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

Pelvic Pain and Pelvic Floor Disorders in Women: A Physiatrist's Approach to Epidemiology and Examination

Chronic pelvic pain is a complex diagnosis that has a significant impact on quality of life and function in women of all ages. Symptoms often span across numerous organ systems and involve several types of pain including visceral, neuropathic, musculoskeletal, and psychological, making management and treatment difficult. To adequately assess and recognize etiologies of pelvic pain, it is critical to first understand the specialized skills required for history taking and physical examination. This article aims to serve as a guide to understanding the physiatrist's approach to history taking and examination of pelvic pain.

Compliance and Adherence to Pelvic Floor Exercise Therapy in People with Pelvic Floor Disorders: A Systematic Review and Meta-Analysis

BACKGROUND

The impact of muscle-training treatment on quality of life and functional outcomes in people with pelvic floor dysfunction may be related to adherence rates.

METHODS

Nine electronic databases were searched for studies published up to 15 October 2024. A qualitative synthesis was used to describe the relationship between adherence or compliance with treatment, quality of life, and symptomatic severity. A meta-analysis of data from selected studies was performed that assessed quality of life and symptomatic severity in the short term.

RESULTS

Seven studies with 2190 participants were included. Of these studies, 42% showed rates greater than 80% in terms of adherence. A beneficial effect was found in terms of urinary incontinence severity without statistical differences between the groups (p = 0.813), while quality of life showed statistically significant improvements favoring the experimental group (p = 0.036). The quality of the evidence was collected or measured from low to high.

CONCLUSIONS

People with pelvic floor disorders show high rates of adherence to pelvic floor muscle exercise and experience an improved quality of life in the short term, but more research is needed on the design of homogeneous systems to measure compliance and adherence to exercise-based treatments.

Pelvic Floor Muscle Strength and Bothersome Urinary Incontinence After Pregnancy: A Cohort Study

INTRODUCTION AND HYPOTHESIS

Postpartum urinary incontinence (UI) is prevalent, and women with bothersome UI tend to seek more help. This study was aimed at evaluating the association between pelvic floor muscle (PFM) strength and bothersome UI in the 1st year postpartum.

METHODS

A prospective cohort study was conducted with 504 participants. UI was evaluated by the International Consultation on Incontinence Questionnaire Short Form (online) and PFM strength was assessed via vaginal palpation (Modified Oxford Scale, MOS), at 3, 6, 9, and 12 months postpartum. Logistic regression analysis was used to analyze the data.

RESULTS

At 3 months postpartum, 52% of women had a PFM strength of ≥ 3 MOS, increasing to 84% at 12 months. 42% of women reported UI at 3 months, which remained unchanged by 12 months. PFM strength ≥ 3 MOS was moderately associated with less UI at 3 months (OR = 0.63, 95% CI 0.42-0.94) and at timepoints 6, 9, and 12 months. Antepartum UI was strongly associated with postpartum UI at all time points: 3 months (OR = 10.23, 95% CI 4.90-21.37), 6 months (OR = 7.75, 95% CI 3.95-15.21), 9 months (OR = 9.95, 95% CI 4.61-21.47), and 12 months (OR = 4.55, 95% CI 2.29-9.04). Grade 2 perineal tears were moderately associated with UI at 9 months postpartum (OR = 1.82, 95% CI 1.11-3.0).

CONCLUSIONS

A stronger pelvic floor was associated with less bothersome UI in the 1st year postpartum. UI during pregnancy was most strongly associated with bothersome UI after childbirth. Antenatal screening for UI and promoting PFM training may be warranted to support postpartum recovery and minimize UI.

A Brazilian Association of Women´s Health Physical Therapy (ABRAFISM) guideline on the terminology of pelvic floor muscle function and assessment

BACKGROUND

There has been many efforts and updates over the years to develop a consensus for English terminology related to the pelvic floor (PF). There is a similar need to standardize physical therapy related PF terminology in Brazil.

OBJECTIVE

To propose a guideline in Brazilian Portuguese language on the terminology related to the female PF function and assessment.

METHODS

The Brazilian Association of Physical Therapy in Women's Health (ABRAFISM) established a working group (Steering committee) responsible for conducting a systematic review on PF terminology, propose definitions in Portuguese, and manage the developmental stages. A systematic review of international consensus was conducted and the terms related to the PF were identified, listed, and defined in Portuguese. A Delphi method was used to reach a consensus on the definitions by querying a panel of expert professionals with clinical and research experience in the PF field. This panel included 19 physical therapists from all Brazilian regions and two physicians. The Delphi process included the following steps: evaluation of proposed terms by the panel of experts; review of suggestions made by the panel of experts, modification of terms based on those suggestions, and a new round of evaluation of the modified terms until reaching an 80% agreement.

RESULTS

Two rounds were necessary for terms related to anatomy and signs/symptoms of the PF, while a 90% consensus for terms related to assessment of the PF muscles was achieved in the first round.

CONCLUSION

A final Brazilian-Portuguese guideline with consensus terminology on anatomy, symptoms, signs, and terms related to assessment of PF muscles was developed.

Investigation of pelvic floor influence on prostate displacement in image-guided radiotherapy

PURPOSE

The uncertainty of target location during prostate cancer radiotherapy plays an important role in accurate dose delivery and radiation toxicity in adjacent organs. This study analyzed displacement correlations between the prostate and pelvic floor.

METHODS AND MATERIALS

We retrospectively analyzed registration results from 467 daily cone-beam computed tomography (CT) in 12 patients with prostate cancer who received radiation therapy. We analyzed prostate displacement and the pelvic floor relative to the pelvic bone's anatomy in the translational and rotational directions and identified statistical correlations.

RESULTS

The systematic (Σ) and random (σ) displacements of the prostate in the three translational directions, anterior-posterior (AP), superior-inferior (SI), and right-left (RL), were 1.49 ± 1.45, 2.10 ± 1.40, and 0.24 ± 0.53 mm, respectively, and in the rotational directions of the pitch, roll, and yaw were 2.10 ± 2.02°, 0.42 ± 0.74°, and 0.42 ± 0.64°, respectively. The pelvic floor displacements were 2.37 ± 1.96, 2.71 ± 2.28, and 0.47 ± 0.84 mm in the AP, SI, and RL directions, respectively, and 0.93 ± 1.49°, 0.98 ± 1.28 °, and 0.87 ± 0.94° in the pitch, roll, and yaw directions, respectively. Additionally, there were statistically significant correlations between the displacement of the prostate and pelvic floor in the AP and SI directions, with correlation coefficients (r) of 0.74 (p < 0.001) and 0.69 (p < 0.001), respectively.

CONCLUSIONS

The movement of the pelvic floor may be an important factor that causes prostate displacement, affecting the accuracy of radiotherapy. Therefore, it is necessary to take appropriate measures to ensure that the pelvic floor muscle tension is as consistent as possible in the treatment' CT scan and daily treatment.

Intra- and Inter-Rater Reliability, Measurement Error and Criteria and Convergent Validities of the Dualpex Plus for the Vaginal Manometry of Pelvic Floor Muscles in Women With Urinary Incontinence

OBJECTIVE

To test the Intra- and inter-rater reliability, measurement error and criteria and convergent validities of the Dualpex Plus (DP) for vaginal manometry in women with urinary incontinence (UI).

DESIGN

This is a clinimetric properties study.

SETTING

University Hospital in Brazil.

POPULATION

One hundred and two women with UI.

METHODS

Vaginal manometry was performed with DP and Peritron (Pr), in a random order. Intra-rater reliability was tested within a 1-week interval; inter-rater reliability was tested on the same day by two different evaluators. Perception of contraction and comfort with each device were assessed and compared with Chi-square or paired t tests. Reliability was evaluated by intraclass correlation coefficient (ICC) with a 95% confidence interval (CI). Criteria (with Pr) and convergent (with Oxford score) validities were evaluated by Pearson's correlation. The standard error of measurement (SEM) and the minimum detectable change were also calculated.

MAIN OUTCOME MEASURES

Intra- and inter-rater reliability, measurement error and criteria and convergent validities of the Dualpex Plus.

RESULTS

DP showed substantial inter-rater and excellent intra-rater reliability (ICC = 0.85; 95% CI 0.76-0.91 and 0.90; 95% CI 0.86-0.93, respectively); strong and positive criteria validity (r = 0.83; p < 0.001) and convergent validity (r = 0.45; p < 0.001). Pressure values for pelvic floor muscle contraction were different between DP and Pr [17.61 ± 12.22 vs. 34.91 ± 21.22 cmH2O; p < 0.001]. SEM was doubtful (19%) and the minimum detectable change was 0.152 cmH2O. DP was more comfortable than Pr and perception of contraction was higher for Pr.

CONCLUSION

Dualpex Plus showed adequate clinimetric properties. Measurement error was considered doubtful. DP was more comfortable than Pr and perception of contraction was higher for Pr.

Transperineal ultrasound evaluation of pelvic floor muscle function in male patients with constipation

OBJECTIVE

To investigate the application of transperineal ultrasound for assessing pelvic floor muscle (PFM) function in male patients with constipation and to evaluate its clinical value.

METHODS

The study included 32 male patients with constipation and 32 healthy controls, all of whom underwent transperineal ultrasound examinations. Measured parameters included the anorectal angle (ARA), levator plate angle (LPA), excursions of the ARA and LPA, and displacements of the bulb of the penis (BP), mid-urethra (MU), urethra-vesical junction (UVJ), and anorectal junction (ARJ) at rest, during maximal voluntary contraction (MVC), and during maximal Valsalva maneuver. Reliability was evaluated in 20 healthy controls using intraclass correlation coefficients (ICCs) and Bland-Altman analysis.

RESULTS

(1) The ICCs for each parameter measured by both the same and different observers were above 0.84, indicating high repeatability. At least 90% of the measurements by the same and different observers fell within the 95% confidence interval (CI). (2) At rest, the ARA in patients with constipation was significantly larger than in healthy men (P < 0.05). During MVC, LPA, the ARA excursion, LPA excursion, BP displacement, UVJ displacement, and ARJ displacement in constipation patients were also significantly larger than in healthy men (P < 0.05). Furthermore, BP displacement, UVJ displacement, and ARA excursion during maximal Valsalva maneuver in constipation patients were significantly larger than in healthy men (P < 0.05). (3) Receiver operating characteristic curve analysis revealed that the following indicators demonstrated area under the curve (AUC) values exceeding 0.75: ARA excursion of MVC, ARA excursion of maximal Valsalva maneuver, resting ARA, and ARJ displacement of MVC, with AUC values of 0.782, 0.778, 0.770, and 0.765, respectively. No significant differences in diagnostic performance were found among these indicators (P > 0.05).

CONCLUSION

 Transperineal ultrasound is a reliable and practical technique for assessing the morphology and function of male PFMs. Parameters such as ARA excursion during MVC, ARA excursion during maximal Valsalva maneuver, resting ARA, and ARJ displacement during MVC are valuable for diagnosing PFM dysfunction in constipated patients.

Pelvic Floor Muscle Evaluation in Older Women with Urinary Incontinence: A Feasibility Study

INTRODUCTION AND HYPOTHESIS

The objective of this feasibility study was to characterize the pelvic floor muscles (PFMs) in older women with urinary incontinence (UI) via clinical and magnetic resonance imaging (MRI) evaluation.

METHODS

This cross-sectional study included women aged ≥ 70 years with symptomatic UI confirmed by a 3-day bladder diary. Clinical evaluation of the PFMs included the Modified Oxford Scale strength assessment (grade 0-5). PFM defects were also characterized as none/normal, minor, and major based on MRI evaluation. Descriptive statistics were utilized. Spearman's correlation with 95% confidence intervals was calculated between PFMs strength, MRI defects, and age.

RESULTS

Participants (n = 20) were 76.6 ± 4.7 years. Clinical evaluation demonstrated poor PFM strength in 95% (n = 19) of participants with the following grades: 15% (n = 3) grade 0, 45% (n = 9) grade 1, and 35% (n = 7) grade 2. MRI evaluation demonstrated PFMs= defects in 100% of participants with 45% (n = 9) minor and 55% (n = 11) major defects. The correlation coefficients between PFM strength and MRI defects, MRI defects and age, and PFM strength and age were -0.29 (95% CI -0.64, 0.18; p = 0.22), -0.01 (95% CI = -0.44, 0.44; p = 0.99), and 0.04 (95% CI = -0.41, 0.47; p = 0.88) respectively.

CONCLUSION

Clinical and MRI evaluation of PFMs in older women with UI is feasible. Clinical evaluation of PFMs demonstrated poor strength in 95% of women, and MRI revealed PFM defects in all participants.

Development of an educational program in pelvic floor health for women: A consensus using the Delphi method

OBJECTIVE

Pelvic floor health education workshops for women appear to improve women's knowledge and pelvic floor symptoms. Our aim was to obtain expert consensus on the content and format of a pelvic floor health education program using the Delphi method.

MATERIAL AND METHODS

A two-round Delphi study was conducted involving French-speaking multidisciplinary experts in pelvic floor dysfunction management. The first round questionnaire contained 44 items (31 about the program's content and 13 about the materials). They were also consulted about the optimal format of the program (duration and number of workshops) as open questions. Participants rated their level of agreement with each item on a Likert scale from 1-9. Consensus was defined by a level of agreement≥80% and a median≥7. Non-consensus items were reworked and resubmitted to the experts for the second round.

RESULTS

Of the 110 experts contacted, 52 responded for the first and second rounds. Sixty-one percent of the proposed items met with consensus in the first round and 60% in the second. The final program comprises 33 items: eight on anatomy, four on biomechanics, nine on urinary and defecatory physiology, seven on risk factors, and five on materials. The format selected by the experts consisted of four or five 75-minute health education sessions with a paper summary hand out at the end of the program.

CONCLUSIONS

This study defined the content of a pelvic floor health education program for the general population of adult women validated by a consensus of experts. After validation of an English version, it should be evaluated in international interventional studies.

LEVEL OF EVIDENCE

LE5 (expert opinion).

Do young women have an accurate perception about their pelvic floor muscle contraction? An agreement study about self-perception and physical evaluation of the pelvic muscles contraction by the PERFECT scheme

BACKGROUND

Many women have difficulty in activating the pelvic floor muscles (PFM). This is a concerning factor for health professionals and public government institutions, as an unhealthy PFM could be associated with the presence of PFM dysfunctions. Therefore, the aim of the study was to analyze the agreement between the perception of young women about their PFM contraction and the results of a physical assessment, according to the strength, endurance, and contraction repetitions.

METHOD

Cross-sectional study with 43 university students between 18 and 35 years old. Examiner A filled out a semi-structured questionnaire to assess the self-perception about the ability to contract the PFM. The physical exam was performed by bidigital vaginal palpation, conducted by Examiner B, blinded to the answers of the previous stage, and according to the PERFECT scheme (P = power; E = endurance; R = repetitions of item "E; " F = fast contractions). Data was assessed by the Cohen's linear weighted kappa (Kw).

RESULTS

The agreement between the self-perception and the physical evaluation of the PFM function presented a very poor agreement for all the items of the PERFECT scheme (P(Kw) = 0.12; E(Kw) = 0.07; R(Kw) = 0.09; F(Kw) = 0.04).

CONCLUSION

Young women do not have sufficient knowledge about PFM contraction and function. It should concern health government and institutions, as a poor PFM awareness might increase the difficulty to identify signs and symptoms related to PFM dysfunctions and reduces demand for and adherence to PFM treatment programs.

Bidirectional Relationships between Sarcopenia and Pelvic Floor Disorders

Sarcopenia and pelvic floor disorders (PFDs) are prevalent and often cooccurring conditions in the aging population. However, their bidirectional relationship and underlying mechanisms remain underexplored. This narrative review aims to elucidate this relationship by exploring potential causative interplays, shared pathophysiological mechanisms, and common risk factors. A comprehensive literature search was conducted to identify relevant studies focusing on epidemiological associations, interaction mechanisms, and implications for patient care. While epidemiological studies demonstrate associations between sarcopenia and PFDs, our findings reveal a cyclical relationship where sarcopenia may exacerbate PFDs through mechanisms such as decreased muscle strength and mobility. Conversely, the presence of PFDs often leads to reduced physical activity due to discomfort and mobility issues, which in turn exacerbate the muscle atrophy associated with sarcopenia. Additionally, shared risk factors such as physical inactivity, nutritional deficiencies, metabolic syndrome, and menopausal hormonal changes likely contribute to the onset and progression of both conditions. These interactions underscore the importance of concurrently integrated care approaches that address both conditions. Effective management requires comprehensive screening, the recognition of contributing factors, and tailored exercise regimens supported by a multidisciplinary approach. Future research should focus on longitudinal studies tracking disease progression and evaluating the efficacy of multidisciplinary care models in optimizing patient outcomes.

Advancing women's pelvic floor muscle function diagnosis: the EFSMAP examination and its reliability evaluation

BACKGROUND

The accurate diagnosis of pelvic floor muscle impairments is essential. The plethora of terms and the lack of evidence to support widely used pelvic floor muscle function (PFMF) measurements hinder diagnostic labels.

OBJECTIVE

To structure an examination of PFMF using visual observation and digital palpation and terms consistent with the ICF terminology, and to test its intra and interrater reliability/agreement.

METHODS

A panel of 9 physical therapists applied Delphi method to structure the PFMF exam under ICF terminology and to verify its measurements reproducibility. For reliability and agreement, a convenience sample of women aged 51.2 ± 14.7 years had the sensitivity to pressure, pain, muscle tone, involuntary movement reaction, control of voluntary movement (contraction/relaxation), coordination, strength, and endurance examined by two raters, in the same day for interrater (n = 40), and one week apart, for intrarater reliability (n = 25). Percent agreement, linear weighted kappa, intraclass correlation coefficient, and Bland-Altman's limits of agreement were calculated (alpha = 0.05).

RESULTS

Four round Delphi discussion structured the PFMF exam, named EFSMAP (Exame das Funções Sensoriais e Motoras do Assoalho Pélvico/Examination of Pelvic Floor Sensory and Motor Functions), set a list of concepts and instructions targeted at reproducibility and established PFMF diagnostic labels. Reliability, except for pain and tone, were moderate to excellent (Kw= 0.67-1.0 and ICC=0.48-0.82). Agreement was substantial for most PFMF features (0.64-1.00), except pain.

CONCLUSIONS

The EFSMAP was successfully developed as a valid and reliable exam to be used in research and clinical practice; it provides labels for the diagnosis of pelvic floor muscle impairments. It might be easily adopted worldwide as it uses ICF terminology.

Pelvic floor muscle training in telerehabilitation: a systematic review and meta-analysis

PURPOSE

This systematic review aims to identify, critically appraise, and summarize current evidence regarding the feasibility and efficacy of pelvic floor muscle training in telerehabilitation.

METHODS

Three bibliographic databases, PubMed, Embase, and Scopus were searched from inception to October 1, 2023. Clinical trials assessing the feasibility and efficacy of pelvic floor muscle training in telerehabilitation were eligible for inclusion. The Physiotherapy Evidence Database scale and National Institutes of Health Study Quality Assessment Tool were used for methodological quality assessment. Study selection, data extraction, and quality assessment were completed by two independent reviewers. Meta-analyses were performed to determine the effects of pelvic floor muscle training in telerehabilitation.

RESULTS

Five randomized controlled trials and three single cohort clinical trials were included in this review. Four studies were evaluated as good quality, and four as fair. Pelvic floor telerehabilitation was well tolerated and demonstrated good patient compliance and satisfaction. Pooled analysis indicated significant effects of pelvic floor telerehabilitation on the severity of urinary incontinence with a large effect size, pelvic floor muscle strength with a large effect size, and quality of life with a medium effect size.

CONCLUSION

This systematic review demonstrates that pelvic floor muscle training in telerehabilitation is a feasible and effective approach and highlights its efficacy in patients with urinary incontinence. This review supports the application of pelvic floor muscle training in telerehabilitation and informs further clinical and research endeavors to incorporate digital health technologies in managing pelvic floor dysfunction.

Assessment of Involuntary PFM Contractions in Comparison with Existing Literature and IUGA/ICS Terminology Reports

INTRODUCTION AND HYPOTHESIS

Involuntary pelvic floor muscle (PFM) contractions are thought to occur during an increase in intra-abdominal pressure (IAP). Although no studies have assessed their presence in women with normal pelvic floor (PF) function, existing literature links the absence of involuntary PFM contractions to various PF dysfunctions. This study rectifies this lacuna by evaluating involuntary PFM contractions during IAP in healthy nulliparous women with no PF dysfunction, using visual observation and vaginal palpation. Results were compared with the literature and the IUGA/ICS Terminology Reports.

METHODS

Nulliparous (n=149) women performed three sets of three maximal coughs. Visual observation and vaginal palpation were conducted in the standing and supine positions. The women were not instructed to contract their PFMs. Occurrence rates were calculated for each assessment method and position; differences between positions were analyzed using the Chi-squared test.

RESULTS

Rates of occurrence of involuntary PFM contraction were low across both assessments and positions (5-17%). Significant differences were found between standing (5%) and supine (15%) positions for visual observation, but not vaginal palpation (15%, 17% respectively). Occurrence rates also differed compared with the literature and terminology reports.

CONCLUSIONS

Contrary to clinical expectations, rates of occurrence of involuntary PFM contraction among our cohort of nulliparous women were extremely low. Digital palpation results showed high agreement with the terminology reports, but only partial agreement was observed for the visual observation results. Our study underscores the need for more research aimed at defining normal involuntary PF functions, a review of our understanding of involuntary PFM contractions, and better standardized guidelines for involuntary PFM assessment methods.

[Effectiveness of early pelvic muscle training on pelvic floor strength, urinary incontinence symptoms, sexual function, and quality of life in post-radical prostatectomy patients: Systematic review of randomized clinical trials]

This study aimed to evaluate the effectiveness of early pelvic muscle training in reducing urinary incontinence symptoms, improving quality of life, sexual function, and increasing pelvic floor strength in post-radical prostatectomy patients. A search was carried out in 8 databases until October 26, 2022, the methodological quality and the risk of bias of 14 included studies (n=1236) were evaluated, moreover, the evidence and the meta-analysis were calculated. The intervention significantly reduced urinary incontinence symptoms compared to a control group (SMD=-2.80, 95% CI=-5.21 to -0.39, P=.02), with significant heterogeneity (I2=83%; P=<.0001) and moderate evidence. In addition, it presented moderate evidence to improve quality of life, and very low evidence to improve sexual function and pelvic floor strength. These results should be viewed with caution due to the significant heterogeneity of the studies analysed.

Pelvic Pain of Myofascial Origin in Women: Correlation with Lower Urinary Tract Symptoms

Introduction

Women with lower urinary tract symptoms (LUTS) and high-tone pelvic floor often experience pain and have positive trigger points upon pelvic floor examination. However, the correlation of these findings has not yet been systematically examined and sufficiently understood. The aim of this cross-sectional study is to examine the correlation of pelvic myofascial pain with LUTS and pelvic floor tone.

Materials and Methods

All participants filled a standardized pelvic floor questionnaire to assess LUTS, which consists of a total of 43 questions regarding bladder, bowel, and sexual function as well as prolapse symptoms. Myofascial trigger points in different muscle groups including pubococcygeus, iliococcygeus, and obturator as well as pelvic floor muscle tone were assessed using a standardized digital examination technique.

Results

110 women were included in the study. There was a significant correlation between pain in various muscle groups and LUTS as well as high-tone pelvic floor muscle. A significant correlation could also be found between high pelvic floor muscle tone and the overall questionnaire score (p < 0.001) as well as the bladder function score (p < 0.001) and various pain scores of the different groups. Individuals with high-tone pelvic floor were more likely to have more LUTS and higher pain scores.

Conclusions

The existence of myofascial pelvic floor trigger points and high pelvic floor muscle tone seem to be reflective of pelvic floor symptoms, as assessed with a standardized pelvic floor questionnaire.

Lateral abdominal muscle thickness and contractile function in women with and without stress urinary incontinence

INTRODUCTION AND HYPOTHESIS

Stress urinary incontinence (SUI) primarily results from the weakness of pelvic floor muscles, working synergistically with the abdominal muscles. The current study aimed to compare thickness and contractile function of lateral abdominal muscles in women with and without SUI.

METHODS

Thirty-nine women with SUI (SUI group; age: 38.87 ± 8.96 years, body mass index (BMI): 24.03 (5.94) kg/m2) and 42 healthy women (control group; age: 36.21 ± 11.46 years, BMI: 23.90 (5.85) kg/m2) were included. Transverse abdominis (TrA) and internal oblique (IO) muscle thickness at rest and during abdominal drawing-in maneuver (ADIM) were measured with ultrasound imaging in B-mode using a Logiq S7/Expert device and a 9-11 MHz linear transducer. Percentage change in thickness and contractile function of these muscles were also calculated.

RESULTS

No significant differences in the thickness of TrA and IO muscles at rest and during ADIM between the groups were found (p > 0.05). The percent change in thickness and contractile function of both right and left side TrA muscles and the right side IO muscle were lower in SUI group than control group (p < 0.05). The percentage change in thickness and the contractile function of the left side IO muscle did not change (p > 0.05).

CONCLUSION

Women with SUI had a smaller percentage change in thickness and contractile function of TrA and IO muscle than women without SUI. However, there was no difference in the morphological features of these muscles between the groups. Considering the lateral abdominal muscle, training may be important for management of SUI.

Psychometric evaluation and cross-cultural adaptation of the Australian Pelvic Floor Questionnaire (APFQ-IR) in Iranian reproductive age women

Pelvic floor disorders (PFDs), as a silent alert, is one of the pervasive debilitating health concerns among women all over the world, such that in developed countries, one in four women, suffers from PFDs. Validity and reliability of the Australian Pelvic Floor Questionnaire (APFQ) has not been determined in Iran, so to determine APFQ's psychometric characteristics, we decided to conduct this study on women of reproductive age in Tabriz city, Iran. This methodological cross-sectional study was intended to determine the psychometric properties of the Persian version of the APFQ-IR in 5 steps including "translation process, content validity, face validity, construct validity (exploratory and confirmatory factor analyses and examination of ceiling and floor effects) and reliability" on 400 reproductive age women referring to health centers in Tabriz city, Iran, with cluster random sampling method in the period between May 2022 to September 2022. The translation process was done based on two approaches, Dual panel, and Beaton et al.'s five steps. Then, in order to evaluate content validity, face validity, and construct validity, 10 instrument and PFDs experts, 10 women from the target group investigated the instrument's items, and 400 eligible women completed the instrument. Finally, to determine the reliability, two internal consistency methods, (Cronbach's alpha and McDonald's omega) and test-retest method (ICC) were used. In the present study, content validity assessment of APFQ-IR, showed a good level of validity (CVR = 0.96, CVI = 0.94). To assess construct validity, exploratory factor analysis results on 36 items, led to the identification of 4 factors including bladder function, bowel function, prolapse symptom and sexual function, which explained 45.53% of the cumulative variance and indicated the sufficiency of the sample size (Kaiser-Meyer-Olkin = 0.750). Implementing confirmatory factor analysis, (RMSEA = 0.08, SRMR = 0.08, TLI = 0.90, CFI = 0.93, χ2/df = 3.52) confirmed the model fit indices. Finally the internal consistency and reliability was high for the entire instrument (Cronbach's alpha = 0.85; McDonald's omega (95% CI) = 0.85 (0.83-0.87) and Intraclass Correlation Coefficient (95% CI) = 0.88 (0.74-0.94)). The Persian version of the APFQ-IR, has a good validity and reliability and has acceptable psychometric properties, thus can be used both for research purposes and for clinical evaluation of pelvic floor disorders symptoms in health centers.

Myofascial urinary frequency syndrome is a novel syndrome of bothersome lower urinary tract symptoms associated with myofascial pelvic floor dysfunction

This study describes a novel, distinct phenotype of urinary symptoms named "myofascial urinary frequency syndrome" (MUFS) present in one-third of individuals presenting with urinary frequency. In addition to a characteristic symptom constellation suggestive of myofascial dysfunction, MUFS subjects exhibit "persistency": a persistent feeling of needing to urinate regardless of urine volume. On examination, 97% of MUFS patients demonstrated pelvic floor hypertonicity with either global tenderness or myofascial trigger points, and 92% displayed evidence of impaired muscular relaxation, hallmarks of myofascial dysfunction. To confirm this symptom pattern was attributable to the pelvic floor musculature, we confirmed the presence of "persistency" in 68 patients with pelvic floor myofascial dysfunction established through comprehensive examination and electromyography and corroborated by improvement with pelvic floor myofascial release. These symptoms distinguish subjects with myofascial dysfunction from subjects with OAB, IC/BPS, and asymptomatic controls, confirming MUFS is a distinct LUTS symptom complex.

Amsterdam complex pelvic pain symptom scale with subscales: Based on a Norwegian translation, psychometric assessment and modification of the Amsterdam hyperactive pelvic floor scale

INTRODUCTION

Women with an abnormally high pelvic floor muscle tone may have a clinical presentation that is complex, involving urinary, anorectal and/or sexual dysfunction, genital/pelvic pain and psychological distress. The Amsterdam Hyperactive Pelvic Floor Scale (AHPFS) is a Dutch 30-item condition-specific self-report questionnaire developed to measure these complex pelvic pain symptoms. The aim of this study was to translate the Dutch version into Norwegian, to assess the psychometric properties, and to present a valid factor structure.

MATERIAL AND METHODS

Translation, back-translation and a review of the back-translated version were performed. Thereafter, a pilot test including feedback from six clinical experts and cognitive interviews with 11 patients from the target group was conducted. Next, a field test was performed among women who were (1) patients at the gynecological outpatient clinic/pelvic floor physiotherapist at St. Olav's Hospital, (2) members of the Vulvodynia or the Endometriosis Patient Associations or (3) female students and employees from the Faculty of Medicine and Health Science, the Norwegian University of Science and Technology, in a web-based survey. To ensure a sample with symptomatic women, only women who scored ≥11 according to the Dutch prespecified factor structure were included in the statistical analyses (n = 232).

RESULTS

Content/face validity demonstrated that the questionnaire was perceived as relevant, comprehensive and understandable. Some adjustments in the instructions of the questionnaire and the response categories were made, which lead to the Norwegian translation ACPPS-30. Assessment of the questionnaire's dimensionality revealed a five-factor structure similar to the original Dutch Amsterdam Hyperactive Pelvic Floor Scale (AHPFS) but without the Urinary tract infection factor and seven other items. The translated and modified ACPPS-16 total score and subscales correlated as expected with scales measuring similar conditions. Test-retest reliability demonstrated good stability for scales (intraclass correlation coefficient 0.85-0.93) and single items (weighted kappa values from 0.34 to 0.90).

CONCLUSIONS

A modified Norwegian version ACPPS-30 was presented, in addition to a shorter version with only 16 of the translated items distributed among five factors similar to the original Dutch version (ACPPS-16). Both versions proved to be valid, stable and reliable tools to investigate complex pelvic pain symptoms possibly due to an abnormally high-toned pelvic floor muscle.

How life events are perceived to link to bodily distress: A qualitative study of women with chronic pelvic pain

Chronic pelvic pain (CPP) is highly prevalent among women and the condition is poorly understood. In addition to multiple symptoms from the pelvis, CPP patients frequently suffer bodily distress like musculoskeletal pain and negative emotional, behavioral, and sexual implications. This paper is based on a qualitative study including semi-structured interviews with eight women with CPP. Our project has been conducted within the framework of phenomenology, particularly shaped by the concept of embodiment. We discuss the link between the lived body and CPP and address the value of making the life experiences of the patient relevant to understand this complex condition.

The RISE FOR HEALTH study: Methods for in-person assessment and biospecimen collection

OBJECTIVES

To describe the methods for the in-person assessment of the RISE FOR HEALTH (RISE) study, a population-based multicenter prospective cohort study designed to identify factors that promote bladder health and/or prevent lower urinary tract symptoms in adult women, conducted by the Prevention of Lower Urinary Tract Symptoms Research Consortium (PLUS).

METHODS AND RESULTS

A subset of RISE participants who express interest in the in-person assessment will be screened to ensure eligibility (planned n = 525). Eligible consenting participants are asked to complete 15 physical assessments in addition to height and weight, to assess pelvic floor muscle function, musculoskeletal (MSK) status, and pain, and to provide urogenital microbiome samples. Pelvic floor muscle assessments include presence of prolapse, strength, levator attachment integrity (tear) and myofascial pain. MSK tests evaluate core stability, lumbar spine, pelvic girdle and hip pain and function. Participants are asked to complete the Short Physical Performance Battery to measure balance, lower extremity strength, and functional capacity. All participants are asked to provide a voided urine sample and a vaginal swab for microbiome analyses; a subset of 100 are asked to contribute additional samples for feasibility and validation of a home collection of urinary, vaginal, and fecal biospecimens.

RESULTS

Online and in-person training sessions were used to certify research staff at each clinical center before the start of RISE in-person assessments. Standardized protocols and data collection methods are employed uniformly across sites.

CONCLUSIONS

The RISE in-person assessment is an integral portion of the overall population-based RISE study and represents an innovative approach to assessing factors hypothesized to promote bladder health and/or prevent lower urinary tract symptoms. Data collected from this assessment will be used to prioritize future research questions and prevention strategies and interventions. This description of the assessment methods is intended to provide methodologic transparency and inform other researchers who join efforts to understand and improve bladder health.

Women know about perineal trauma risk but do not know how to prevent it: Knowledge, attitude, and practice

OBJECTIVE

To evaluate the knowledge, attitude, and practice (KAP) of pelvic floor muscle (PFM) preparation for birth among postpartum women, and its related factors.

METHODS

Cross-sectional study conducted in a maternity unit among Brazilian women aged 14 years or older during the first 72 h postpartum, who desired and had vaginal birth. Sociodemographic, clinical, and obstetric data were collected using a standardized form from medical charts. A 15-question questionnaire was used to measure the KAP of PFM preparation for birth. Knowledge was categorized as: poor, average, and good.

RESULTS

In all, 326 women completed the survey (mean age 24.3 ± 6.2 years) and 167 (51.2%) women had poor knowledge. The attitude of searching for information on how to prevent perineal trauma was reported by 14 (4.3%) women. Only 13 (4.0%) participants reported that they had practiced at least one session of PFM preparation during pregnancy (PFM training, perineal massage, etc.) Multivariate analysis showed that lower educational level was associated with poor knowledge (P < 0.05).

CONCLUSION

The KAP of PFM preparation for birth is inadequate among postpartum women. Health education regarding PFM care during pregnancy and postpartum should be addressed among pregnant women, specifically younger women with lower levels of education and income.

Myofascial Frequency Syndrome: A novel syndrome of bothersome lower urinary tract symptoms associated with myofascial pelvic floor dysfunction

Background

Patients presenting with lower urinary tract symptoms (LUTS) are historically classified to several symptom clusters, primarily overactive bladder (OAB) and interstitial cystitis/bladder pain syndrome (IC/BPS). Accurate diagnosis, however, is challenging due to overlapping symptomatic features, and many patients do not readily fit into these categories. To enhance diagnostic accuracy, we previously described an algorithm differentiating OAB from IC/BPS. Herein, we sought to validate the utility of this algorithm for identifying and classifying a real-world population of individuals presenting with OAB and IC/BPS and characterize patient subgroups outside the traditional LUTS diagnostic paradigm.

Methods

An Exploratory cohort of 551 consecutive female subjects with LUTS evaluated in 2017 were administered 5 validated genitourinary symptom questionnaires. Application of the LUTS diagnostic algorithm classified subjects into controls, IC/BPS, and OAB, with identification of a novel group of highly bothered subjects lacking pain or incontinence. Symptomatic features of this group were characterized by statistically significant differences from the OAB, IC/BPS and control groups on questionnaires, comprehensive review of discriminate pelvic exam, and thematic analysis of patient histories. In a Reassessment cohort of 215 subjects with known etiologies of their symptoms (OAB, IC/BPS, asymptomatic microscopic hematuria, or myofascial dysfunction confirmed with electromyography), significant associations with myofascial dysfunction were identified in a multivariable regression model. Pre-referral and specialist diagnoses for subjects with myofascial dysfunction were catalogued.

Findings

Application of a diagnostic algorithm to an unselected group of 551subjects presenting for urologic care identified OAB and IC/BPS in 137 and 96 subjects, respectively. An additional 110 patients (20%) with bothersome urinary symptoms lacked either bladder pain or urgency characteristic of IC/BPS and OAB, respectively. In addition to urinary frequency, this population exhibited a distinctive symptom constellation suggestive of myofascial dysfunction characterized as "persistency": bothersome urinary frequency resulting from bladder discomfort/pelvic pressure conveying a sensation of bladder fullness and a desire to urinate. On examination, 97% of persistency patients demonstrated pelvic floor hypertonicity with either global tenderness or myofascial trigger points, and 92% displayed evidence of impaired muscular relaxation, hallmarks of myofascial dysfunction. We therefore classified this symptom complex "myofascial frequency syndrome". To confirm this symptom pattern was attributable to the pelvic floor, we confirmed the presence of "persistency" in 68 patients established to have pelvic floor myofascial dysfunction through comprehensive evaluation corroborated by symptom improvement with pelvic floor myofascial release. These symptoms distinguish subjects with myofascial dysfunction from subjects with OAB, IC/BPS, and asymptomatic controls, confirming that myofascial frequency syndrome is a distinct LUTS symptom complex.

Interpretation

This study describes a novel, distinct phenotype of LUTS we classified as myofascial frequency syndrome in approximately one-third of individuals with urinary frequency. Common symptomatic features encompass elements in other urinary syndromes, such as bladder discomfort, urinary frequency and urge, pelvic pressure, and a sensation of incomplete emptying, causing significant diagnostic confusion for providers. Inadequate recognition of myofascial frequency syndrome may partially explain suboptimal overall treatment outcomes for women with LUTS. Recognition of the distinct symptom features of MFS (persistency) should prompt referral to pelvic floor physical therapy. To improve our understanding and management of this as-yet understudied condition, future studies will need to develop consensus diagnostic criteria and objective tools to assess pelvic floor muscle fitness, ultimately leading to corresponding diagnostic codes.

Funding

This work was supported by the AUGS/Duke UrogynCREST Program (R25HD094667 (NICHD)) and by NIDDK K08 DK118176 and Department of Defense PRMRP PR200027, and NIA R03 AG067993.

Pelvic floor dysfunctions in women with fibromyalgia: A cross-sectional study

BACKGROUND

Fibromyalgia (FM) is a rheumatic syndrome that causes musculoskeletal disorders and is associated with several problems that affect quality of life. As the musculoskeletal system is affected, it can have an impact on the pelvic floor muscles, leading to pelvic floor dysfunction (PFD).

OBJECTIVE

Investigate the occurrence of PFD, such as urinary incontinence (UI) and anal incontinence (AI), sexual problems, and pelvic organ prolapse (POP), in women with FM compared to a control group composed of women without FM; and investigate the association between FM and PFD.

STUDY DESIGN

This was an online cross-sectional survey. Demographic and anthropometric data, the description of PFD (UI, nocturia, AI, genital-pelvic pain/penetration disorder, and POP), and previous obstetric history were collected through a web-based questionnaire. The groups were compared using the independent t-test for quantitative variables and the chi-square test for categorical variables. The association between FM and PFD was tested using logistic regression analysis.

RESULTS

A total of 175 women answered the questionnaire (97 with FM and 78 healthy controls). The women with FM reported significantly more UI, mixed urinary incontinence, AI, POP, and vaginismus than the healthy controls (p ≤ 0.05). FM was associated with mixed urinary incontinence (OR: 2.6; 95 % CI: 1.1-6.4; p = 0.04), anal incontinence (OR: 2.9; 95 % CI: 1.3-6.1; p = 0.01), and flatus incontinence (OR: 2.6; 95 % CI: 1.2-5.4; p = 0.01).

CONCLUSION

The prevalence of PFD was significantly higher in women with FM compared to healthy women. Indeed, the women with FM were 2.6-fold to 2.9-fold more likely to report mixed urinary incontinence, anal and flatus incontinence than those in the control group. The present findings show possible impairment of the pelvic floor musculature in women with FM.

Childhood Sexual Abuse and Pelvic Floor Dysfunction in Midlife Women in the Study of Women's Health Across the Nation

Objectives: Research has shown a link between childhood sexual abuse (CSA) and lower urinary tract and sexual disorders in clinical settings. We examined whether CSA was associated with two specific aspects of high tone, elevated resting tension pelvic floor dysfunction (PFD) in community-dwelling women. Materials and Methods: Data were from 2068 participants (25.5% Black, 9.6% Chinese, 10.8% Japanese, 5.0% Hispanic, and 49.1% Non-Hispanic White) in the Study of Women's Health Across the Nation (SWAN), a multirace/multiethnic longitudinal observational study of women's midlife health. At baseline, enrolled women were 42-52 years old and premenopausal or early perimenopausal. Annual or biennial assessments conducted over 20 years (1996 through 2017) included single-item queries about urgency urinary incontinence and pain with sexual activity used to assess PFD outcomes. The 12th follow-up visit conducted in 2009-2011 assessed the primary exposure, history of CSA, using a single-item response. Multivariate logistic regression models tested study objectives. Results: The prevalence of CSA was 15%, self-reported in 313/2068 women. CSA and PFD, both pain with sexual activity (odds ratio [OR] = 1.56 confidence interval [95% CI = 1.12-2.18]) and urgency urinary incontinence (OR = 1.87 [95% CI = 1.29-2.71]), were significantly associated in unadjusted models. The final adjusted model that included sociodemographic variables and physical and behavioral risk factors was significant for pain with sexual activity (OR = 1.48 [95% CI = 1.08-2.02]), but not for urgency urinary incontinence (OR = 1.38 [95% CI = 0.96-1.98]). Conclusions: In midlife women, pain with sex, but not urgency urinary incontinence, was associated with a history of CSA. A multidisciplinary diagnostic and therapeutic approach to PFD is key, inclusive of CSA screening.

Pilates Method and/or Photobiomodulation Therapy Combined to Static Magnetic Field in Women with Stress Urinary Incontinence: A Randomized, Double-Blind, Placebo-Controlled Clinical Trial

This clinical trial aims to provide evidence about the effectiveness of the Pilates method on stress urinary incontinence (SUI), as well as to elucidate the effects of photobiomodulation therapy associated with static magnetic field (PBMT/sMF) alone or associated with the Pilates Method on Pelvic floor muscle (PFM) in women affected by SUI. For that, a three-arm, parallel randomized, double-blinded, placebo-controlled trial was conducted (NCT05096936). We recruited thirty-three women diagnosed with SUI, randomly allocated to three groups: placebo PBMT/sMF plus method Pilates, PBMT/sMF active plus method Pilates and only PBMT/sMF active. The evaluation consisted of anamnesis and physical examination, muscle strength, completion of the ICIQ-SF questionnaire, and urinary loss. The evaluation of muscle strength and filling the ICIQ-SF were performed on the first and last days, while the Pad test was applied in baseline, one month, two months, and three months of intervention. We observed an increase in strength (p < 0.01), tone (p < 0.01), and quality of life (p < 0.01), in addition to a decrease in urinary lost (p < 0.01) for all groups comparing the pre and post-intervention. The PBMT/sMF alone, the Pilates, and the combination of the two therapies proved to be effective in improving the signs and symptoms of women with SUI.

Effects of the Oxytocin Hormone on Pelvic Floor Muscles in Pregnant Rats

Background and Objectives: Oxytocin induction is a known risk factor for pelvic floor disorders (PFDs). The aim of the study was to investigate the effects of oxytocin induction on pelvic floor muscles in pregnant rats. Methods: Thirty-two female Wistar rats were included and divided into four groups (n = 8). The groups were as follows: virgin group (group I)-from which muscles were dissected at the beginning of the experiment; spontaneous vaginal delivery (group II) which has delivery spontaneously; saline control group (group III) and oxytocin group (group IV). In groups III and IV, pregnancy was induced on d 21 of pregnancy, with 2.5 mU saline solution or iv oxytocin, respectively, delivered by the intravenous (iv) route in pulses at 10-min intervals for 8 h. Then, the rats were euthanized, the m. coccygeus, m. iliocaudalis and m. pubocaudalis muscles were excised and tissue samples were taken. After histological processing, the vertical and horizontal dimensions of the muscles were analyzed under a light microscope. Results: In group IV; the measurement of the horizontal dimension of the m. pubocaudalis muscles was 50.1 ± 5.4 µm and it was significantly higher than other groups (p < 0.001). In group III; the mean value of the horizontal dimension of m. coccygeus muscle was found to be 49.5 ± 10.9 µm and it was significantly higher than other groups (p < 0.009). Between-group comparisons revealed no difference in mean m. iliocaudalis muscle dimension (p > 0.05). Conclusions: As a result of our study it can say that whether oxytocin induced or not, vaginal birth is a process that affects the pelvic muscles.

Comprehensive pelvic muscle assessment: Developing and testing a dual e-Learning and simulation-based training program

OBJECTIVE

The Prevention of Lower Urinary Tract Symptoms (PLUS) research consortium launched the RISE FOR HEALTH (RISE) national study of women's bladder health which includes annual surveys and an in-person visit. For the in-person exam, a standardized, replicable approach to conducting a pelvic muscle (PM) assessment was necessary. The process used to develop the training, the products, and group testing results from the education and training are described.

METHODS

A comprehensive pelvic muscle assessment (CPMA) program was informed by literature view and expert opinion. Training materials were prepared for use on an electronicLearning (e-Learning) platform. An in-person hands-on simulation and certification session was then designed. It included a performance checklist assessment for use by Clinical Trainers, who in collaboration with a gynecology teaching assistant, provided an audit and feedback process to determine Trainee competency.

RESULTS

Five discrete components for CPMA training were developed as e-Learning modules. These were: (1) overview of all the clinical measures and PM anatomy and examination assessments, (2) visual assessment for pronounced pelvic organ prolapse, (3) palpatory assessment of the pubovisceral muscle to estimate muscle integrity, (4) digital vaginal assessment to estimate strength, duration, symmetry during PM contraction, and (5) pressure palpation of both myofascial structures and PMs to assess for self-report of pain. Seventeen Trainees completed the full CPMA training, all successfully meeting the a priori certification required pass rate of 85% on checklist assessment.

CONCLUSIONS

The RISE CPMA training program was successfully conducted to assure standardization of the PM assessment across the PLUS multicenter research sites. This approach can be used by researchers and healthcare professionals who desire a standardized approach to assess competency when performing this CPMA in the clinical or research setting.

Myofascial Pelvic Pain: Best Orientation and Clinical Practice. Position of the European Association of Urology Guidelines Panel on Chronic Pelvic Pain

CONTEXT

Despite the high prevalence of a myofascial pain component in chronic pelvic pain (CPP) syndromes, awareness and management of this component are lacking among health care providers.

OBJECTIVE

To summarize the current state of the art for the management of myofascial pain in chronic primary pelvic pain syndromes (CPPPS) according to scientific research and input from experts from the European Association of Urology (EAU) guidelines panel on CPP.

EVIDENCE ACQUISITION

A narrative review was undertaken using three sources: (1) information in the EAU guidelines on CPP; (2) information retrieved from the literature on research published in the past 3 yr on myofascial pelvic pain; and (3) expert opinion from panel members.

EVIDENCE SYNTHESIS

Studies confirm a high prevalence of a myofascial pain component in CPPPS. Examination of the pelvic floor muscles should follow published recommendations to standardize findings and disseminate the procedure. Treatment of pelvic floor muscle dysfunction and pain in the context of CPP was found to contribute to CPP control and is feasible via different physiotherapy techniques. A multidisciplinary approach is the most effective.

CONCLUSIONS

Despite its high prevalence, the myofascial component of CPP has been underevaluated and undertreated to date. Myofascial pain must be assessed in all patients with CPPPS. Treatment of the myofascial pain component is relevant for global treatment success. Further studies are imperative to reinforce and better define the role of each physiotherapy technique in CPPPS.

PATIENT SUMMARY

Pain and inflammation of the body's muscle and soft tissues (myofascial pain) frequently occurs in pelvic pain syndromes. Its presence must be evaluated to optimize management for each patient. If diagnosed, myofascial pain should be treated.

Rumba Dance Combined with Breathing Training as an Exercise Intervention in the Management of Stress Urinary Incontinence in Postmenopausal Women: A Randomized Controlled Trial

Purpose: Stress urinary incontinence (SUI) refers to involuntary leakage from the urethra, synchronous with exertion/effort, sneezing or coughing, which has a negative effect on quality of life. Studies have shown that mild-to-moderate physical activities reduce the risk of SUI by multiple mechanisms. The objective of this study was to determine whether the Rumba dance combined with breathing training (RDBT) can reduce the severity of incontinence and improve the quality of life of patients with SUI. Methods: A randomized clinical trial was conducted with women who were sedentary, were postmenopausal, reported mild-to-moderate SUI on a 1-h pad test, were not already engaged in Rumba dance and did not receive estrogen replacement therapy. The patients were randomly assigned to the RDBT group (n = 13) or the control group (n = 11). The intervention included 90 min of RDBT three times per week for 16 weeks, and the vaginal resting pressure (VRP), pelvic floor muscle (PFM) strength and endurance, 1-h pad test, International Consultation on Incontinence Questionnaire—Urinary Incontinence Short Form (ICIQ—UI SF), and the Incontinence Quality of Life Questionnaire (I—QOL) were measured or completed at baseline and 16 weeks. None of the participants reported adverse events. Results: The mean (±SD) age of the participants was 55.75 ± 5.58 years. After 16 weeks, in the RDBT group, the urine leakage on the 1-h pad test was significantly decreased −2.91 ± 0.49 from the baseline (p = 0.000). The VRP increased from 76.00 ± 16.23 cmH2O to 95.09 ± 18.90 cmH2O (p = 0.000), the PFM endurance of class I (−3.15 ± 1.99% vs. −0.46 ± 0.97%, p = 0.000) and class II (−0.69 ± 0.95% vs. −0.23 ± 0.44%, p = 0.065) increased, and the grades of PFM strength of class I and class II were significantly enhanced (p < 0.01). Finally, the severity of self-reported incontinence (ICIQ—UI SF) significantly decreased from 6.12 ± 2.15 to 3.81 ± 1.68 (p = 0.000), and quality of life (I—QOL) improved from 75.73 ± 11.93 to 83.48 ± 7.88 (p = 0.005). Conclusion: A 16-week RDBT program can increase PFM strength and endurance to reduce the severity of incontinence symptoms and improve the quality of life in patients with SUI, demonstrating the feasibility of recruiting and retaining postmenopausal women with SUI into a RDBT therapeutic program.

Conservative non-pharmacological interventions in women with pelvic floor dysfunction: a systematic review of qualitative studies

BACKGROUND

Women's adherence is essential to physiotherapeutic treatment of pelvic floor dysfunction, but its related factors are not usually considered in the development of treatment approaches. This study aims to understand how women with pelvic floor dysfunction experience pelvic floor conservative non-pharmacological treatment options.

METHODS

A systematic review of qualitative studies. The electronic search was performed in MEDLINE/PubMed, CINAHL, Lilacs, SCOPUS, and Web of Science databases. Primary articles on qualitative methods focused on the experience of women regarding pelvic floor conservative non-pharmacological interventions, i.e., pelvic floor muscle training (PFMT), either associated or not with biofeedback, perineal massage, vaginal dilators, and others. A meta-aggregation was performed.

RESULTS

It was included 22 manuscripts in this review. It was found seven studies about the use of vaginal devices, two about manual intervention and 14 studies on women's experience with PFMT. The findings were synthesized as follows: I) women's experience of manual interventions; II) women's experience using vaginal devices changes according to health professional attitudes; III) women's experiences using vaginal devices varied depending on their pelvic floor dysfunction; IV) reported side effects due to the use of vaginal devices; V) external factors influencing PFMT performance; VI) women's perception of their own personal factors influencing PFMT performance; VII) PFMT characteristics influencing women's adherence; VIII) strategies used by women to include PFMT in their routine.

CONCLUSION

Women's experience with pelvic floor conservative non-pharmacological treatment options is a complex phenomenon that involves many more variables than simply personal aspects. This is a systematic review of qualitative studies registered in the PROSPERO (CRD42018080244).

Sexually Induced Orgasm to Improve Postpartum Pelvic Floor Muscle Strength and Sexual Function in Primiparous Women After Vaginal Delivery: A Prospective Randomized Two-Arm Study

BACKGROUND

Postpartum pelvic floor dysfunction is known to affect the quality of life of women and the methods to treat it are more complex with majority requiring training under supervision.

AIM

To compare the efficacy of sexually induced orgasm along with Kegels exercises versus Kegels exercises alone as a treatment method to enhance postpartum pelvic floor muscle strength and sexual function in primiparous women undergoing uncomplicated vaginal deliveries.

METHODS

The prospective randomized two-arm study was conducted on sexually active primiparous women who had undergone uncomplicated vaginal deliveries. Those with risk factors for female sexual dysfunction and pelvic floor muscle dysfunction were excluded. Participants in Group 1 were advised daily Kegel's exercises, whereas, those in Group 2 were advised to initiate self-initiated/partnered sexual activity-induced orgasms along with daily Kegel's exercises. Their pelvic floor muscle strength on voluntary contraction, ability to relax pelvic floor voluntarily, and sexual function (using FSFI-6) were assessed monthly for 6 months and the analysis was done using G* Power software (© 2021 Heinrich-Heine-Universität Düsseldorf, Germany).

MAIN OUTCOME MEASURE

Postpartum pelvic floor strength and sexual function in 2 groups of women under study.

RESULTS

The study period was from January 2020 to December 2020. The Group 1 had 26 participants (mean age 29.69 ± 2.2 years) and Group 2 had 29 participants (mean age 30.07 ± 2.57 years). The sexual function as well as ability to relax pelvic floor were significantly better in Group 2 compared to Group 1 at each monthly intervals whereas strength of pelvic floor muscles during voluntary contraction was significantly higher in Group 2 compared to Group 1 at the end of 6 months and it was statistically significant at a P value of .05.

CLINICAL IMPLICATIONS

Novel method of using naturally occurring sexually induced orgasms for postpartum pelvic floor rehabilitation can revolutionize postpartum pelvic floor training in women, as it can be practiced at home with ease, along with easily performable Kegel's exercises.

STRENGTHS AND LIMITATIONS

Use of prospective randomization and minimization of confounding factors is the strength of the study. The small sample size is the limitation of the study.

CONCLUSIONS

Postpartum pelvic floor muscle strength and sexual function in primiparous women who have undergone uncomplicated vaginal deliveries can be significantly improved with the addition of sexually induced orgasm as a therapeutic tool along with physical exercises such as Kegels exercises in these women.

Exploring concomitant pelvic floor symptoms in community-dwelling females and males

OBJECTIVES

Researchers and clinicians tend to focus on one pelvic floor symptom (PFS) at the time. However, the pelvic floor acts as one functional unit, increasing the likelihood of concurrent PFS in patients with pelvic floor dysfunction. There is also a paucity of literature on the prevalence of concomitant PFS, especially in males. Therefore, we explored the occurrence of concomitant PFS in community-dwelling males and females.

MATERIALS AND METHODS

This prospective observational population-based cohort study included males and females aged ≥16 years from a single Dutch municipality. Participants completed validated questionnaires on lower urinary tract symptoms (LUTS), defecation problems, sexual dysfunction, pelvic pain, and pelvic organ prolapse. Medical general practitioner records were examined. Furthermore, a randomly selected group of non-responders aged &lt;80 years received a short questionnaire, to study response bias.

RESULTS

We invited 11 724 people, among which 839 females and 566 males completed the questionnaires. Of the female participants, 286 (34.1%) reported no PFS, and 251 (29.9%) reported two or more PFS. The most prevalent PFS clusters in females were sexual dysfunction and pelvic pain, sexual dysfunction and defecation problems, LUTS and defecation problems, and LUTS, defecation problems, and pelvic pain. Of the male participants, 212 (37.5%) reported no PFS, and 191 (33.7%) reported two or more PFS. The most prevalent clusters in males were sexual dysfunction and LUTS, defecation problems and LUTS, and sexual dysfunction, LUTS, and defecation problems.

CONCLUSION

A considerable overlap existed between PFS, with differences in PFS clusters between females and males. Of note, females reported pelvic pain more than males. We conclude that healthcare providers should address all PFS in males and females.

Effect of exercise on female pelvic floor morphology and muscle function: a systematic review

INTRODUCTION AND HYPOTHESIS

The objective was to synthesize the scientific evidence on the relationship of exercise with morphology and muscle function parameters of the female pelvic floor. The design was a systematic review.

METHODS

Searches were performed in MEDLINE, PubMed, CINAHL, Web of Science, SCOPUS, SportDiscuss, and Google Scholar up to April 2021. Observational and experimental studies evaluating the morphology and/or function of the pelvic floor muscles (PFMs) in women were eligible. Studies reporting exercise or sports disciplines as exposure/intervention were included.

RESULTS

Twenty-five studies were included. Compared with the control group, women performing vigorous and high-impact exercises exhibited lower maximum voluntary contraction of the PFM and those performing moderate exercise had better maximum voluntary contraction. Exercise practitioners had a larger hiatal area at rest, during contraction, and during Valsalva, and greater bladder neck descent than the control group.

CONCLUSIONS

The results of this review demonstrate an inverse relationship of PFM maximum voluntary contraction with exercise intensity. Qualitative synthesis showed that the studies found favorable outcomes for the control group in terms of hiatal area during contraction and Valsalva and bladder neck displacement.

Two devices to facilitate the perception of pelvic floor muscle contraction in the sitting position in women with urinary incontinence: comparative analysis

ABSTRACT The use of support devices may facilitate the perception of pelvic floor muscle (PFM) contraction, which is difficult to be performed. Therefore, this study aimed to compare the perception of PFM contraction in the sitting position during the use of two different support devices on women with PFM dysfunction. This is a cross-sectional study performed with 37 women with stress or mixed urinary incontinence (UI). All women performed three free PFM contractions sitting on a chair, followed by three contractions using each support device (sand pads and a cylindrical foam, which provide sciatic and perineal support, respectively). Women scored the perception of PFM contraction from 1 to 5, as well as the perception of facilitation of contraction (higher grades show better results) and discomfort (higher grades show more discomfort) when compared with free contraction. The cylindrical foam presented similar results to sand pads for the perception of PFM contraction (2.84±1.61 vs. 3.19±1.43; p=0.34) and facilitation of contraction (3.38±1.34 vs. 3.19±1.54; p=0.61), as well as for their discomfort (1.83±1.23 vs. 1.5±1.16; p=0.20). Of all women, 57% preferred sand pads. Thus, both sand pads (sciatic support) and the cylindrical foam (perineal support) improved the perception of PFM contraction and facilitation of contraction in the sitting position of women with PFM dysfunction when compared with sitting with no device. The two devices presented no difference between them.

Pelvic floor dysfunctions in women with systemic lupus erythematosus: A cross-sectional study

INTRODUCTION AND HYPOTHESIS

As a result of the impairment of the musculoskeletal system, the pelvic floor muscles are likely compromised in women with systemic lupus erythematosus (SLE). We hypothesized that women with SLE would report more symptoms of pelvic floor dysfunction (PFD) and there will be an association between SLE and PFD.

METHODS

An online cross-sectional survey was conducted. Data were collected on demographic and anthropometric characteristics, PFD (urinary incontinence, nocturia, anal incontinence, genital-pelvic pain/penetration disorder and pelvic organ prolapse) and obstetric history using a web-based questionnaire. The groups were compared using the Mann-Whitney test for quantitative variables and the chi-squared test for categorical variables. The association between SLE and PFD was tested using logistic regression analysis.

RESULTS

A total of 196 women answered the questionnaire (102 with SLE and 94 healthy controls). Women with SLE reported significantly more urinary incontinence, nocturia, anal incontinence, pelvic organ prolapse and genital-pelvic pain/penetration disorder than the healthy controls (p ≤ 0.05). Women with SLE were 2.8- to 3.0-fold more likely to report genital-pelvic pain/penetration disorder than healthy women.

CONCLUSIONS

The prevalence of PFD was significantly higher in women with SLE compared to healthy women. Thus, PFD seems to be an important problem in women with this disease. An in-depth investigation of these disorders could contribute to the understanding of how SLE impacts pelvic floor function.

Verbal and Visual Feedback Immediately Affect the Electromyographic Activity of Female Pelvic Floor Muscles

OBJECTIVE

The purpose of this study was to assess the immediate effect of verbal and visual feedback on pelvic floor muscles (PFM) in nulliparous women without pelvic floor dysfunction.

METHODS

In this observational, single-assessor, cross-sectional study, 45 female university students were evaluated using bidigital vaginal palpation and vaginal surface electromyography (EMG). EMG assessments were performed at 2 time points (T1 and T2). According to the protocol, participants performed 5 maximal voluntary contractions (MVC) with 10-second intervals, 5 sustained voluntary contractions (SVC) for 10 seconds, and a 60-second voluntary contraction until fatigue (CUF) before (T1) and after (T2) receiving verbal instructions and visual feedback on PFM contractions. At T2, women received visual feedback on their PFM contraction. Root mean square (RMS) for each repetition (MVC and VCF) was recorded, and mean value was calculated. Compensatory mechanisms during contraction were recorded visually. The difference in mean RMS (mV) for MVC, SVC, and CUF; curve integral for MVC, SVC, and CUF; median frequency (Hz) for CUF between T1 and T2 were analyzed with repeated measures multivariate analysis of variance.

RESULTS

Before the instructions, most participants (95.6%) performed PFM MVC using at least 1 compensatory mechanism. PFM EMG outcomes changed at T2: RMS and curve integral were reduced in T2 (P < .05) for MVC, SVC, and CUF. The median frequency increased from T1 to T2 in the CUF group (P = .01).

CONCLUSION

Verbal and visual feedback had an immediate impact on the EMG activity of PFM in nulliparous continent women.

The effect of pelvic floor muscle exercises applied during pregnancy on genito-pelvic pain level in postpartum period

INTRODUCTION AND HYPOTHESIS

The goal of the study is to determine the effect of pelvic floor muscle exercises on genito-pelvic pain levels during the postpartum period.

METHODS

The data of the study, which was carried out in a randomized controlled experimental design, were collected in the antenatal policlinic of a public hospital from June-December 2019. There were 60 pregnant women in the experimental and control groups. Pelvic floor muscle exercises were applied to the pregnant women in the experimental group from the 30th week of gestation to the 6th week postpartum. The control group was not given pelvic floor muscle exercise training, and only data collection forms were filled in. During the study, the Descriptive Form, Verbal Category Scale, Pelvic Floor Distress Inventory-20, and Labour and Postpartum Information Form were given to the pregnant women in both groups.

RESULTS

After pregnant women in the experimental group performed pelvic floor muscle exercises, pain levels were significantly lower than in the control group (p < 0.01). Pelvic Floor Distress Inventory-20 total score and sub-dimension scores of the experimental group were statistically significantly lower than in the control group (p < 0.01). In addition, a statistically significant difference was found (p < 0.01) in the postpartum 72 h findings of the experimental group in which pelvic floor muscle exercises were applied compared to the control group.

CONCLUSIONS

According to the result of the study, as the gestational weeks progress, the genito-pelvic pain increases. Pelvic floor muscle exercises applied during pregnancy prevent the development and progression of pelvic floor disorders in both the antenatal and postnatal periods.

TRIAL REGISTRATION

NCT05343520.

Breathing, (S)Training and the Pelvic Floor—A Basic Concept

Background: The current scientific literature is inconsistent regarding the potential beneficial or deleterious effects of high-intensity physical activities on the pelvic floor (PF) in women. So far, it has not been established with certainty whether disparate breathing mechanisms may exert short- or long-term influence on the PF function in this context, although based on the established physiological interrelationship of breathing with PF activation, this seems plausible. Objective: To propose a basic concept of the influence of different breathing patterns on the PF during strenuous physical efforts. Methodical approaches: Review of the recent literature, basic knowledge of classical western medicine regarding the principles of muscle physiology and the biomechanics of breathing, additional schematic illustrations, and magnetic resonance imaging (MRI) data corroborate the proposed concept and exemplify the consequences of strenuous efforts on the PF in relation to respective breathing phases. Conclusion: The pelvic floor muscles (PFMs) physiologically act as expiratory muscles in synergy with the anterolateral abdominal muscles, contracting during expiration and relaxing during inspiration. Obviously, a strenuous physical effort requires an expiratory motor synergy with the PFM and abdominal muscles in a co-contracted status to train the PFM and protect the PF against high intra-abdominal pressure (IAP). Holding breath in an inspiratory pattern during exertion stresses the PF because the high IAP impinges on the relaxed, hence insufficiently protected, PFMs. It seems conceivable that such disadvantageous breathing, if performed regularly and repeatedly, may ultimately cause PF dysfunction. At any rate, future research needs to take into account the respective breathing cycles during measurements and interventions addressing PFM function.

Are Perineal Massage and Instrument-Assisted Perineal Stretching With Short Protocol Effective for Increasing Pelvic Floor Muscle Extensibility? A Randomized Controlled Trial

OBJECTIVE

The purpose of this study was to compare (1) the effects of the instrument-assisted perineal stretching technique with different application protocols in combination with perineal massage and (2) the effects of the isolated techniques on the extensibility and strength of the pelvic floor muscles (PFMs).

METHODS

A randomized controlled clinical trial with parallel randomization, assessor blinding, and concealed allocation was conducted in the Campus Physical Education at the Federal University of Uberlândia in Brazil. Ninety-six pregnant women (18-40 years of age) were allocated into 4 groups: perineal massage (PnM) group (PnM protocol for 10 minutes); instrument-assisted perineal stretching with a long static protocol for 15 minutes [IStrLS group]); PnM + IStrLS group (both techniques applied in the 2 previous groups); and PnM + IStrSR group (the same techniques as used in the PnM + IStrLS group but with a short repeated protocol; 4 sets lasting 30 seconds each). Eight interventions were performed in all 4 groups twice weekly (beginning at the 34th gestational week). The primary outcome was PFM extensibility, assessed using vaginal dilator circumference, and the secondary outcome was PFM strength, assessed using vaginal manometry.

RESULTS

For the PFM extensibility variable, a significant main effect of time (F2,88 = 87.951) and group (F3,88 = 7.193) was found. Tukey post hoc test results showed that the PnM + IStrSR group presented greater extensibility than the PnM and IStrLS groups. The PnM group showed increased PFM strength after 8 sessions compared with the other groups.

CONCLUSIONS

Women who were pregnant and received the combination of perineal massage and instrument-assisted perineal stretching with short repeated application had a greater increase in PFM extensibility than perineal massage and instrument-assisted perineal stretching alone.

IMPACT

The combination of perineal massage and instrument-assisted perineal stretching techniques with a short, repeated protocol led to better PFM extensibility results than the application of the techniques alone in women who were pregnant.

LAY SUMMARY

Pregnant women can benefit from intervention using the combination of perineal massage and instrument-assisted perineal stretching techniques with a short, repeated protocol.

Pelvic floor muscle exercise and training for coping with urinary incontinence

The pelvic floor consists of levator ani muscles including puborectalis, pubococcygeus and iliococcygeus muscles, and coccygeus muscles. Pelvic floor muscle exercise (PFME) is defined as exercise to improve pelvic floor muscle strength, power, endurance, relaxation, or a combination of these parameters. PFME strengthens the pelvic floor muscles to provide urethral support to prevent urine leakage and suppress urgency. This exercise has been recommended for urinary incontinence since first described by Kegel. When treating urinary incontinence, particularly stress urinary incontinence, PFME has been recommended as first-line treatment. This article provides clinical application of PFME as a behavioral therapy for urinary incontinence. Clinicians and physical therapist should understand pelvic floor muscle anatomy, evaluation, regimen, and instruct patients how to train the muscles properly.

Understanding the Cheerleader as an Orthopaedic Patient: An Evidence-Based Review of the Literature

Cheerleading is a highly popular youth sport in the United States and has been increasingly recognized in recent years for its athleticism and competitive nature. The sport has changed dramatically since its inception. When the sport of cheerleading was first developed, its primary purpose was to entertain crowds and support other athletes. Today, cheerleaders are competitive athletes themselves. Cheerleaders, most of whom are in the pediatric age group, and their parents commonly approach orthopaedic surgeons and sports medicine physicians with questions regarding the risks associated with participation in the sport. Appropriate clinical guidance is especially important for athletes returning to the sport after an injury. However, unlike other popular sports (eg, football, basketball, and volleyball), the intricacies of cheerleading are not well-known to those outside the sport, including many health care providers. Previous studies have reported on the epidemiological patterns of injuries associated with cheerleading and how such aesthetic sports affect the body, finding that fractures and concussions are prevalent and that catastrophic injuries are more common than in most other sports. Here, we provide an evidence-based discussion of 10 pertinent topics regarding cheerleading and its risks to the musculoskeletal system. The purpose of this review is to provide a comprehensive resource for orthopaedic surgeons and sports medicine physicians who care for these athletes.

Electrostimulation and pelvic floor muscle training: immediate effect after one single session

Abstract Introduction: Pelvic floor muscle training (PFMT) and neuromuscular electrical stimulation (NMES) are physiotherapeutic conservative treatments to prevent and to treat pelvic floor dysfunctions. Objective: To investigate the immediate effect of one session of PFMT versus NMES associated to pelvic floor muscle (PFM) contraction on the PFM function in nulliparous women. Methods: This is a cross-sectional experimental study. Twenty women were randomized into the “PFMT Group” and “NMES Group”. PFM function evaluation was performed by vaginal palpation and manometry before and after a single session. PFMT was composed by one series of eight sustained contractions of 6 seconds and one series of four fast contractions, in four different positions. NMES parameters were: biphasic pulsed current; frequency: 50 Hz; pulse duration: 0.7 ms; cycle on:off 4:8s; rise/decay: 2/2s, time: 20 minutes; and intensity: participant' sensibility. Data was analyzed by the ANOVA two-way for repeated measures to verify the difference between groups, within group and the interactions for PFM function. A 5% probability was considered in all tests. Results: There were no significant differences between groups. At intra-group analysis, there was a significant decrease in the maximal voluntary contraction (p = 0.01), by manometry, between pre- and post-session for both groups. Conclusion: The immediate effects of a single session of PFMT and NMES associated with voluntary PFM contraction are similar on PFM function, that is, no difference was found between groups.