[Pelvic floor muscle contraction and maximum urethral closure pressure]

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 training: Novel versus traditional remote rehabilitation methods. A systematic review and meta-analysis on their effectiveness for women with urinary incontinence

OBJECTIVE

To investigate the effectiveness of supervised remote rehabilitation programs comprising novel methods of pelvic floor muscle (PFM) training for women with urinary incontinence (UI).

DESIGN

A systematic review and meta-analysis including randomized controlled trials (RCTs), involving novel supervised PFM rehabilitation programs as intervention groups (e.g., mobile applications programs, web-based programs, vaginal devices) versus more traditional PFM exercise groups (acting as control); both sets of groups being offered remotely.

METHODS

Data have been searched and retrieved from the electronic databases of Medline, PUBMED, and PEDro using relevant key words and MeSH terms. All included study data were handled as reported in the Cochrane Handbook for Systematic Reviews of Interventions and the evaluation of their quality was undertaken utilizing the Cochrane risk-of-bias tool 2 (RoB2) for RCTs. The included RCTs, involved adult women with stress UI (SUI) or mixed urinary incontinence, where SUI were the most predominant symptoms. Exclusion criteria involved pregnant women or up to 6-month postpartum, systemic diseases and malignancies, major gynecological surgeries or gynecological problems, neurological dysfunction or mental impairments. The searched outcomes included subjective and objective improvements of SUI and exercise adherence in PFM exercises. Meta-analysis was conducted and included studies pulled by the same outcome measure.

RESULTS

The systematic review included 8 RCTs with 977 participants. Novel rehabilitation programs included mobile applications (1 study), web-based programs (1 study) and vaginal devices (6 studies) versus more traditional remote PFM training, involving home-based PFM exercise programs (8 studies). Estimated quality with Cochrane's RoB2, presented the 80% of the included studies as "some concerns" and the 20% as "high risk." Meta-analysis included 3 studies with no heterogeneity (I2  = 0) across them. Weak-evidenced results presented home PFM training equally effective with novel PFM training methods (mean difference: 0.13, 95% confidence interval: -0.47, 0.73), with small total effect size (0.43).

CONCLUSIONS

Novel PFM rehabilitation programs presented as effective (but not superior) to traditional ones in women with SUI, both offered remotely. However, individual parameters of novel remote rehabilitation including supervision by the health professional, remains in question and larger RCTs are required. Connection between devices and applications in combination with real-time synchronous communication between patient and clinician during treatment is challenged for further research across novel rehabilitation programs.

Variations in maximum urethral closure pressure in stress urinary incontinence

Introduction:

Urethral Pressure Profilometry (UPP) assesses the urethral closing function. The literature is scarce regarding the change in the Maximum Urethral Closure Pressure (MUCP) values during Pelvic Floor Muscle Contraction (PFMC). The objective was to evaluate the change in the urethral closure pressure (UCP) at rest and during a PFMC in patients with Stress Urinary Incontinence.

Materials and methods:

This was a descriptive, comparative, and observational study. The study comprised female patients with either Pure Stress Urinary Incontinence (PSUI) or Complicated Stress Urinary Incontinence (CSUI). The urethral closure pressure was measured at rest and during PFMC using urethral profilometry. The effect of the pelvic musculature contraction was evaluated by comparing the changes in the indicated values.

Results:

Patients with pure stress urinary incontinence had a mean age of 57.18 ± 10.74 years ( p = 0.12), while those with complicated stress urinary incontinence had a mean age of 58.26 ± 14.39 years ( p = 0.12). UCP in PSUI was 58.58 ± 26.96 cmH2O at rest compared to 61.26 ± 34.17 cmH2O in CSUI ( p = 0.59), with MUCP increasing to 73.93 ± 31.51 and 79.71 ± 36.26 cmH2O during PFMC ( p = 0.001). Between the two measurements, there was an average rise of 26.2% (range 26.2%−32.59%) ( p = 0.001). MUCP during PFM contractions was found to be inversely associated to age ( r = −0.28, p = 0.007).

Conclusion:

The urethral pressure profile is the same for all types of urinary stress incontinence, whether simple or complicated. When comparing UCP at rest to MUCP during PFMC, there is at least a functional 25% increase.

Wearing high heels with an appropriate height is protective for pelvic floor function

Background

Wearing high-heeled shoes is a common phenomenon among women. However, the association between wearing high heels and pelvic floor function is largely unknown. Our aim was to evaluate the effects of wearing different height shoes on pelvic floor function and to analyze the influencing factors.

Methods

This was a population-based, cross-sectional study performed in general hospitals with a pelvic floor subspecialty in some cities of China. All participants completed a Urogenital Distress Inventory (UDI-6) questionnaire that consisted of demographic data, information about wearing shoes, and information about pelvic floor function (UDI-6). One-way ANOVA was carried out to compare the differences among 4 groups according to the heel height (<3, 3–5, 5–7, and >7 cm groups). Multivariate logistic regression was performed to identify the factors influencing the effect of wearing 3–5 cm high-heeled shoes on pelvic floor function.

Results

In total, 1,263 participants finished the questionnaire and full data were collected. The 4 groups were comparable for clinical data, and participants who wore 3–5 cm high-heeled shoes had the lowest UDI-6 scores. Multivariate analysis revealed that the number of hours (≥8 h) wearing high heels per day and the thickness diameter (≥3 cm) of the heel were important factors affecting the protective effect of wearing 3–5 cm high-heeled shoes on pelvic floor function.

Conclusions

Wearing heeled shoes with a 3–5 cm heel height and ≥3 cm thickness for a long period of time is good for the pelvic floor function of women.

Ankle positions potentially facilitating greater maximal contraction of pelvic floor muscles: a systematic review and meta-analysis

Objectives: To evaluate the effect of ankle positions on pelvic floor muscles in women. Methods: Multiple databases were searched from inception-July 2017. Study quality was rated using the grading of recommendations, assessment, development, and evaluation system and the "threats to validity tool". Results: Four studies were eligible for inclusion. Meta-analysis revealed significantly greater resting activity of pelvic floor muscles in neutral ankle position (-1.36 (95% CI -2.30, -0.42) p =  0.004) and induced 15° dorsiflexion (-1.65 (95% CI -2.49, -0.81) p =  0.0001) compared to induced 15° plantar flexion. Significantly greater maximal voluntary contraction of pelvic floor was found in dorsiflexion compared to plantar flexion (-2.28 (95% CI -3.96, -0.60) p =  0.008). Meta-analyses revealed no significant differences between the neutral ankle position and 15° dorsiflexion for either resting activity (0.30 (95% CI -0.75, 1.35) p =  0.57) or maximal voluntary contraction (0.97 (95% CI -0.77, 2.72) p =  0.27). Conclusion: Pelvic floor muscle-training for women with urinary incontinence could be performed in standing with ankles in a neutral position or dorsiflexion to facilitate greater maximal pelvic floor muscle contraction. As urethral support requires resting contraction of pelvic floor muscles, decreased resting activity in plantar flexion identified in the meta-analysis indicates that high-heel wearers with urinary incontinence might potentially experience more leakage during exertion in a standing position. Implications for rehabilitation Pooled analyses revealed that maximal voluntary contraction of pelvic floor muscle is greater in induced ankle dorsiflexion than induced plantar flexion. As pelvic floor muscle strengthening involves achieving a greater maximal voluntary contraction, pelvic floor muscle training for women with stress urinary incontinence could be performed in standing either with ankles in a neutral position or dorsiflexion. Decreased resting activity in plantar flexion identified in the meta-analysis indicates that high-heel wearers with stress urinary incontinence might potentially experience more leakage during exertion in a standing position. Women with stress urinary incontinence should be advised to wear flat shoes instead of high-heels and should be cautioned about body posture and ankle positions assumed during exercise and daily activities.

Stress Urinary Incontinence in Women With Multiple Sclerosis

Purpose

To report the prevalence and risk factors of stress urinary incontinence (SUI) and the prevalence of intrinsic sphincter deficiency in women with multiple sclerosis (MS).

Methods

We conducted a retrospective study. Female patients with MS, followed for lower urinary tract symptoms (LUTS) during a 15-year period were included. Demographic data, MS history, expanded disability status scale (EDSS) score at the urodynamic visit, obstetrical past, birth weight, LUTS, and urodynamic findings were collected. SUI was defined as incontinence during cough, or any effort. A maximum urethral closure pressure less than 30 cm H₂O defined intrinsic sphincter deficiency.

Results

We included 363 women with a mean age of 46.7±10.8 years and a mean disease duration of 12.9±8.7 years. The incidence of relapsing remitting MS, a secondary progressive form, and a primary progressive form was 60.6%, 32.8%, and 6.6%, respectively. The prevalence of SUI was 31.4%. The prevalence of intrinsic sphincter deficiency was 1.4% and 0.8% of these patients had a SUI (P=0.300). In a multivariate analysis, women with a SUI had significantly higher birth weight (P=0.030), a pelvic organ prolapse (P=0.021), urgent urinary incontinence (P=0.006), a lower EDSS score (P=0.019), and a weaker containing effort (P<0.001).

Conclusions

The prevalence of SUI in women with MS was 31.4%. This symptom could affect the quality of life of women with MS.