Intravaginal pressure generated during voluntary pelvic floor muscle contractions and during coughing: the effect of age and continence status

Do pelvic floor muscle function parameters differ in women according to continence status? A systematic review

BACKGROUND

Current literature highlights the difficulty in identifying which pelvic floor muscle (PFM) functions are correlated with urinary incontinence (UI).

AIM

In this study, we compared parameters of PFM function (strength, endurance, tone, control, reaction, and/or coordination) according to continence status in women (presence or absence, type and/or severity of urinary incontinence).

EVIDENCE ACQUISITION

A systematic review was conducted following the 2020 PRISMA guidelines. Three databases (Pubmed, Web of Science, and LiSSa) were searched from inception to December 31, 2021. Assessment of risk of bias was performed using the Joanna Briggs Institute critical appraisal checklist.

EVIDENCE SYNTHESIS

The initial research yielded 4733 studies. Forty-two studies met the inclusion criteria, including 4015 participants. No statistical association was found between PFM function and the presence or absence of UI, the different type of UI or the different levels of severity of UI. The heterogeneity in methodologies and analyzes of the results only with the P-value are important limitations of this review.

CONCLUSION

It appears that muscle function is not always associated with presence or absence of UI. No association is found between PFM function and type or severity of UI. These results reinforce the need to carry out a bio-psycho-social evaluation of UI that does not only focus on PFM functions. As such, the results reported herein can be considered a resource for more specific research.

Pelvic floor muscle function in the standing position in women with pelvic floor dysfunction

INTRODUCTION AND HYPOTHESIS

Clinical assessment of the pelvic floor muscles (PFMs) in a standing position may provide a more valid representation of PFM function experienced by patients in daily life than assessment in the lying position. The primary aim of this study was to examine PFM function in a standing versus a lying position in parous women with any type of urinary incontinence and/or pelvic organ prolapse.

METHODS

In this exploratory cross-sectional study, participant symptom status was determined using the Australian Pelvic Floor Questionnaire. Pelvic floor muscle function was assessed in standing and lying positions with a randomised order of testing. The primary outcome measure was vaginal squeeze pressure (VSP) using intra-vaginal manometry. Secondary outcomes included vaginal resting pressure, total PFM work and digital muscle testing. The difference between PFM function in a standing position compared with a lying position was analysed using paired t test or Wilcoxon's signed rank test.

RESULTS

Vaginal squeeze pressure assessed with manometry was higher in a standing than in a lying position (p = 0.001): standing (mean [SD]) 24.90 [12.67], lying 21.15 [14.65]. In contrast, PFM strength on digital muscle testing was lower in a standing position than in a lying position.

CONCLUSIONS

This study has demonstrated that PFM function in a standing position is different from that in a lying position in women with pelvic floor dysfunction. Whether the higher VSP observed in a standing position reflects a true difference in strength between positions, or a higher pressure reading due to incorrect PFM contraction technique in a standing position is uncertain. Further research with larger cohorts and a measurement tool that can accurately distinguish a rise in intra-vaginal pressure from PFM contraction rather than increasing intra-abdominal pressure is required to confirm this difference, and the clinical significance of any difference.

An assessment of techniques and practices used to elevate intra-abdominal pressure when assessing pelvic floor dysfunction

AIMS

To determine terminology and methods for raising intra-abdominal pressure (IAP) currently used by clinicians to assess pelvic floor dysfunction (PFD) and to measure the effect of these maneuvers on IAP.

METHODS

Three-hundred questionnaires were distributed at two scientific meetings in the United Kingdom to determine methods clinicians used to raise IAP and their perceptions of these methods. Twenty healthy volunteers were also recruited to measure the effect of two methods of raising IAP: Valsalva maneuver (VM) and bear down maneuver (BDM). IAP pressure was measured with rectal catheters connected to pressure sensors. The IAP was measured during each maneuver in both standing and supine positions.

RESULTS

Maneuvers used in practice were cough (79%), BDM (60%), and VM (38%). 44% of clinicians felt patients found it difficult to raise their IAP. There was uncertainty among clinicians as to which method was the most effective in raising IAP and whether the different methods produced the same rise in IAP. On testing IAP in 20 healthy volunteers, median (interquartile range) IAP generated during BDM; 101 (59.1) cmH₂ O was significantly higher than that generated during VM; 80.3 (43.6) cmH₂ O (p < .0001).

CONCLUSION

Clinicians varied widely in the maneuvers they used to raise patients' IAP to test for PFD and there was uncertainty about the maneuvers' effect on IAP. In healthy volunteers, BDM produced significantly higher IAP than VM. We recommend standardization of terminology and techniques used to raise IAP when assessing PFD, to ensure consistency of diagnosis and assessment of treatment outcomes.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

IMPACT

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

Effect of segmental stabilizing exercises augmented by pelvic floor muscles training on women with postpartum pelvic girdle pain: A randomized controlled trial

BACKGROUND

Pelvic girdle pain (PGP) is a significant problem that affects daily living activities in postpartum women.

OBJECTIVE

This study aimed to investigate the effect of stabilizing exercises with or without pelvic floor muscles (PFM) training on pain, functional disability, trunk range of motion (ROM) and PFM strength in women with PGP.

METHODS

Forty postpartum women participated in the study. Their age ranged from 25-35 years and their body mass index (BMI) was 25-29.9 kg/m2. They were randomly assigned into two groups equal in number. Group (A) received local stabilizing exercises, while group (B) received stabilizing exercises and PFM training. Pain, functional disability, trunk ROM and PFM strength have been evaluated using visual analogue scale (VAS), Oswestry Disability Index (ODI), Schober test and Kegel periniometer respectively.

RESULTS

Both groups (A and B) revealed a significant decrease (p= 0.001) in pain and functional disability and a significant increase (p= 0.001) in trunk ROM and PFM strength. However, group (B) showed a significant decrease (p= 0.001) in pain, and functional disability and a significant increase in PFM strength when compared with group (A).

CONCLUSIONS

PFM training should be an essential part in rehabilitation programs of PGP postpartum.

Task-specific differences in respiration-related activation of deep and superficial pelvic floor muscles

The female pelvic floor muscles (PFM) are arranged in distinct superficial and deep layers that function to support the pelvic/abdominal organs and maintain continence, but with some potential differences in function. Although general recordings of PFM activity show amplitude modulation in conjunction with fluctuation in intra-abdominal pressure such as that associated with respiration, it is unclear whether the activities of the two PFM layers modulate in a similar manner. This study aimed to investigate the activation of the deep and superficial PFM during a range of respiratory tasks in different postures. Twelve women without pelvic floor dysfunction participated. A custom-built surface electromyography (EMG) electrode was used to record the activation of the superficial and deep PFM during quiet breathing, breathing with increased dead space, coughing, and maximal and submaximal inspiratory and expiratory efforts. As breathing demand increased, the deep PFM layer EMG had greater coherence with respiratory airflow at the frequency of respiration than the superficial PFM (P = 0.038). During cough, the superficial PFM activated earlier than the deep PFM in the sitting position (P = 0.043). In contrast, during maximal and submaximal inspiratory and expiratory efforts, the superficial PFM EMG was greater than that for the deep PFM (P = 0.011). These data show that both layers of PFM are activated during both inspiration and expiration, but with a bias to greater activation in expiratory tasks/phases. Activation of the deep and superficial PFM layers differed in most of the respiratory tasks, but there was no consistent bias to one muscle layer. NEW & NOTEWORTHY Although pelvic floor muscles are generally considered as a single entity, deep and superficial layers have different anatomies and biomechanics. Here we show task-specific differences in recruitment between layers during respiratory tasks in women. The deep layer was more tightly modulated with respiration than the superficial layer, but activation of the superficial layer was greater during maximal/submaximal occluded respiratory efforts and earlier during cough. These data highlight tightly coordinated recruitment of discrete pelvic floor muscles for respiration.

Pelvic floor muscle activation in stress urinary incontinent women: Impact of a distraction task

AIMS

Our purpose was to explore the involvement of cognition in voluntary and involuntary pelvic floor muscle (PFM) contraction in stress urinary incontinent women.

METHODS

PFM contraction monitored by surface electromyography (EMG) was measured without a mental distraction task (DT), and with a DT called "paced auditory serial additional test" (PASAT). Forty stress incontinent women performed voluntary contractions of the external anal sphincter (EAS), and reflex EAS contractions induced by means of coughing were studied using the external intercostal muscle (EIC) EMG pattern.

RESULTS

A DT altered PFM pre-activation when coughing: the reaction time between EIC muscle contraction and EAS contraction (called RT3) was respectively -54.94 ms (IQR -87.12; 3.12) without the PASAT and -3.99 ms (IQR: -47.92; 18.69) with a DT (P = 0.02, Wilcoxon's test). Concerning voluntary contraction, women activated their PFM sooner without than with a DT.

CONCLUSION

The PASAT altered voluntary and reflex contractions of the PFM in stress urinary incontinent women. Our study suggests that cognition plays a role in urinary pathophysiology. Future studies should investigate rehabilitation programs that consider the role of cognition in stress urinary incontinent women.

Terminology of Pelvic Floor Muscle Function in Women With and Without Urinary Incontinence: A Systematic Review

BACKGROUND

Pelvic floor muscle function (PFMF) is a target of the physical therapist intervention for women with urinary incontinence (UI). However, possible variations in PFMF terminology might hamper communication among researchers and health care professionals in Women's Health.

OBJECTIVE

The objective of this study was to investigate the terminology of PFMF regarding clear terms, conceptual definitions, and operational definitions.

DATA SOURCES

Data sources include PUBMED, CINAHL, LILACS, and SCIELO.

STUDY SELECTION

Observational studies investigating any PFMF in women with or without UI, published in English, Spanish, or Portuguese from 2005 through 2017, were considered.

DATA EXTRACTION

The risk of bias was assessed by a questionnaire on the quality of observational studies. Data on terminology were extracted as terms, conceptual definitions, and operational definitions of PFMF and were synthesized according to key words, key ideas, and key operationalization, respectively. Consistencies and variations were identified for the most frequently investigated PFMF.

DATA SYNTHESIS

Sixty-four studies were included, and a low risk of bias was identified. All studies presented terms and operational definitions of PFMF, but only 29.7% presented conceptual definitions of those terms. One hundred ninety-six different terms referred to PFMF. According to similarities in terminology, 161 PFMF terms could be grouped under 26 terms; the other 35 were left ungrouped. Therefore, a total of 61 different PFMF terms were identified in the literature.

LIMITATIONS

A limitation in the study was that only observational studies were included.

CONCLUSIONS

A large variation in PFMF terminology was identified, precluding data gathering and meta-analysis. The lack of use of standardized terminology delays the progress of scientific knowledge and evidence-based practice dissemination. Efforts toward creating a collaborative, consensual terminology based on a sound framework are necessary.

Assessment of bioelectrical activity of synergistic muscles during pelvic floor muscles activation in postmenopausal women with and without stress urinary incontinence: a preliminary observational study

OBJECTIVE

Muscles such as adductor magnus (AM), gluteus maximus (GM), rectus abdominis (RA), and abdominal external and internal oblique muscles are considered to play an important role in the treatment of stress urinary incontinence (SUI), and the relationship between contraction of these muscles and pelvic floor muscles (PFM) has been established in previous studies. Synergistic muscle activation intensifies a woman's ability to contract the PFM. In some cases, even for continent women, it is not possible to fully contract their PFM without involving the synergistic muscles. The primary aim of this study was to assess the surface electromyographic activity of synergistic muscles to PFM (SPFM) during resting and functional PFM activation in postmenopausal women with and without SUI.

MATERIALS AND METHODS

This study was a preliminary, prospective, cross-sectional observational study and included volunteers and patients who visited the Department and Clinic of Urology, University Hospital in Wroclaw, Poland. Forty-two patients participated in the study and were screened for eligibility criteria. Thirty participants satisfied the criteria and were categorized into two groups: women with SUI (n=16) and continent women (n=14). The bioelectrical activity of PFM and SPFM (AM, RA, GM) was recorded with a surface electromyographic instrument in a standing position during resting and functional PFM activity.

RESULTS

Bioelectrical activity of RA was significantly higher in the incontinent group than in the continent group. These results concern the RA activity during resting and functional PFM activity. The results for other muscles showed no significant difference in bioelectrical activity between groups.

CONCLUSION

In women with SUI, during the isolated activation of PFM, an increased synergistic activity of RA muscle was observed; however, this activity was not observed in asymptomatic women. This may indicate the important accessory contribution of these muscles in the mechanism of continence.

Influence of a distraction task on pelvic floor muscle contraction

AIMS

Attention may play a key role in the contraction of pelvic floor muscles in stressful situations, meaning that mental distraction may be involved in urinary incontinence.

METHODS

Informed consent was obtained from 20 healthy volunteers. The electromyographic (EMG) activity of the external anal sphincter (EAS) was recorded during voluntary contraction elicited by local stimulation. The trials were carried out twice: combined (or not) with a mental distraction task (PASAT), Paced auditory serial additional test. Reaction time, latency between the stimulus and maximum EAS EMG activity, duration of the contraction, maximum EAS EMG activity, and the area under the EAS EMG activity curve were measured.

RESULTS

The mental distraction task led to a 3.98 times greater reaction time (RT), (P = 0.00001 Wilcoxon's test). The RT increased from 217 (IQR: 170-270) to 779 msec (IQR: 550-1,025, P < 0.0001) when the EAS contraction was combined with PASAT. However, the maximum EAS EMG activity was weaker during PASAT than in the absence of a mental distraction task: 0.0850 mv versus 0.0701 mv, that is, 1.21 times weaker (P = 0.00077, Wilcoxon's test). Finally, when the two conditions (respectively with and without the mental distraction task) were compared, no significant difference was found in the area under the EAS EMG activity curve (0.0157 mv sec vs. 0.0162 mv sec, ratio 1.01, P = 0.52).

CONCLUSIONS

The mental distraction task altered voluntary contraction of the pelvic floor muscles.

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

INTRODUCTION AND HYPOTHESIS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

[Micturition and cognition]

PURPOSE

The physiopathology of the voiding and urinary continence was one of the hot topic of research these last few years. Unfortunately, anyone have already found a unique cause which could explain urinary incontinence (urge or stress). The concept of cognitive function highlights new ways of research to show the fundamental role of the cortex and the sub-cortex in these diseases.

METHODS

A comprehensive literature review using Pubmed, Medline, Embase and Cochrane: "cognition, urinary tract, urinary continence, neuroimaging, IRMf, micturition, urge, brain factor and cognitive therapy". In all the articles, 72 really dealt with micturition and cognition.

RESULTS

New imaging techniques allowed to show the relationship between the different brain area involved in the bladder control such as the periaqueductal gray, the hypothalamus, the insula, the anterior cingulated cortex and the prefrontal cortex. These cortical area are equally involved in cognition. An alteration of urinary continence implies a modification of activation of these cortical areas.

CONCLUSION

A better knowledge of the cognitive side of micturition and urinary continence will allow to improve the treatment of their associated diseases.

[Nurses' interventions in the management of urinary incontinence in the elderly: an integrative review]

The objective of this study was to verify the strategies that nurses use to manage urinary incontinence (UI) in the elderly. An integrative literature review was performed on the following databases: WEB OF SCIENCE, MEDLINE, SCOPUS and CINAHL, in the period from 2006 to 2010. A total of 186 articles were located, and after excluding duplicates and performing a careful reading of the full articles, the sample was comprised of seven articles. Most studies utilize an overall approach to urinary incontinence, without characterizing the type or the subjects' claims. Only one study addressed the management of urinary incontinence in the elderly with dementia; another specified the type (hyperactive bladder). Therefore, there is a need for further clinical nursing studies regarding the management of urinary incontinence, aiming to provide scientific evidence to support this practice.