Reliability of the PERFECT scheme assessed by unidigital and bidigital vaginal palpation

Relationship Between the PERFECT Scheme, Vaginal Manometry, and Transperineal Ultrasound in Women With and Without Stress Urinary Incontinence: A Cross-Sectional Study

INTRODUCTION AND HYPOTHESIS

The objective was to compare the functional assessment of the pelvic floor (PERFECT [P = power; E = endurance; R = repetitions; F = fast contractions; ECT = every contraction timed] scheme), vaginal manometry and transperineal ultrasound in women with and in those without stress urinary incontinence (SUI) and to evaluate the correlation among the variables of the three modalities of assessment in both groups.

METHODS

This was a cross-sectional study involving nonpregnant women with and those without SUI aged between 18 and 60 years. Women with sphincter deficiency, Oxford scale = 0, and prolapse grade ≥ 2 were excluded. Women were evaluated using the PERFECT scheme, vaginal manometry, and transperineal ultrasound. Groups were compared using the Student's t test, the chi-square test and general linear models. The Spearman correlation test was also performed.

RESULTS

Fifty-one women with SUI (aged 48.5 ± 9.5 years) and 47 women without SUI (aged 47.2 ± 9.2 years) were evaluated. In women with SUI, there was a correlation between vaginal manometry and power (r = 0.87), endurance (r = 0.47) and fast (r = 0.69); between power and endurance (r = 0.53) and fast (r = 0.67); and between endurance and fast (r = 0.61). For the ultrasound variables, there was correlation between the bladder neck and H height, both at rest (r = 0.44) and under stress (r = -0.62); between the ureteric angle at stress and H height at rest (r = 0.49); the ureteric angle at rest (r = 0.74); and the levator anterior area (r = 0.40; p = 0.05 for all measures). None of the ultrasound variables correlated with the PERFECT scheme or the vaginal manometry.

CONCLUSION

There was no correlation between the ultrasound variables and vaginal manometry or the PERFECT scheme. There was correlation between specific measurements of the PERFECT scheme and vaginal manometry and among some of the ultrasound variables.

Relationship of female pelvic floor muscle function and body composition: cross-sectional study

PURPOSE

Investigate the relationship between female pelvic floor muscle (PFM) function and body composition.

METHODS

Cross-sectional study-participants answered sociodemographic and urogynecological questions. The amount of fat mass was measured by dual-emission X-ray densitometry (DXA), and subcutaneous fat thickness was assessed by abdominal ultrasound. PFM assessment was performed using the Modified Oxford Scale and vaginal manometry. Descriptive analysis, independent t test, spearman correlation, and univariate regression were performed.

RESULTS

Ninety-nine women were included. All body composition variables evaluated, except subcutaneous fat thickness, indicated that women with a higher concentration of fat in the pelvic, android, and visceral region have lower maximum voluntary PFM contraction strength assessed by Modified Oxford Scale and manometry. The univariate model pointed out that the fat concentration increases the chances of reduced PFM strength in the entire body (0.6%), android (5.4%), visceral region (25.3%), and pelvic (89.9%). There was a correlation between the concentration of total, pelvic, and android fat with MVC/average peak.

CONCLUSION

The accumulation of "total", "pelvic", "android", and "visceral" fat mass is correlated with reduction in PFM strength, and there is an association between MVC and the variables of total and segmented fat. However, pelvic fat concentration is predictive in 89.9% of cases.

Diagnostic accuracy and cut-off points for vaginal manometry to differentiate between weak and strong pelvic floor muscle contraction in pregnant women

BACKGROUND

Identifying a weak/strong pelvic floor muscle (PFM) contraction in pregnant women may help prevent and treat dysfunctions during late pregnancy and postpartum.

OBJECTIVE

To determine whether the Peritron™ manometer can accurately differentiate a weak from a strong PFM contraction and the respective cut-offs for its variables in pregnant women.

METHODS

This is a diagnostic accuracy study. Forty-four women in the third trimester of pregnancy participated (mean±SD age: 29±5 years). The reference test was vaginal palpation, and the index test was vaginal manometry (Peritron™ manometer). Variables assessed by vaginal manometry were rest, maximal voluntary contraction (MVC), MVC average, duration, gradient, area under the curve (AUCm), and contraction speed. The Receiver Operating Curve (AUC/ROC) was used to analyze the data and obtain cut-off points for these variables.

RESULTS

Perfect discrimination (AUC=1.00) to differentiate between a weak/strong PFM contraction in pregnant women was observed for peak MCV (cut-off: 40.56 cmH2O). The MVC average showed excellent discriminative ability (AUC=0.96; cut-off: 30.66 cmH2O). The gradient variable (AUC=0.85; cut-off: 27.83 cmH2O/s) and AUCm (AUC=0.86; cut-off: 1315.6 cm²*s) showed a good discriminative ability.

CONCLUSION

The best variables to discriminate between weak/strong PFM contraction in pregnant women using vaginal manometry were peak MVC, MVC average, gradient, and AUCm.

Developing new ways to assess neural control of pelvic organ function in spinal conditions: ICI-RS 2023

OBJECTIVES

Several central nervous system (CNS) centers affect muscle groups of the lower urinary tract (LUT) and anorectal tract (ART) via autonomic and somatic pathways, working in different modes (storage or expulsion). Hence spinal cord dysfunction can affect the LUT and ART by several possible mechanisms.

METHODS

This review reports the discussions of a workshop at the 2023 meeting of the International Consultation on Incontinence Research Society, which reviewed uncertainties and research priorities of spinal dysfunction.

RESULTS

Discussion focussed on the levator ani nerve, mechanisms underpinning sensory function and sensation, functional imaging, dyssynergia, and experimental models. The following key research questions were identified. (1) Clinically, how can we evaluate the levator ani muscle to support assessment and identify prognosis for effective treatment selection? (2) How can we reliably measure levator ani tone? (3) How can we evaluate sensory information and sensation for the LUT and the ART? (4) What is the role of functional CNS imaging in development of scientific insights and clinical evaluation? (5) What is the relationship of detrusor sphincter dyssynergia to renal failure?

CONCLUSIONS

Spinal cord dysfunction can fundamentally disrupt LUT and ART function, with considerable clinical impact. The evaluation needs to reflect the full scope of potential problems, and new clinical and diagnostic approaches are needed, for prognosis and treatment. The preclinical science evaluating spinal cord function in both LUT and ART storage and elimination remains a major priority, even though it is a challenging experimental context. Without this underpinning evidence, development of new clinical evidence may be held back.

Sexual functioning is not, but psychological burden is predictive for receiving help in pelvic physical therapy practice: A cross-sectional study

Background

Pelvic floor complaints are common among women and often accompanied by sexual dysfunction and psychological burden. They are also associated with pregnancy and childbirth. However, not all women with these complaints receive help in pelvic physical therapy practice. This study explored if pregnancy, parity, pelvic floor complaints, sexual functioning, and psychological burden are predictive of receiving help in pelvic physical therapy practice.

Methods

In a cross-sectional exploratory design, women completed an online survey about pelvic floor complaints, sexual function, and psychological burden. Binary logistic analysis was used to analyze the predictive value of the above-mentioned factors.

Results

Data from 542 participants were analyzed. Pregnancy and parity, PFC severity, psychological burden, and the interaction between pelvic floor complaints and psychological burden were significant predictors of receiving help. Against expectations, sexual functioning was not predictive of receiving help.

Conclusions

Women's psychological burden is an important factor in determining if or when women receive help in PPT practice. More research is needed to unravel the role of sexual functioning in the context of pelvic floor complaints and women's psychological burden. More insight into this area of expertise could possibly improve and enhance pelvic health care for women with pelvic floor complaints.

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.

Acute Effect of a Half-Marathon over the Muscular Function and Electromyographic Activity of the Pelvic Floor in Female Runners with or without Urinary Incontinence: A Pilot Study

OBJECTIVE

to verify the acute effect of running a half marathon on pelvic floor muscle (PFM) function and electromyographic (EMG) activity in female runners with and without urinary incontinence.

METHODS

This is a cross-sectional pilot study. The sample was divided into two groups: runners with urinary incontinence (with UI) and runners without urinary incontinence (without UI). A semi-structured form and the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-UI-SF) were used for data collection. The EMG and PFM function were evaluated using the PERFECT method before and immediately after running a half marathon.

RESULTS

A total of 14 runners were included (8 with UI; 6 without UI). Runners with and without UI did not show significant differences for EMG and PERFECT. The acute effects of the half marathon on runners without UI were reduced PFM function in terms of strength (p = 0.00), reduced endurance (p = 0.02), and reduced repetition (p = 0.03), and an increase in EMG measured by the median frequency (p = 0.02). Runners with UI showed reduced PFM function in terms of strength (p = 0.05) and repetition (p = 0.01).

CONCLUSION

there was no difference in the acute effects of the half marathon on PFM function and EMG in women with and without UI.

Application of transperineal ultrasound combined with shear wave elastography in pelvic floor function assessment after hysterectomy

This study explored the application of transperineal ultrasound (TPUS) combined with shear wave elastography (SWE) in evaluating the pelvic structure function of women after total hysterectomy. Seventy healthy women and 76 women who underwent total hysterectomy were selected for ultrasound examination. They were divided into normal (nulliparous) group, (parous) group without hysterectomy, and (parous) group with hysterectomy. TPUS combined with SWE was used to evaluate the pelvic floor structure and function in the 3 groups of women. Posterior urethrovesical angle in resting and maximal Valsalva state, anteroposterior diameter of hiatus in the 3 states, the bladder neck descent, the urethral rotation angle, the Young modulus of left and right puborectalisis muscle in resting state, and the incidence of pelvic floor dysfunction diseases were all higher in the group with hysterectomy than in the group without hysterectomy (P < .05). Bladder neck-symphyseal distance and anorectal junction-symphyseal distance in the maximum Valsalva state, and the difference in Young modulus between the left and right PR before and after anus contraction were all lower in the group with hysterectomy than the group without hysterectomy (P < .05). The incidence of pelvic floor dysfunction in postmenopausal patients in the group with hysterectomy was higher than that in premenopausal patients (P < .05). Total hysterectomy had negative effects on female pelvic floor structure and function. TPUS combined with SWE can be used to evaluate pelvic floor function in multiple dimensions.

Staff awareness of pelvic floor muscle training (PFMT) in tertiary care - a qualitative cross-sectional study

Pelvic floor muscle training (PFMT) is proven to protect against pelvic-floor weakness in the form of urinary incontinence (UI) and pelvic organ prolapse (POP). National Institute for Health and Care Excellence (NICE) guidelines advise supervised PFMT as first-line treatment of stress or mixed UI and POP. Healthcare professionals play a crucial role in educating patients. Our aim is to study the extent of awareness of PFMT amongst healthcare professionals by a single-centre cross-sectional study of voluntarily participating 44 healthcare professionals. The term 'pelvic floor exercise' had varied explanations; 53% staff thought they knew how to undertake pelvic-floor assessment, although there was no standard method or terminology to describe the technique or outcome. Staff were unaware of PERFECTR method, Modified Oxford Grading, slow and fast contractions which form the basic criteria of standardised pelvic floor assessment and training. Only 43% staff were aware of online resources.Impact StatementWhat is already known on this subject? There have been many studies confirming the effectiveness of pelvic floor muscle training (PFMT) in the prevention and treatment of long-term morbidities like urinary incontinence, pelvic organ prolapse and sexual dysfunction. However, there have been no studies in the published literature about staff awareness of this important evidence based health intervention in women's health services.What do the results of this study add? We believe the awareness among health care staff about PFMT is still limited. Our study is the first of its kind in literature to highlight that staff awareness about this health intervention is still poor which in turn means staff are not well equipped to offer the support and guidance the patients need.What are the implications of these findings for clinical practice and/or further research? The lack of awareness of staff needs addressing on an urgent basis. Knowledge of PFMT is essential for health care staff to provide appropriate patient education and support. We recommend including information of PFMT and assessment methods in local and national guidelines to help increase awareness of staff and patients alike and help achieve better global pelvic health.

Is there agreement between the preference of examiner and women for unidigital and bidigital vaginal palpation? A qualitative study

INTRODUCTION AND HYPOTHESIS

The International Continence Society recommends vaginal palpation as a method for assessing pelvic floor muscle (PFM) function. Our aim was to analyze the agreement between preferences of examiner and participants according to unidigital and bidigital vaginal palpation during PFM assessment. The second aim was to investigate qualitatively women's perception of vaginal palpation.

METHODS

Maximal voluntary contractions (MVCs) were requested during both types of vaginal palpation and were classified by the Modified Oxford Scale (MOS). Examiner and participants answered if they had preferences regarding vaginal palpation. Women answered qualitatively what they felt during the assessment. Cohen's linear kappa (κ) evaluated the agreement after allocation of the women with a weaker and stronger MVC and qualitative analysis was performed by transcription considering age range (18-35; 36-59; ≥60 years).

RESULTS

Agreement was almost zero for women with weaker and stronger MVC at unidigital (κ = 0.06 and κ = -0.12) and bidigital vaginal palpation (κ = 0.008 and κ = 0.005). Participants associated bidigital palpation with more perception and an easier way of contracting the PFMs. Women between 36 and 59 years associated unidigital palpation with a harder but comfortable way of contracting the PFMs. Subjects aged ≥60 years associated bidigital palpation with an uncomfortable, harder way of contracting PFM, with less space into the vagina.

CONCLUSIONS

Agreement between preferences was almost zero neither between women with a weaker and stronger PFM contraction, nor between the types of vaginal palpation. Bidigital palpation increased women's perception, made the contraction easier, and was associated with less space in the vaginal canal and less comfort.