Reliability of pelvic floor muscle strength measurement in elderly incontinent women

What are the cut-off points for vaginal manometry to differentiate women with a weak from those with a strong pelvic floor muscle contraction?: Vaginal manometry to classify a pelvic floor muscle contraction

BACKGROUND

Vaginal manometry is regarded as an objective method to assess pelvic floor muscles (PFM) function and can measure several variables during contraction.

OBJECTIVE

To determine which variables could differentiate women with/without a weak/strong PFM contraction and determine their cut-off points.

METHODS

This is a diagnostic accuracy study performed on 156 women with a mean age of 40.4 (SD, 15.9) years. The reference test was vaginal palpation and the index test was vaginal manometry (Peritron™ manometer). Variables were pressure at rest, pressure achieved with maximal voluntary contraction (MVC), MVC average, duration, gradient, and area under the curve (AUCm). The Receiver Operating Curve (AUC/ROC) and logistic regression were used to analyze the data and obtain cut-off points.

RESULTS

Excellent ability to discriminate women with a weak/strong PFM contraction was found for MVC average (cut-off: 28.93 cmH2O), MVC (cut-off: 38.61 cmH2O), and the AUCm (cut-off: 1011.93 cm²*s). The gradient variable had good discrimination ability (AUC/ROC=0.81; cut-off: 28.68 cmH2O/s). The MVC average assessed by manometry, menopausal status, and the presence of stress urinary incontinence (SUI) were associated with a weak/strong PFM contraction in the multivariate analysis; however, the most parsimonious model to discriminate weak/strong PFM contraction included only the MVC average (AUC/ROC = 0.95; sensitivity: 0.87; specificity: 0.91).

CONCLUSION

These results suggest which manometry variables are appropriate to assess and classify PFM function in females. These could be used to help physical therapists to make clinic decisions about the management of female PFM.

Advancements in Phosphodiesterase 5 Inhibitors: Unveiling Present and Future Perspectives

Phosphodiesterase 5 (PDE5) inhibitors presented themselves as important players in the nitric oxide/cGMP pathway, thus exerting a profound impact on various physiological and pathological processes. Beyond their well-known efficacy in treating male erectile dysfunction (ED) and pulmonary arterial hypertension (PAH), a plethora of studies have unveiled their significance in the treatment of a myriad of other diseases, including cognitive functions, heart failure, multiple drug resistance in cancer therapy, immune diseases, systemic sclerosis and others. This comprehensive review aims to provide an updated assessment of the crucial role played by PDE5 inhibitors (PDE5-Is) as disease-modifying agents taking their limiting side effects into consideration. From a medicinal chemistry and drug discovery perspective, the published PDE5-Is over the last 10 years and their binding characteristics are systemically discussed, and advancement in properties is exposed. A persistent challenge encountered with these agents lies in their limited isozyme selectivity; considering this obstacle, this review also highlights the breakthrough development of the recently reported PDE5 allosteric inhibitors, which exhibit an unparalleled level of selectivity that was rarely achievable by competitive inhibitors. The implications and potential impact of these novel allosteric inhibitors are meticulously explored. Additionally, the concept of multi-targeted ligands is critically evaluated in relation to PDE5-Is by inspecting the broader spectrum of their molecular interactions and effects. The objective of this review is to provide insight into the design of potent, selective PDE5-Is and an overview of their biological function, limitations, challenges, therapeutic potentials, undergoing clinical trials, future prospects and emerging uses, thus guiding upcoming endeavors in both academia and industry within this domain.

Cause of non-specific low back pain in women: pelvic floor muscle weakness

INTRODUCTION AND HYPOTHESIS

This study aimed to evaluate the relationship between pelvic floor muscle (PFM) strength and low back pain (LBP) in women with and without non-specific low back pain (NSLBP) with similar demographic and physical characteristics.

METHODS

The study included 40 women (35.73±6.74 years) with NSLBP (with LBP group) and 32 women (34.59±5.93) without LBP (without LBP group). PFM strength with a perineometer, pain intensity with a Visual Analog Scale (VAS), quality of life with the Short Form-36 (SF-36), and perceptions of LBP and related disability with the Rolland Morris Disability Questionnaire (RMDQ) were evaluated.

RESULTS

There was no difference between the groups in terms of age, BMI, number of births (0, 1, and 2 births) and mode of delivery (vaginal/cesarean section) (p>0.05). There was a statistical difference between the groups in all parameters except SF-36 Emotional Role Limitation subscale (p<0.05). We found PFM strength an independent predictor of the RMDQ score, and RMDQ and VAS scores as independent predictors of SF-36 physical and mental components (p<0.05).

CONCLUSIONS

Decreased PFM strength in women causes non-specific mechanical low back pain and disability independent of age, BMI, and the number and type of delivery. Decreased PFM strength is a predictor of disability. Disability and pain are also independent predictors of decreased quality of life. PFM measurement should be prioritized when evaluating women with NSLBP. PFM strength may be a determinant of LBP.

Pelvic floor muscle strength in women with diabetes

Introduction and Aim: Diabetes mellitus (DM) is a global health problem with increasing prevalence linked to the alterations in the lifestyle, growing obesity rates and ageing. Women with insulin resistance (IR)/high insulin levels have worse electromyographic activity in the PFMs than women without IR/high insulin levels which prove the effect of IR/high insulin levels on PFMs. This study aimed at assessing and strengthening the pelvic floor muscles in women with diabetes and urinary incontinence.   Materials and Methods: The subjects were diabetic women of age group 45-55 with urinary incontinence assigned to one of two groups namely the group A (experimental group) and the group B (control group) which consisted of 30 patients each. The strength of the pelvic floor muscle was measured by vaginal examination prior and after the treatment and a Kegels Perineometer was inserted to measure the Strength of contraction (MOS), Length of hold (s), Repetitions (n) and Fast contractions (n) for both the groups. Experimental group was advised to do pelvic floor strengthening exercises in various positions with differing durations and increasing repetitions while control group received the regular physiotherapy care.   Results: The results revealed that there was significant increase in the pelvic floor strengths in both the groups but while comparing the post test results of both the groups there was a significant higher strength of contraction, length of hold, repetitions and fast contractions scores in experimental group.   Conclusion: It is evident from the study that performing the pelvic floor strengthening exercises in various positions as in the experimental group exhibited more improved post test results which proved to show reduced symptoms of urinary incontinence and improved quality of life than that of the subjects in the control group.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

4.

The pathophysiology of stress urinary incontinence: a systematic review and meta-analysis

Introduction and hypothesis

To evaluate the evidence for pathologies underlying stress urinary incontinence (SUI) in women.

Methods

For the data sources, a structured search of the peer-reviewed literature (English language; 1960–April 2020) was conducted using predefined key terms in PubMed and Embase. Google Scholar was also searched. Peer-reviewed manuscripts that reported on anatomical, physiological or functional differences between females with signs and/or symptoms consistent with SUI and a concurrently recruited control group of continent females without any substantive urogynecological symptoms. Of 4629 publications screened, 84 met the inclusion criteria and were retained, among which 24 were included in meta-analyses.

Results

Selection bias was moderate to high; < 25% of studies controlled for major confounding variables for SUI (e.g., age, BMI and parity). There was a lack of standardization of methods among studies, and several measurement issues were identified. Results were synthesized qualitatively, and, where possible, random-effects meta-analyses were conducted. Deficits in urethral and bladder neck structure and support, neuromuscular and mechanical function of the striated urethral sphincter (SUS) and levator ani muscles all appear to be associated with SUI. Meta-analyses showed that observed bladder neck dilation and lower functional urethral length, bladder neck support and maximum urethral closure pressures are strong characteristic signs of SUI.

Conclusion

The pathology of SUI is multifactorial, with strong evidence pointing to bladder neck and urethral incompetence. While there is also evidence of impaired urethral support and levator ani function, standardized approaches to measurement are needed to generate higher levels of evidence.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

Objectives

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

Methods

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

Results

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

Conclusions

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

Perioperative pelvic floor muscle training did not improve outcomes in women undergoing pelvic organ prolapse surgery: a randomised trial

QUESTION

In women undergoing surgery for pelvic organ prolapse (POP), what is the average effect of the addition of perioperative pelvic floor muscle training on pelvic organ prolapse symptoms, pelvic floor muscle strength, quality of life, sexual function and perceived improvement after surgery?

DESIGN

Randomised controlled trial with concealed allocation, blinded assessors, and intention-to-treat analysis.

PARTICIPANTS

Ninety-six women with an indication for POP surgery.

INTERVENTION

The experimental group received a 9-week pelvic floor muscle training protocol with four sessions before the surgery and seven sessions after the surgery. The control group received surgery only.

OUTCOME MEASURES

Symptoms were assessed using the Pelvic Floor Distress Inventory (PFDI-20), which is scored from 0 'unaffected' to 300 'worst affected'. Secondary outcomes were assessed using vaginal manometry, validated questionnaires and Patient Global Impression of Improvement, which is scored from 1 'very much better' to 7 'very much worse'. All participants were evaluated 15 days before surgery, and at Days 40 and 90 after surgery.

RESULTS

There was no substantial difference in POP symptoms between the experimental and control groups at Day 40 (31 (SD 24) versus 38 (SD 42), adjusted mean difference -6, 95% CI -25 to 13) or Day 90 (27 (SD 27) versus 33 (SD 33), adjusted mean difference -4, 95% CI -23 to 14). The experimental group perceived marginally greater global improvement than the control group; mean difference -0.4 (95% CI -0.8 to -0.1) at Day 90. However, the estimated effect of additional perioperative pelvic floor muscle training was estimated to be not beneficial enough to be considered worthwhile for any other secondary outcomes.

CONCLUSION

In women undergoing POP surgery, additional perioperative pelvic floor muscle training had negligibly small effects on POP symptoms, pelvic floor muscle strength, quality of life or sexual function.

TRIAL REGISTRATION

ReBEC, RBR-29kgz5.

"Comparative intra- and inter-rater reliability of maximal voluntary contraction with unidigital and bidigital vaginal palpation and construct validity with Peritron manometer"

AIMS

Evaluate the intra- and inter-rater reliability of maximal voluntary contraction (MVC) of pelvic floor muscle (PFM) assessment by unidigital and bidigital vaginal palpation. As a secondary aim, evaluate the construct validity of vaginal palpation and a manometer.

METHODS

A total of 120 women were recruited and allocated into three groups according to age (group 1 [G1]: 18-35; G2: 36-59; G3: ≥60 years). Examiner A conducted an interview and examiners B and C performed evaluations of PFM function using both unidigital and bidigital vaginal palpation. Seven to 10 days later, examiner B repeated both types of vaginal palpation and measured the MVC pressure with a Peritron. Reliability was analyzed using Cohen's linear weighted Kappa (κ_w ). The construct validity was calculated using the Spearman's correlation (r_s ).

RESULTS

Intra-rater reliability of unidigital and bidigital palpation was κ_w  = 0.75 and κ_w  = 0.58 in G1, κ_w  = 0.59 and κ_w  = 0.73 in G2, and κ_w  = 0.79 and κ_w  = 0.86 in G3, respectively. Inter-rater reliability of unidigital and bidigital palpation was κ_w  = 0.52 and κ_w  = 0.48 in G1, κ_w  = 0.47 and κ_w  = 0.52 in G2, and κ_w  = 0.50 and κ_w  = 0.64 in G3, respectively. Spearman's correlation coefficients were significant at r_s  = 0.79 and r_s  = 0.80 for unidigital and bidigital vaginal palpation, respectively.

CONCLUSIONS

Unidigital or bidigital vaginal palpation were indicated to evaluate G1 and G2 but bidigital palpation was more reliable in G3 when two examiners performed the evaluation. For the assessment conducted by one examiner, unidigital palpation was more reliable in G1 while bidigital palpation was more reliable in G2 and G3. Both unidigital and bidigital palpation have high measures of validity.

Development of a near-infrared spectroscopy interface able to assess oxygen recovery kinetics in the right and left sides of the pelvic floor

Near-infrared spectroscopy (NIRS) muscle oxygenation data are relied on in sports medicine. Many women with urinary incontinence (UI) have dysfunctional pelvic floor muscles (PFMs) but their evaluation lacks such measures; a transvaginal NIRS interface would enable the PFM to be interrogated. Paired miniature fiber-optic cables were configured on a rigid foam insert so their emitter detector arrays with an interoptode distance of 20 mm apposed the right and left inner sides of a disposable clear plastic vaginal speculum, and linked to a standard commercial NIRS instrument. Measurement capability was assessed through conduct of three maximum voluntary contractions (MVCs) and one sustained maximum voluntary contraction of the PFM with calculation of HbDiff (½RT), a validated muscle reoxygenation kinetic parameter. In all four asymptomatic controls, mean age 40, mean BMI 21.4, MVCs were associated with changes in PFM oxyhemoglobin (O2Hb), deoxyhemoglobin (HHb) concentration, and their difference (HbDiff) comparable to those in voluntary muscle sports medicine studies. NIRS data during recovery (reoxygenation) allowed calculation of HbDiff (½RT). New techniques are called for to evaluate UI. This NIRS interface warrants further development as the provision of quantitative reoxygenation kinetics offers more comprehensive evaluation of patients with PFM dysfunction.

Parity: a risk factor for decreased pelvic floor muscle strength and endurance in middle-aged women

INTRODUCTION AND HYPOTHESIS

The incidence of pelvic floor muscle (PFM) dysfunction increases rapidly with menopause and aging. Despite the raised magnitude and prevalence of pelvic floor disorders in middle-aged women, the risk factors underlying PFM dysfunction still remain to be identified. PFM function can be clinically measured as the maximum strength and endurance using manometry. The aim of this study was to evaluate PFM function in terms of strength and endurance by perineometer and to assess the risk factors that decrease PFM strength and endurance in middle-aged women.

METHODS

This was a cross-sectional study. Overall, 125 parous women (age 40-60 years) completed the study. A questionnaire was used to collect information on several demographic and obstetric variables. The Peritron perineometer measured PFM strength and endurance. Multiple linear regression analysis was used to evaluate the effects of sociodemographic variables on PFM function.

RESULTS

Both average strength of PFMs and maximum muscle strength significantly reduced as the number of parity increased. Average and maximum strength of PFMs showed a significant difference between women with parities of two and one (β = -0.435, p < .001; β = -0.441, p < 0.001, respectively). Both were even more influenced in women with parity of three (β = -0.503, p < .001; β = -0.500, p < .001). However, PFM endurance did not decrease with increasing parity number until the parity of two; however, it decreased in women with parity of three (β = -0.302, p < 0.05).

CONCLUSION

Parity appeared to have a dominant influence on weakness of PFM, and strength was more significantly associated with parity than endurance in middle-aged women.

Review of pelvic and perineal neuromuscular fatigue: Evaluation and impact on therapeutic strategies

BACKGROUND

Pelvic floor fatigue is known by its clinical consequences (fecal incontinence, stress urinary incontinence, pelvic organ prolapse), but there are still few studies on the subject.

OBJECTIVE

This article presents an overview of the current knowledge of pelvic and perineal fatigue, focusing on its assessment and consequences in terms of evaluation and therapeutic strategies, to propose an evaluation that could be routinely performed.

METHODS

We performed a systematic review of the literature in MEDLINE via PubMed and Cochrane Library databases by using the keywords pelvic floor, muscular fatigue, physiopathology, stress urinary incontinence, pelvic organ prolapse, fecal incontinence, physical activity, and pelvic rehabilitation. We included reports of systematic reviews and retrospective and prospective studies on adult humans and animals in English or French published up to April 2018 with no restriction on start date.

RESULTS

We selected 59 articles by keyword search, 18 by hand-search and 3 specific guidelines (including the 2009 International Continence Society recommendations); finally 45 articles were included; 14 are described in the Results section (2 reviews of 6 and 20 studies, and 12 prospective observational or cross-over studies of 5 to 317 patients including 1 of animals). Perineal fatigue can be assessed by direct assessment, electromyography and spectral analysis and during urodynamics. Because pelvic floor fatigue assessments are not evaluated routinely, this fatigability is not always identified and is often falsely considered an exclusive pelvic floor weakness, as suggested by some rehabilitation methods that also weaken the pelvic floor instead of enhancing it.

CONCLUSION

Pelvic floor fatigue is not evaluated enough on a routine basis and the assessment is heterogeneous. A better knowledge of pelvic floor fatigue by standardized routine evaluation could lead to targeted therapeutic strategies.

Baseline ICIQ-UI score, body mass index, age, average birth weight, and perineometry duration as promising predictors of the short-term efficacy of Er:YAG laser treatment in stress urinary incontinent women: A prospective cohort study

BACKGROUND AND OBJECTIVE

A growing body of evidence indicates that a non-invasive erbium yttrium-aluminum-garnet (Er:YAG) laser may be an effective and highly tolerable treatment for stress urinary incontinence (SUI) in women. The primary objective was to identify pre-intervention predictors of short-term Er:YAG outcomes. The secondary objective was to identify patient segments with the best Er:YAG laser treatment short-term outcomes.

METHODS

A prospective cohort study performed in 2016 at Ob/Gyn Clinic, Zagreb, Croatia, recruited 85 female patients who suffered from SUI. The intervention was performed with a 2940 nm wave length Er:YAG laser (XS Dynamis, Fotona, Slovenia). Outcomes were absolute change in the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-UI SF) and a relative decrease in ICIQ-UI score of ≥30% 2-6 months after the intervention.

RESULTS

Age and pre-intervention ICIQ-UI values were independent significant predictors of laser treatment efficacy for SUI. A decrease in ICIQ-UI score (minimum important difference, MID) of ≥30% was independently significantly associated with body mass index and ICIQ-UI values before the intervention. All patients with four or five positive predictors saw a clinically relevant decrease in ICIQ-UI of ≥30%. The total accuracy of the predictive model defined by the area under the curve was 0.83 (95%CI 0.74-0.91). At the cut-off ≥3 positive predictors, C-index was 0.80 (95%CI 0.71-0.90), positive predictive value was 0.97 (95%CI 0.87-0.99), and negative predictive value was 0.53 (95%CI 0.45-0.55).

CONCLUSIONS

A relevant decrease in ICIQ-UI (MID) of ≥30% can be predicted based on age, body mass index, average birth weight, perineometer squeeze duration, and ICIQ-UI scores before the intervention. The association between Q-tip test and treatment outcome was moderated by age. Q-tip was a significant predictor for patients between 44 and 53 years of age. The best results should be expected in younger women with a body mass index of ≤23.3, average birth weight of >3.6 kg, ICIQ-UI at a baseline of ≤10, and perineometer squeeze duration at a baseline of ≥3.51 seconds. The critical age for Er:YAG laser effect is 47.5 years. Lasers Surg. Med. © 2018 Wiley Periodicals, Inc.

A manometry classification to assess pelvic floor muscle function in women

OBJECTIVE

To develop a classification scale for manometry of pelvic floor muscles (PFM) in Brazilian women, according to the modified Oxford scale.

METHODS

A cross sectional study, with 288 women enrolled in the Maternity, Natal, Brazil. Manometry and PFM strength data were collected and classified according to the modified Oxford scale. A simple linear regression was performed to determine the classification scale of manometry using the modified Oxford scale as the explanatory variable and the arithmetic mean of the manometry measurements as the response variable.

RESULTS

The average age was 52.80 (±8.78; CI: 51.67-53.93) years. Manometry showed an average of 35.1 (±22.7; CI: 32.1-38.0) cmH2O and most women (29.7%) scored grade 3 on the modified Oxford scale. According to the proposed scale, values between 7.5 to 14.5 cmH2O correspond to very weak pressure; 14.6 to 26.5 cmH2O represent weak pressure; 26.6 to 41.5 cmH2O represent moderate pressure; 41.6 to 60.5 cmH2O represent good pressure, and values above 60.6 cmH2O correspond to strong pressure.

CONCLUSION

Manometry values were rated on a five-point scale. It is possible to rank the pressure levels performed by voluntary contraction of PFM with this new scale.

The evaluation of pelvic floor muscle strength in women with pelvic floor dysfunction: A reliability and correlation study

AIMS

The purposes of this study were: (i) to evaluate the reliability of vaginal palpation, vaginal manometry, vaginal dynamometry; and surface (transperineal) electromyography (sEMG), when evaluating pelvic floor muscle (PFM) strength and/or activation; and (ii) to determine the associations among PFM strength measured using these assessments.

METHODS

One hundred and fifty women with pelvic floor disorders participated on one occasion, and 20 women returned for the same investigations by two different raters on 3 different days. At each session, PFM strength was assessed using palpation (both the modified Oxford Grading Scale and the Levator ani testing), manometry, and dynamometry; and PFM activation was assessed using sEMG.

RESULTS

The interrater reliability of manometry, dynamometry, and sEMG (both root-mean-square [RMS] and integral average) was high (Lin's Concordance Correlation Coefficient [CCC] = 0.95, 0.93, 0.91, 0.86, respectively), whereas the interrater reliability of both palpation grading scales was low (Cohen's Kappa [k] = 0.27-0.38). The intrarater reliability of manometry (CCC = 0.96), and dynamometry (CCC = 0.96) were high, whereas intrarater reliability of both palpation scales (k = 0.78 for both), and of sEMG (CCC = 0.79 vs 0.80 for RMS vs integral average) was moderate. The Bland-Altman plot showed good inter and intrarater agreement, with little random variability for all instruments. The correlations among palpation, manometry, and dynamometry were moderate (coefficient of determination [r² ] ranged from 0.52 to 0.75), however, transperineal sEMG amplitude was only weakly correlated with all measures of strength (r²  = 0.23-0.30).

CONCLUSIONS

Manometry and dynamometry are more reliable tools than vaginal palpation for the assessment of PFM strength in women with pelvic floor disorders, especially when different raters are involved. The different PFM strength measures used clinically are moderately correlated; whereas, PFM activation recorded using transperineal sEMG is only weakly correlated with PFM strength. Results from perineal sEMG should not be interpreted in the context of reporting PFM strength.

Reliability of pelvic floor muscle strength assessment in healthy continent women

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Relationship among vaginal palpation, vaginal squeeze pressure, electromyographic and ultrasonographic variables of female pelvic floor muscles

Background:

The proper evaluation of the pelvic floor muscles (PFM) is essential for choosing the correct treatment. Currently, there is no gold standard for the assessment of female PFM function.

Objective:

To determine the correlation between vaginal palpation, vaginal squeeze pressure, and electromyographic and ultrasonographic variables of the female PFM.

Method:

This cross-sectional study evaluated 80 women between 18 and 35 years of age who were nulliparous and had no pelvic floor dysfunction. PFM function was assessed based on digital palpation, vaginal squeeze pressure, electromyographic activity, bilateral diameter of the bulbocavernosus muscles and the amount of bladder neck movement during voluntary PFM contraction using transperineal bi-dimensional ultrasound. The Pearson correlation was used for statistical analysis (p<0.05).

Results:

There was a strong positive correlation between PFM function and PFM contraction pressure (0.90). In addition, there was a moderate positive correlation between these two variables and PFM electromyographic activity (0.59 and 0.63, respectively) and movement of the bladder neck in relation to the pubic symphysis (0.51 and 0.60, respectively).

Conclusions:

This study showed that there was a correlation between vaginal palpation, vaginal squeeze pressure, and electromyographic and ultrasonographic variables of the PFM in nulliparous women. The strong correlation between digital palpation and PFM contraction pressure indicated that perineometry could easily be replaced by PFM digital palpation in the absence of equipment.

Effect of home-based Kegel exercises on quality of life in women with stress and mixed urinary incontinence

The aim of this study was to assess the effects of home-based Kegel exercises in women with stress and mixed urinary incontinence. A total of 90 women with urodynamically proven urinary stress (SUI) and mixed (MUI) incontinence awaiting anti-incontinence surgery were recruited in the urogynaecology clinic of Ankara Zekai Tahir Burak Women's Health Research and Education Hospital. Of these, 18 women were excluded due to low compliance and the remaining 72 were divided into two groups according to urodynamic diagnosis (SUI group, n = 38; MUI group, n = 34). Age, BMI, menopausal status and medical history of the women were recorded. The women took Kegel exercise, consisting of 10 sets of contractions/day; each set included 10 repetitions, for at least 8 weeks. To evaluate the pelvic floor muscle strength, the modified Oxford grading system was used before and after Kegel exercising. The Incontinence Impact Questionnaire (IIQ-7); Urogenital Distress Inventory (UDI-6) and the Patient Global Impression of Improvement (PGI-I) questions were compared before and after 8 weeks of Kegel exercising. The age, BMI, gravidity, menopausal status, macrosomic fetus history, hypertension and asthma were similar between the groups. There were statistically significant lower scores in both IIQ-7 and UDI-6 before and after Kegel exercises within each group (p < 0.001). The mean change of the IIQ-7 and UDI-6 score was statistically significantly higher in the SUI group than in the MUI group (p = 0.023 and p = 0.003, respectively). Results of the Oxford scale were also statistically significantly higher after Kegel exercises within each group (p = < 0.001). In total, 68.4% of the women in the SUI group and 41.2% of the women in the MUI group reported improvements which were statistically significant (p = 0.02). We conclude that home-based Kegel exercises, with no supervision, have been found effective in women with SUI and MUI. The improvement was more prominent in women with SUI.

Comparison of pelvic floor muscle strength between women undergoing vaginal delivery, cesarean section, and nulliparae using a perineometer and digital palpation

OBJECTIVES

To compare pelvic floor muscle (PFM) strength between women undergoing vaginal delivery, cesarean section, and nulliparae, investigating the factors associated with PFM strength, and observing the correlation between vaginal digital palpation and use of a perineometer.

METHODS

A cross-sectional study was conducted, including 31 women following vaginal delivery, 30 women following cesarean section, and 30 nulliparous women. PFM strength was measured by vaginal digital palpation and use of a perineometer. Multiple linear regression analysis with adjustment for covariables was used to compare the mean PFM strength and identify its associated factors.

RESULTS

The mean PFM strength of women undergoing vaginal delivery and cesarean section was 25.6 ± 14.5 cmH(2)O and 39.6 ± 22.0 cmH(2)O (p < 0.01, adjusted for covariables), respectively. A correlation was observed between measurements of PFM strength obtained by vaginal digital palpation and use of a perineometer (tau = 0.82; p < 0.01). The non-white race/ethnicity was negatively associated with PFM strength (coefficient: -10.2424; p = 0.02).

CONCLUSIONS

A lower PFM strength was observed in women with a history of vaginal delivery compared to those undergoing cesarean section. Non-white race/ethnicity negatively affected PFM strength. Our data suggest that vaginal digital palpation may be used in clinical practice because of its expressive correlation with use of a perineometer.

Inter-rater reliability study of the modified Oxford Grading Scale and the Peritron manometer

OBJECTIVE

To evaluate the inter-rater reliability of the modified Oxford Grading Scale and the Peritron manometer.

DESIGN

All participants were evaluated twice, first by one examiner and 30 days later by a second examiner. Measurements of vaginal squeeze pressure were compared with the results from the palpation test.

PARTICIPANTS

Nineteen women with a mean age of 23.7 years (range 21 to 28 years).

RESULTS

Inter-rater reliability for vaginal palpation was fair (κ=0.33, 95% confidence interval 0.09 to 0.57). Using the Peritron manometer, the difference between examiners was less than 10cmH(2)O in 11 of the 19 (58%) cases. The palpation test did not differentiate between weak, moderate, good and strong muscle contractions. This study found fair inter-rater reliability for the modified Oxford Grading Scale and moderate inter-rater reliability for the Peritron manometer.

CONCLUSIONS

The inter-rater reliability of vaginal squeeze pressure measurement using the Peritron manometer is acceptable and can be used in re-evaluations performed by different examiners in clinical practice. However, for research purposes, the ideal situation would be for a single examiner to assess and re-assess the subject. Vaginal palpation is important in the clinical assessment of correctness of a pelvic floor muscle contraction, but this study does not support the use of the modified Oxford Grading Scale as a reliable and valid method to measure and differentiate pelvic floor muscle strength.

Application of perineometer in the assessment of pelvic floor muscle strength and endurance: a reliability study

Despite different studies on the reliability of pelvic floor muscle assessment, there is still no general consensus on the most valid and reliable method. The purpose of this study was to investigate the intra-rater (within-day and between-days) reliability of perineometer in the assessment of pelvic floor muscle strength and endurance. Following ethical approval, 15 healthy women aged from 22 to 50-years old, with no history of low back pain were recruited. The Peritron perineometer instrument was used to measure pelvic floor muscle strength and endurance. Two measurements were taken on the same day with an hour interval to assess within-day reliability and the third measurement was taken five days later to determine between-days reliability. Intraclass Correlation Coefficients (ICCs) and the level of agreement between measurements were used for data analysis. The high ICC values (0.95 for strength and 0.94 for endurance) and high level of agreement between measurements indicated high within-day reliability for pelvic floor muscle strength and endurance. The perineometer was also shown to be reliable for between-days measurements with high ICC (0.88 for strength and 0.83 for endurance) and high level of agreement between measurements. The results demonstrated that the perineometer appears to be a highly reliable method of measuring pelvic floor muscle strength and endurance when measurements are taken in healthy subject by the same investigator.

Comparison between measurements obtained with three different perineometers

OBJECTIVE

To analyze the results obtained in the evaluation of intra-vaginal pressure using three different brands of perineometers in nulliparous volunteers.

MATERIALS AND METHODS

Twenty nulliparous women with no anatomical alterations and/or dysfunction of the pelvic floor were enrolled in our study. All the women had the ability to voluntarily contract their PFM (Pelvic Floor Muscles), as assessed by digital palpation. The intra-vaginal pressure was assessed using three different brands of perineometer (Neurodyn Evolution, SensuPower and Peritron). Each volunteer was evaluated on three alternate days by a single examiner using a single brand of perineometer on each day. In the assessment, the volunteers were required to pull (contract) their PFM in and up as strongly as possible 3 times and to sustain the contraction for 5 seconds, with an interval of 30 seconds between each pull. For the statistical analysis, a concordance correlation coefficient was used to compare the values that were obtained with each brand of perineometer.

RESULTS

A moderate concordance (0.51) was found between the results from the Peritron and Neurodyn perineometers, a fair concordance (0.21) between the Peritron and SensuPower brands and a poor concordance (0.19) between the Neurodyn and SensuPower brands.

CONCLUSION

The concordance of the measurements of the intra-vaginal pressure ranged from poor to moderate, suggesting that perineometers of different brands generate different results.

Reliability of speed of contraction and endurance dynamometric measurements of the pelvic floor musculature in stress incontinent parous women

AIMS

To evaluate the test-retest reliability of dynamometric measurements of the pelvic floor muscles (PFM) during speed and endurance tests.

METHODS

Nineteen parous women suffering from stress urinary incontinence (SUI) participated in the study. Two PFM evaluation sessions were conducted using the dynamometric speculum. For the speed test, the women were instructed to contract maximally and relax as quickly as possible during a 15-s test period. The speed of contraction was quantified by the rate of force development of the first contraction and the number of contractions performed. The maximal strength value attained during the speed test was also extracted from the curves. For the endurance test, the subjects were asked to maintain a maximal contraction for 90 s. The normalized area under the force curve was utilized as the endurance parameter. The reliability of the data was evaluated using the generalizability theory. Two reliability estimates were calculated, the dependability indices (Phi) and the standard error of measurement (SEM), for one measurement session involving one trial.

RESULTS

The indices of dependability obtained indicate that the reliability of the speed of contraction and endurance parameters are good (Phi=0.79-0.92). The corresponding SEMs were 1.39 N/s, 1 contraction, 1.00 N, and 298%*s for the rate of force development, number of contractions, maximal strength and normalized area, respectively.

CONCLUSION

This study indicates that the speed of contraction and endurance parameters possess good test-retest reliability. The inclusion of these parameters in the PFM assessment is therefore highly recommended for assessing changes in PFM in incontinent women.

Validity of the incontinence severity index: comparison with pad-weighing tests

The incontinence severity index (ISI) consists of two questions, regarding frequency and amount of leakage. It categorizes urinary incontinence (UI) into slight, moderate, severe, and very severe. The purpose of this study was to test its validity. The index was compared with the results of pad-weighing tests performed by 200 incontinent women referred to a hospital clinic and 103 at a primary care incontinence clinic. Inconvenience was scored by a six-level Likert scale. Mean pad-weighing results (grams per 24 hours, 95% confidence intervals) were 7 (4-10) for slight, 39 (26-51) for moderate, 102 (75-128) for severe, and 200 (131-268) for very severe UI. Spearman's correlation coefficient for pad-weighing results and severity index was 0.58 (p<0.01), and inconvenience increased significantly with increasing severity. The ISI demonstrated good criterion validity against 24-h pad tests. Good construct validity was indicated by a clear link between ISI and inconvenience.

[Female geriatric patients with urinary incontinence symptoms and their control over pelvic floor muscles]

Not only do anatomy and function of the pelvic floor play an important role as possible causes of female urinary incontinence, they are also crucial for its therapy. The aim of this case control study of female geriatric patients with symptoms of urinary incontinence was to determine the knowledge about their pelvic floor and to assess their ability to contract pelvic floor muscles voluntarily and reflexly.

METHODS

A total of 377 female geriatric patients with symptoms of urinary incontinence were investigated in a Basis Assessment for Urinary incontinence. The ability to contract their pelvic floor muscles was examined by a digital vaginal palpation. The extent of the registered muscle strength was graded by the Modified Oxford Grading Scale by Laycock (1994).

RESULTS

Of the patients, 65.5% were not aware of their pelvic floor and were not able to contract the pelvic floor muscles (Grade 0 to 1 by Laycock), 22% had an inaccurate knowledge and only performed an insufficient pelvic floor muscle contraction (Grade 2 by Laycock). Only 12.5% could contract their pelvic floor muscles properly (Grade 3 to 4 by Laycock). A subgroup of 83 patients had already absolved pelvic floor exercises in the past, 80 patients with conventional instructions, 3 patients with digital vaginal control. In this subgroup 54.2% of the patients were not able to contract the pelvic floor muscles (Grade 0 to 1 by Laycock) 25.3% only performed an insufficient contraction (Grade 2 by Laycock), while 20% were able to perform a sufficient and powerful contraction (Grade 3 to 4 by Laycock). The three patients in the past controlled by a digital vaginal palpation were part of this group and managed a pelvic floor muscle strength Grade 4 by Laycock. A high percentage of female geriatric patients with symptoms of urinary incontinence have a lack of understanding regarding the position and function of their pelvic floor. These results suggest that conventional pelvic floor muscle exercises without specific control are not an appropriate method to improve geriatric patients' ability to contract their pelvic floor muscles and to prevent urine leakage.

Reliability of pelvic floor muscle strength assessment using different test positions and tools

AIMS

The aims of this study were to determine the intra-therapist reliability for digital muscle testing and vaginal manometry on maximum voluntary contraction strength and endurance. In addition, we assessed how reliability varied with different tools and different testing positions.

METHODS

Subjects included 20 female physiotherapists. The modified Oxford scale was used for the digital muscle testing, and the Peritron perineometer was used for the vaginal resting pressure and vaginal squeeze pressure assessments. Strength and endurance testing were performed. The highest of the maximum voluntary contraction scores was used in strength analysis, and a fatigue index value was calculated from the endurance repetitions. Bent-knee lying, supine, sitting, and standing positions were used. The time interval for between-session reliability was 2-6 weeks.

RESULTS

Kappa values for the between-session reliability of digital muscle testing were 0.69, 0.69, 0.86, and 0.79 for the four test positions, respectively. Intra-class correlation coefficient (ICC) values for squeeze pressure readings for the four positions were 0.95, 0.91, 0.96, and 0.92 for maximum voluntary contraction, and 0.05, 0.42, 0.13, and 0.35 for endurance testing. ICC values for resting pressure were 0.74, 0.77, 0.47, and 0.29.

CONCLUSIONS

Reliability of digital muscle testing was very good in sitting and good in the other three positions. vaginal resting pressure demonstrated very good reliability in all four positions for maximum voluntary contraction, but was unreliable for endurance testing. Vaginal resting pressure was not reliable in upright positions. Both measurement tools are reliable in certain positions, with manometry demonstrating higher reliability coefficients.

A randomized, double-blinded, sham-controlled trial of postpartum extracorporeal magnetic innervation to restore pelvic muscle strength in primiparous patients

OBJECTIVE

The purpose of this study was to determine the effects of extracorporeal magnetic innervation (ExMI) on pelvic muscle strength of primiparous patients.

STUDY DESIGN

Primigravid patients were randomized to receive either active or sham ExMI postpartum treatments for 8 weeks. The main outcome measure was pelvic muscle strength measured by perineometry at baseline (midtrimester), 6 weeks (before treatments), 14 weeks, 6 months, and 12 months postpartum. Mixed randomized-repeated measures ANOVA was used to analyze the mean perineometry values between the 2 groups and across all 5 time periods.

RESULTS

Fifty-one patients enrolled, and 18 were lost to attrition. There were no differences in demographics or delivery characteristics between the active and sham groups. There was an overall time effect, F(3,85) = 3.1, P = .049, but no group, F(1,31) = 0.007, P = .94, or (group)(time) interaction, F(3,85) = 1.8, P = .15.

CONCLUSION

We found no differences in pelvic muscle strength between patients receiving active or sham ExMI treatments in the early postpartum period.

A comparison of perineometer to brink score for assessment of pelvic floor muscle strength

OBJECTIVE

The Brink scale is a commonly used digital assessment of pelvic floor muscle strength. The Peritron perineometer, a compressible vaginal insert that records pressure in centimeters of water, offers an objective method for this evaluation. This study evaluates the inter- and intrarater reliability of perineometry measurements and correlates those values with Brink scores.

STUDY DESIGN

Subjects were prospectively enrolled and underwent pelvic floor muscle strength assessment by 2 examiners each using a perineometer and the Brink scale. Perineometer measurements of maximum pressure, average pressure, and total duration were recorded for 3 consecutive pelvic floor muscle contractions (Kegels). The Brink assessment was performed by placing 2 fingers vaginally during a single Kegel contraction. Brink scores consisted of 3 separate 4-point rating scales for pressure, vertical finger displacement, and duration. The order of the examiners and the 2 assessment methods were randomized, and each examiner was blinded to the results of the other. Pearson and Spearman correlation coefficients were used for analysis as appropriate. Repeated-measures analysis of variance was used to assess intrarater reliability between repeated perineometer measurements.

RESULTS

One hundred women were consecutively enrolled and completed the study. Interrater reliability for the perineometer maximum squeeze pressure (r = 0.88) and baseline resting pressure (r = 0.78) was high. Maximum squeeze pressure correlation was unaffected by the presence or absence of estrogen (r = 0.89 versus r = 0.85), nulliparity versus parity (0.85 versus 0.88), or genital hiatus 4 or greater or less than 4 (r = 0.96 versus r = 0.86). Total Brink score and each individual submeasurement showed good correlations (total: r = 0.68; pressure: r = 0.68; displacement: r = 0.58; duration: r = 0.44). The correlation between maximum squeeze pressure and total Brink score during the first and second exams was good (r = 0.68 versus r = 0.71). For intrarater reliability, there were no significant differences among the 3 maximum squeeze pressures recorded during the first exam (P = .11), but for the second exam, the first squeeze was significantly stronger than the successive 2 (P = .009) attempts.

CONCLUSION

Perineometer measurements of pelvic floor muscle contractions show very good inter- and intrarater reliability. The Brink total and pressure scores had a slightly lower interrater reliability. Variables such as estrogen status, parity, and genital hiatus did not appear to affect correlation. There was good correlation between the maximum perineometer pressure and the total Brink score, suggesting that these 2 methods of assessment have similar levels of reproducibility. Additionally, the perineometer demonstrated good short-term test-retest reliability.

Initial experience with a new method for the dynamic assessment of pelvic floor function in women: the Kolpexin Pull Test

The aim of this study was to evaluate a newly developed, simple test for assessing pelvic floor muscular function in women. Pelvic floor strength in women with symptomatic pelvic floor dysfunction was evaluated with a newly developed assessment tool, the Kolpexin Pull Test, and compared to a clinically validated digital pelvic floor strength assessment scale (DPA). A 36-mm Kolpexin sphere was inserted into the vagina above the levator plate and connected to a digital tensiometer/force gauge. The force required to remove the sphere was recorded for three resting trials and three maximum pelvic floor contractions. Results of the DPA and Kolpexin Pull Test were analyzed using ANOVAs of contrast variables, intraclass correlations, and regression analyses. Twenty-one women participated in the study. Age range was 36-85 years, parity range was 2-5. All six trials required less than 5 min to perform in each patient. Intraperson maximum contraction data were correlated at 0.96 (95% CI: 0.91, 0.98), and were greater at higher DPA scores ( p=0.016). There were positive correlations between the maximum contraction and DPA data (adjusted R(2)=0.52; p <0.001), and the maximum contraction minus resting vs DPA data (adjusted R(2)=0.54; p< 0.001). The Kolpexin Pull Test is reproducible, rapid, and correlates with digital clinical assessment of pelvic floor strength during maximal contractions.

Pelvic floor maximal strength using vaginal digital assessment compared to dynamometric measurements

AIM

To compare vaginal digital assessment with dynamometric measurements for determining the maximal strength of the pelvic floor muscles (PFM).

MATERIALS AND METHODS

Eighty-nine women aged between 21 and 44 participated in the study. An experienced physiotherapist evaluated the maximal strength of the PFM of these women using the modified Oxford grading system (six categories, range 0-5) and dynamometric measurements. The mean maximal forces obtained for all women with the instrumented speculum for each category of digital assessment were compared using ANOVAs. Spearman's rho coefficients were calculated to assess the correlation between the dynamometric and the digital assessments.

RESULTS

According to their symptoms and pad test results, 30 women were continent and 59 had stress urinary incontinence (SUI). Based on dynamometric measurements, important overlaps were observed between each category of digital assessment. The ANOVAs indicated that force values differ across categories (F = 10.08; P < 0.001), although contrast analyses revealed no differences in the mean maximal forces between adjacent digital-assessment categories (1-2, 2-3, 3-4, 4-5). Mean force values differed significantly only between non-adjacent levels in digital assessment, for example, between 1 and 3; 1 and 4; 1 and 5; 2 and 4; 2 and 5 (P < 0.05). Significant correlations were found between the two measurements with coefficients of r = 0.727, r = 0.450, and r = 0.564 for continent, incontinent, and all women, respectively (P < 0.01).

CONCLUSIONS

Even if the dynamometric mean forces of the PFM increased across subsequent categories of digital assessment, the force values between two adjacent categories do not differ. This limitation of digital assessment should be considered by clinicians and researchers when choosing treatment orientation and evaluating treatment outcomes.