Physioanatomical relationship of the external anal sphincter to the bulbocavernosus muscle in the female

Pleasurable and problematic receptive anal intercourse and diseases of the colon, rectum and anus

The ability to experience pleasurable sexual activity is important for human health. Receptive anal intercourse (RAI) is a common, though frequently stigmatized, pleasurable sexual activity. Little is known about how diseases of the colon, rectum, and anus and their treatments affect RAI. Engaging in RAI with gastrointestinal disease can be difficult due to the unpredictability of symptoms and treatment-related toxic effects. Patients might experience sphincter hypertonicity, gastrointestinal symptom-specific anxiety, altered pelvic blood flow from structural disorders, decreased sensation from cancer-directed therapies or body image issues from stoma creation. These can result in problematic RAI - encompassing anodyspareunia (painful RAI), arousal dysfunction, orgasm dysfunction and decreased sexual desire. Therapeutic strategies for problematic RAI in patients living with gastrointestinal diseases and/or treatment-related dysfunction include pelvic floor muscle strengthening and stretching, psychological interventions, and restorative devices. Providing health-care professionals with a framework to discuss pleasurable RAI and diagnose problematic RAI can help improve patient outcomes. Normalizing RAI, affirming pleasure from RAI and acknowledging that the gastrointestinal system is involved in sexual pleasure, sexual function and sexual health will help transform the scientific paradigm of sexual health to one that is more just and equitable.

The effect of cadaveric hands-on training model on surgical skills and confidence for transobturator tape surgery

Objective:

To demonstrate the role of cadaveric hands-on training model on surgical skills and confidence levels of surgeons during transobturator tape (TOT) surgery.

Material and Methods:

A pre-test and post-test evaluation to measure skills during the practice of the steps of TOT surgery was performed on a total of 15 postgraduate urologists and gynecologists during a urogynecologic cadaveric dissection course. The course was shaped with regard to theoretical lessons, full pelvic cadaveric dissection and TOT surgery on cadavers.

Results:

Good handling of the TOT needle, identifying the right place for groin incision, adequate size of groin incision, identifying the right place for incision at the anterior vagina, dissection of bladder pillars from the vagina, identifying the right place at the vaginal foramina for TOT needle exit, and good placement of mesh were reviewed. The post-test scores were statistically significant for all parameters and also for self confidence level (p<0.001).

Conclusion:

Cadaveric workshops are important landmarks of surgical education to improve surgical skills, and gain experience and confidence.

Is Pelvic Floor sEMG a Measure of Women's Sexual Response?

INTRODUCTION

Pelvic floor surface electromyography (sEMG) is often used in the assessment and treatment of individuals with pelvic floor abnormalities to measure muscle tone and neural control of the pelvic floor muscles (PFM); however, little is known about the role of the PFM in sexual arousal.

AIM

The aim of this pilot study was to examine whether changes in deep and superficial PFM activity-assessed with sEMG-can be observed during the presentation of sexual stimuli.

METHODS

Deep PFM sEMG activity was assessed with a vaginal probe. Superficial PFM activity was assessed with sEMG electrodes placed over the bulbocavernosus and perianal muscles. 15 sexually healthy women (mean age 27 years) watched a series of neutral, anxiety-evoking, and sexually explicit films. Continuous subjective sexual arousal was measured using a handheld arousometer.

MAIN OUTCOME MEASURE

Changes in microvolts were measured by sEMG sensors, from neutral to anxiety-evoking and neutral to sexually explicit films.

RESULTS

There was an increase in intravaginal and perianal sEMG for both the erotic and anxiety films. Bulbocavernosus sEMG responses did not differ among the 3 films. Concordance between self-reported continuous sexual arousal for the erotic film and bulbocavernosus sEMG (r = 0.349) was not significantly different than concordance using intravaginal sEMG (r = 0.293) or perianal sEMG (r = 0.236).

CLINICAL IMPLICATIONS

Understanding more about which parts of the PFM respond specifically to sexual stimuli may have implications for measuring the effects of treatments aimed at improving sexual response in women.

STRENGTH & LIMITATIONS

The results of this pilot study provide a preliminary understanding of which pelvic floor muscles respond to sexual stimuli. A limitation of this study was the small sample size.

CONCLUSION

Taken together, these findings suggest that intravaginal and perianal sEMG respond to erotic stimuli, whereas bulbocavernosal sEMG responses do not. Hannan-Leith MN, Dayan M, Hatfield G, et al. Is Pelvic Floor Surface Electromyography a Measure of Women's Sexual Response? A Pilot Study. J Sex Med 2019;16:70-82.

Perineal body anatomy in living women: 3-dimensional analysis using thin-slice magnetic resonance imaging

OBJECTIVE

The objective of the study was to describe a framework for visualizing the perineal body's complex anatomy using thin-slice magnetic resonance (MR) imaging.

STUDY DESIGN

Two millimeter thick MR images were acquired in 11 women with normal pelvic support and no incontinence/prolapse symptoms. Anatomic structures were analyzed in axial, sagittal, and coronal slices. Three-dimensional (3-D) models were generated from these images.

RESULTS

Three distinct perineal body regions are visible on MR imaging: (1) a superficial region at the level of the vestibular bulb, (2) a midregion at the proximal end of the superficial transverse perineal muscle, and (3) a deep region at the level of the midurethra and puborectalis muscle. Structures are best visualized on axial scans, whereas craniocaudal relationships are appreciated on sagittal scans. The 3-D model further clarifies interrelationships.

CONCLUSION

Advances in MR technology allow visualization of perineal body anatomy in living women and development of 3-D models that enhance our understanding of its 3 different regions: superficial, mid, and deep.

Pelvic floor muscle assessment outcomes in women with and without provoked vestibulodynia and the impact of a physical therapy program

INTRODUCTION

Physical therapy (PT) may reduce the pain associated with provoked vestibulodynia (PVD) based on previous findings that pelvic floor muscle dysfunction (PFMD) is associated with PVD symptoms.

AIMS

The goals of this study were: (i) to determine whether women with and without PVD differ on measures of pelvic floor muscle (PFM) behavior; and (ii) to assess the impact of PT treatment for women with PVD on these measures.

METHODS

Eleven women with PVD and 11 control women completed an assessment evaluating PFM behavior using surface electromyography (SEMG) recordings and a digital intravaginal assessment. Women with PVD repeated the assessment after they had undergone eight PT treatment sessions of manual therapy, biofeedback, electrical stimulation, dilator insertions, and home exercises.

MAIN OUTCOME MEASURES

Superficial and deep PFM SEMG tonic activity and phasic activity in response to a painful pressure stimulus, PFM digital assessment variables (tone, flexibility, relaxation capacity, and strength).

RESULTS

At pretreatment, women with PVD had higher tonic SEMG activity in their superficial PFMs compared with the control group, whereas no differences were found in the deep PFMs. Both groups demonstrated contractile responses to the painful pressure stimulus that were significantly higher in the superficial as compared with the deep PFMs, with the responses in the PVD group being higher than those in control women. Women with PVD had higher PFM tone, decreased PFM flexibility and lower PFM relaxation capacity compared with control women. Posttreatment improvements included less PFM responsiveness to pain, less PFM tone, improved vaginal flexibility, and improved PFM relaxation capacity, such that women with PVD no longer differed from controls on these measures.

CONCLUSION

Women with PVD demonstrated altered PFM behavior when compared with controls, providing empirical evidence of PFMD, especially at the superficial layer. A PT rehabilitation program specifically targeting PFMD normalized PFM behavior in women with PVD.