: 24 women received rehabilitation (REH) and 20 women were treated with medication (MED) (oxybutynin ER). Outcomes measures included frequency of urination, quality of life (QoL), and number of side effects (no/SE), which were measured upon entry into the study (entry), completion of the intervention (3 months), and at follow-up 3 and 21 months after completion of treatment. In the follow-up period, there was a significant group-time interaction effect on freq/day and freq/night (p < 0.01). At the end of follow-up, the mean number of no/SE was significantly greater in the MED group compared to the REH group (3.3 +/- 0.5 vs 2.4 +/- 0.4; p < 0.05). A significant negative association was found between the urinary symptoms and the I-QoL at the 21-month follow-up (r (p) = -0.45 to-0.57, p < 0.05). In the long-term, the REH patients maintained and even improved the achievements of the intervention period while the MED patients deteriorated to baseline values in urinary frequency. The suggestion for future work is to investigate the effect of each REH treatment component on UUI symptoms.

Follow-up after polypropylene mesh repair of anterior and posterior compartments in patients with recurrent prolapse

To retrospectively analyze the outcome of surgery in women followed up for 1 year after vaginal repair with the Apogee (support of posterior vaginal wall) or Perigee (support of anterior vaginal wall) system. A total of 120 patients with recurrent cystocele and/or rectocele or with combined vaginal vault prolapse were treated by either posterior or anterior mesh interposition depending on the defect. Follow-up after 1 year (+/-31 days) comprised a vaginal examination with prolapse grading using the POP-Q system, measurement of vaginal length, evaluation of the vaginal mucosa, and exploration for mesh erosions. Postoperatively, 112 (93%) women were free of vaginal prolapse, whereas 8 (7%) had level 2 defects. Erosions occurred significantly more often (p = 0.042) in patients treated with the Perigee system. Our results suggest that the Apogee and Perigee repair systems (monofilament polypropylene mesh) yield excellent short-term results after 1 year.

Randomized, double-blind, sham-controlled evaluation of the effect of functional continuous magnetic stimulation in patients with urgency incontinence

AIMS

To evaluate the effect of functional continuous magnetic stimulation (FCMS) on urgency incontinence in randomized, sham-controlled manner.

METHODS

Thirty-nine patients with urgency incontinence, 16 males and 23 females (aged 66.0 +/- 16.5 years), who were refractory to pelvic floor muscle training (PFMT), were randomly assigned either to the treatment schedule performing 10-week active treatment, followed by 4-week non-treatment interval and then by 10-week sham treatment (A-S, n = 20) or to that performing the sham treatment first followed by 10-week active treatment (S-A, n = 19).

RESULTS

At 10 weeks, the number of leaks/week, the total score of the International Consultation on Incontinence-Questionnaire: Short Form (ICIQ-SF), and maximum cystometric capacity (MCC) were significantly improved as compared with the initial levels (P < 0.001, P < 0.001, and P = 0.003, respectively) in the former group, but not in the latter group. Four (20.0%) patients were cured in the A-S group, while no patient was cured in the S-A group. At the end of the A-S schedule (24 weeks of study), the effect of the active treatment was still maintained at a significantly improved level, as compared with the initial level. At the end of the S-A schedule, the number of leaks/week was significantly improved as compared with the initial level and with its 10-week level (P < 0.001 and P = 0.049, respectively), as well as ICIQ-SF total score (P = 0.001 and P = 0.006, respectively). MCC significantly increased from its initial level (P = 0.030).

CONCLUSION

Magnetic stimulation was effective on urgency incontinence in comparison to sham stimulation in this small patient group.

REVIEWS: Pelvic Floor Involvement in Male and Female Sexual Dysfunction and the Role of Pelvic Floor Rehabilitation in Treatment: A Literature Review

INTRODUCTION

The sphincteric and supportive functions of the pelvic floor are fairly well understood, and pelvic floor rehabilitation, a specialized field within the scope and practice of physical therapy, has demonstrated effectiveness in the treatment of urinary and fecal incontinence. The role of the pelvic floor in the promotion of optimal sexual function has not been clearly elucidated.

AIM

To review the role of the pelvic floor in the promotion of optimal sexual function and examine the role of pelvic floor rehabilitation in treating sexual dysfunction.

MAIN OUTCOME MEASURE

Review of peer-reviewed literature.

RESULTS

It has been proposed that the pelvic floor muscles are active in both male and female genital arousal and orgasm, and that pelvic floor muscle hypotonus may impact negatively on these phases of function. Hypertonus of the pelvic floor is a significant component of sexual pain disorders in women and men. Furthermore, conditions related to pelvic floor dysfunction, such as pelvic pain, pelvic organ prolapse, and lower urinary tract symptoms, are correlated with sexual dysfunction.

CONCLUSIONS

The involvement of the pelvic floor in sexual function and dysfunction is examined, as well as the potential role of pelvic floor rehabilitation in treatment. Further research validating physical therapy intervention is necessary.

Urodynamic and ultrasound characteristics of incontinence after radical hysterectomy

AIMS

To test whether symptoms of urinary incontinence after radical hysterectomy could be objectified with urodynamics and ultrasound.

METHODS

This case-control study comprised 100 women who underwent radical hysterectomy for cervical cancer without post-operative radiotherapy. Fifty women reporting urinary incontinence were matched with 50 women reporting continence. All women were assessed with ultrasound of the bladder neck movements and urodynamics.

RESULTS

No differences were found in ultrasound or urodynamic findings regarding mobility of the bladder neck, maximal detrusor pressure, post-voiding residual urine, flow of urine, or bladder capacity. A significant reduction in urethral pressure at rest and at contraction among the incontinent women was, however, demonstrated. Among urge-incontinent women, urethral pressure at rest was significantly lower than among continent and stress-incontinent women, respectively. Stress-incontinent women had significantly lower urethral pressure at contraction than did urge-incontinent and continent women.

CONCLUSIONS

No differences in urodynamic or ultrasound findings were observed between the two groups, except for an overall difference in the intraurethral pressure. A decrease in the urethral pressure could contribute to the characterization of incontinence after radical hysterectomy, indicating that the urethral sphincter mechanism plays a role in the pathophysiology. In this study design, the mobility of the bladder neck did not play any role.

Sitting posture affects pelvic floor muscle activity in parous women: an observational study

QUESTION

Do different sitting postures require different levels of pelvic floor and abdominal muscle activity in healthy women?

DESIGN

Observational study.

PARTICIPANTS

Eight parous women with no pelvic floor dysfunction.

OUTCOME MEASURES

Bilateral activity of pelvic floor muscles (assessed vaginally) and two abdominal muscles, obliquus internus abdominis and obliquus externus abdominis, during three sitting postures.

RESULTS

There was a significant increase in pelvic floor muscle activity from slump supported sitting (mean 7.2% maximal voluntary contraction, SD 4.8) to both upright unsupported sitting (mean 12.6% maximal voluntary contraction, SD 7.8) (p = 0.01) and very tall unsupported sitting (mean 24.3% maximal voluntary contraction, SD 14.2) (p = 0.004). Activity in both abdominal muscles also increased but did not reach statistical significance.

CONCLUSION

Both unsupported sitting postures require greater pelvic floor muscle activity than the supported sitting posture.

Ultrasound imaging of sacral reflexes

OBJECTIVES

To investigate the reliability of examination of the guarding reflex of the pelvic floor by dynamic perineal ultrasonography in children with bladder dysfunction and in controls.

METHODS

A total of 40 patients with nonneurogenic bladder/sphincter dyssynergia, 40 with spina bifida, and 40 controls underwent a dynamic ultrasound examination of the pelvic floor while coughing and while being tapped on the abdominal wall. The reflex action of the puborectal muscle in females, and the combined action of the puborectal muscle and external sphincter muscle in males, were recorded.

RESULTS

Of the 40 patients with nonneurogenic bladder/sphincter dyssynergia, 38 had a normal reflex action of the puborectal muscle during the abdominal tap and 36 had a normal reflex action when coughing. Two of these patients had unexplained underactive bladder syndrome and were using clean intermittent catheterization, and two could not be assessed because of hypermobility of the bladder neck when coughing but had a normal reaction during abdominal tapping. Of the 40 patients with spina bifida, none had puborectal activity during coughing and 5 had some puborectal activity during tapping. Of the 40 controls, 39 had normal reflex activity during both coughing and tapping.

CONCLUSIONS

The question of whether a child has nonneurogenic or neuropathic bladder/sphincter dysfunction is often difficult to answer on the basis of urodynamic studies alone. Dynamic perineal ultrasound recording of the S2-S4 reflex arches provides reliable additional information and is noninvasive to the patient.

The assessment of levator trauma: A comparison between palpation and 4D pelvic floor ultrasound

AIMS

Major morphological abnormalities of the pubovisceral muscle are observed in 10-20% of women symptomatic of pelvic floor disorders. Such defects arise in childbirth and are associated with prolapse. While they are clearly evident on 3D ultrasound and MR imaging, such defects can be difficult to detect clinically. We intended to compare findings on palpation with the results of ultrasound imaging.

MATERIAL AND METHODS

Fifty-five women were recruited in a prospective observational study and assessed by interview, vaginal examination by a trained pelvic floor physiotherapist, and 3D/4D pelvic floor ultrasound. The vaginal examination involved digital assessment of muscle strength (modified Oxford grading) and morphological abnormalities. The ultrasound examination involved acquisition of volume datasets taken at rest, on Valsalva and pelvic floor muscle contraction. Assessments were undertaken supine and after voiding. Ultrasound operator and physiotherapist were blind to each other's findings.

RESULTS

A comparison of 3D ultrasound and palpation was possible in 54 cases. Average Oxford grading was weakly associated with reduction in hiatal dimensions on contraction (r = -0.32, P = 0.024). A marked increase in hiatal dimensions detected on palpation was associated with increased hiatal area on Valsalva (P = 0.027). Defects were observed in 7/54 (13%) on ultrasound and in 10/55 (18%) on palpation. There was poor agreement between the methods, with only two defects picked up equally by both methods.

CONCLUSIONS

Palpation of the pubovisceral muscle correlates poorly with 3D/4D pelvic floor ultrasound imaging for the assessment of muscular defects.