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Muro S, Shoji S, Suriyut J, Akita K. Anatomy of muscle connections in the male urethra and anorectal canal. BJU Int 2024; 133:752-759. [PMID: 38456568 DOI: 10.1111/bju.16307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
OBJECTIVES To elucidate the male urethral muscular structure and its relationship with the anorectal canal muscles, as establishing an anatomical foundation for urethral function will contribute to the prevention, diagnosis, and treatment of urinary incontinence. METHODS Eight male cadavers were used. Using a multifaceted approach, we performed macroscopic anatomical examination, histological analysis of wide-range serial sectioning and immunostaining, and three-dimensional (3D) reconstruction from histological sections. In the macroscopic anatomical examination, pelvic halves were meticulously dissected in layers from the medial aspect. In the histological analysis, the tissue, including the urethra and anorectal canal, was serially sectioned in the horizontal plane. The muscular structures were reconstructed and visualised in 3D. RESULTS The membranous portion of the urethra had three muscle layers: the longitudinal and circular muscles (smooth muscle) and the external urethral sphincter (skeletal muscle). The circular muscle was connected posteriorly to the longitudinal rectal muscle. The external urethral sphincter had a horseshoe shape, with its posterior ends continuing to the external anal sphincter, forming a 3D ring-like sphincter. CONCLUSION This study revealed skeletal and smooth muscle connections between the male urethra and anorectal canal, enabling urethral compression and closure. These anatomical muscle connections suggest a functional linkage between them.
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Affiliation(s)
- Satoru Muro
- Department of Clinical Anatomy, Tokyo Medical and Dental University (TMDU), Bunkyo-ku, Tokyo, Japan
| | - Sunao Shoji
- Department of Urology, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Janyaruk Suriyut
- Department of Anatomy, Faculty of Medicine, Srinakharinwirot University, Bangkok, Thailand
| | - Keiichi Akita
- Department of Clinical Anatomy, Tokyo Medical and Dental University (TMDU), Bunkyo-ku, Tokyo, Japan
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Ouchi M, Kitta T, Chiba H, Higuchi M, Abe-Takahashi Y, Togo M, Kusakabe N, Murai S, Kikuchi H, Matsumoto R, Osawa T, Abe T, Shinohara N. Physiotherapy for continence and muscle function in prostatectomy: a randomised controlled trial. BJU Int 2024. [PMID: 38658057 DOI: 10.1111/bju.16369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
OBJECTIVE To assess the effectiveness of pre- and postoperative supervised pelvic floor muscle training (PFMT) on the recovery of continence and pelvic floor muscle (PFM) function after robot-assisted laparoscopic radical prostatectomy (RARP). PATIENTS AND METHODS We carried out a single-blind randomised controlled trial involving 54 male patients scheduled to undergo RARP. The intervention group started supervised PFMT 2 months before RARP and continued for 12 months after surgery with a physiotherapist. The control group was given verbal instructions, a brochure about PFMT, and lifestyle advice. The primary outcome was 24-h pad weight (g) at 3 months after RARP. The secondary outcomes were continence status (assessed by pad use), PFM function, and the Expanded Prostate Cancer Index Composite (EPIC) score. RESULTS Patients who participated in supervised PFMT showed significantly improved postoperative urinary incontinence (UI) compared with the control group (5.0 [0.0-908.0] g vs 21.0 [0.0-750.0] g; effect size: 0.34, P = 0.022) at 3 months after RARP based on 24-h pad weight. A significant improvement was seen in the intervention compared with the control group (65.2% continence [no pad use] vs 31.6% continence, respectively) at 12 months after surgery (effect size: 0.34, P = 0.030). Peak pressure during a maximum voluntary contraction was higher in the intervention group immediately after catheter removal and at 6 months, and a longer duration of sustained contraction was found in the intervention group compared with the control group. We were unable to demonstrate a difference between groups in EPIC scores. CONCLUSION Supervised PFMT can improve postoperative UI and PFM function after RARP. Further studies are needed to confirm whether intra-anal pressure reflects PFM function and affects continence status in UI in men who have undergone RARP.
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Affiliation(s)
- Mifuka Ouchi
- Department of Renal and Genitourinary Surgery, Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Takeya Kitta
- Department of Renal and Urologic Surgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Hiroki Chiba
- Department of Urology, Hokkaido University Hospital, Sapporo, Hokkaido, Japan
| | - Madoka Higuchi
- Department of Urology, Hokkaido University Hospital, Sapporo, Hokkaido, Japan
| | - Yui Abe-Takahashi
- Department of Renal and Genitourinary Surgery, Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Mio Togo
- Department of Renal and Genitourinary Surgery, Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Naohisa Kusakabe
- Department of Renal and Genitourinary Surgery, Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Sachiyo Murai
- Department of Renal and Genitourinary Surgery, Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Hiroshi Kikuchi
- Department of Urology, Hokkaido University Hospital, Sapporo, Hokkaido, Japan
| | - Ryuji Matsumoto
- Department of Renal and Genitourinary Surgery, Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Takahiro Osawa
- Department of Urology, Hokkaido University Hospital, Sapporo, Hokkaido, Japan
| | - Takashige Abe
- Department of Renal and Genitourinary Surgery, Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Nobuo Shinohara
- Department of Renal and Genitourinary Surgery, Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
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Wu L, Liu Y, Xu P, Yang M. Transperineal pelvic floor ultrasound in male. Int Urol Nephrol 2023; 55:3261-3268. [PMID: 37160487 DOI: 10.1007/s11255-023-03617-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 04/24/2023] [Indexed: 05/11/2023]
Abstract
INTRODUCTION The pelvic floor (PF) is a highly complex structure which may be affected by various stimulating factors like decreased PF support. As ultrasound can dynamically observe the position and mobility of anatomical structures, However, there are very few studies on PF ultrasound in males. MATERIALS AND METHODS Twenty-one male patients with normal conditions underwent transperineal pelvic floor ultrasound (TPFU) examination. Ultrasound was performed in a supine lithotomy position. The probe was pressed on the sagittal plane of the perineum and adjusted till the anorectal angle, as well as bladder, were located and the median prostate and pubic symphysis were visible on the sagittal plane. TPFU was carried out to observe the patterns of pelvic floor movement during different phases, measure ultrasound parameters of the PF in men, and assess the potential applications and prospects of the male PF. RESULTS Two-dimensional male PF ultrasound can detect the bladder, prostate, male urethra, anus, rectum. Resting, Valsalva, and contraction phases of the PF are clearly shown, the pelvic organs in the Valsalva phase shift to the dorsal foot side, and shift to the cephalic ventral side when the levator ani muscle (LAM) contracts. Three-dimensional male PF ultrasound can visually show the shape and structure of the levator ani muscle hiatus. CONCLUSION It is a feasible examination tool for detecting PF disorders. However, there are still many fields to explore in the future.
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Affiliation(s)
- Lanying Wu
- Department of Ultrasound, Beijing Shijitan Hospital Affiliated to Capital Medical University, No. 10 Tieyi Road, Yangfangdian, Haidian District, Beijing, China
| | - Yong Liu
- Department of Ultrasound, Beijing Shijitan Hospital Affiliated to Capital Medical University, No. 10 Tieyi Road, Yangfangdian, Haidian District, Beijing, China
| | - Ping Xu
- Department of Ultrasound, Beijing Shijitan Hospital Affiliated to Capital Medical University, No. 10 Tieyi Road, Yangfangdian, Haidian District, Beijing, China
| | - Min Yang
- Department of Ultrasound, Beijing Shijitan Hospital Affiliated to Capital Medical University, No. 10 Tieyi Road, Yangfangdian, Haidian District, Beijing, China.
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Colarieti A, Shaida N, Thiruchelvam N, Barrett T. Transperineal Ultrasound Before and After Prostatectomy: Technical Approach and Description. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2022; 41:3125-3135. [PMID: 35866181 PMCID: PMC9796877 DOI: 10.1002/jum.16064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 06/29/2022] [Accepted: 07/04/2022] [Indexed: 06/15/2023]
Abstract
This study assessed the feasibility of dynamic transperineal ultrasound (TPUS) pre/post-radical prostatectomy (RP). Ninety-eight patients were scanned pre-operatively and at four time-points post-operatively. TPUS was performed in 98 patients using an abdominal transducer at rest, during pelvic floor contraction (PFC) and Valsalva (VS) maneuver in supine and standing positions. Urodynamic evaluations included bladder neck angle at rest/PFC/VS, and degree of bladder neck movement. Pre-operative and post-operative measurements were technically feasible in >85% (supine) and >90% (standing) of patients. TPUS offers a reliable non-invasive dynamic assessment of the pelvic floor post-prostatectomy and may prove a useful adjunct for guiding exercises to preserve continence.
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Affiliation(s)
| | - Nadeem Shaida
- Department of Radiology, Addenbrooke's HospitalUniversity of CambridgeCambridgeUK
| | - Nikesh Thiruchelvam
- Department of Urology, Addenbrooke's HospitalUniversity of CambridgeCambridgeUK
| | - Tristan Barrett
- Department of Radiology, Addenbrooke's HospitalUniversity of CambridgeCambridgeUK
- CamPARI Clinic, Addenbrooke's HospitalUniversity of CambridgeCambridgeUK
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Stafford RE, Doorbar‐Baptist S, Hodges PW. The relationship between pre- and postprostatectomy measures of pelvic floor muscle function and development of early incontinence after surgery. Neurourol Urodyn 2022; 41:1722-1730. [PMID: 36066088 PMCID: PMC9826381 DOI: 10.1002/nau.25034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 07/07/2022] [Accepted: 07/21/2022] [Indexed: 01/11/2023]
Abstract
AIMS The aim of this study is to investigate (i) whether pelvic floor muscle (PFM) shortening can be enhanced by provision of training focused on striated urethral sphincter (SUS) with feedback before prostatectomy, (ii) whether PFM shortening during voluntary efforts and coughing before and after prostatectomy differs between men who do and do not report symptoms of urinary incontinence 1 month after prostatectomy, and (iii) the relationship between severity of incontinence after prostatectomy and features of pelvic floor function (muscle shortening) and urethral length before and after prostatectomy. METHODS Sixty men referred for preoperative PFM training before radical prostatectomy participated. The International Continence Society Male Short Form questionnaire was used to quantify continence status. Transperineal ultrasound (US) imaging was used to record pelvic displacements related to activation of striated urethral sphincter, bulbocavernosus (BC) and puborectalis muscles during cough, "natural" voluntary contraction following pamphlet instruction, and trained voluntary contraction after formal physiotherapist instruction including US feedback. RESULTS Pelvic floor displacements following training differed between continent and incontinent men; continent participants demonstrated increased SUS shortening after training (compared with "natural"), but no difference was observed between trained and "natural" contractions for incontinent participants. Motion at ano-rectal junction during cough was reduced following surgery, but voluntary and involuntary activation of SUS or BC was not consistently affected by surgery. CONCLUSIONS Participants' capacity to improve function of the SUS with training appears related to postprostatectomy continence outcome.
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Affiliation(s)
- Ryan E. Stafford
- The University of QueenslandSchool of Health and Rehabilitation SciencesBrisbaneQLDAustralia,School of Human Sciences (Exercise Science)The University of Western AustraliaPerthWAAustralia
| | | | - Paul W. Hodges
- The University of QueenslandSchool of Health and Rehabilitation SciencesBrisbaneQLDAustralia
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6
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Sayner AM, Tang CY, Toohey K, Mendoza C, Nahon I. Opportunities and Capabilities to Perform Pelvic Floor Muscle Training Are Critical for Participation: A Systematic Review and Qualitative Meta-Synthesis. Phys Ther 2022; 102:6652914. [PMID: 35913726 DOI: 10.1093/ptj/pzac106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 04/07/2022] [Accepted: 06/09/2022] [Indexed: 11/14/2022]
Abstract
OBJECTIVE Pelvic floor muscle training (PFMT) is considered a behavioral task that requires the interaction of physical, social, and cognitive processes. Enablers and barriers to participation in PFMT have been explored primarily in women. This review aimed to identify the barriers and enablers that influence participation in PFMT in all adult populations. METHODS A systematic review and meta-synthesis of qualitative literature was conducted. The inclusion criteria comprised qualitative studies with populations of people aged 18 years and older who have been recommended for PFMT. Line-by-line coding and an inductive thematic analysis identified themes that were applied to the Theoretical Domains Framework and Capabilities, Opportunities, and Motivation Behavioral Model to determine behavioral influences on PFMT. RESULTS Twenty full-text articles met inclusion criteria. PFMT was mostly influenced by individual opportunities impacted by social determinants and competing demands. Capability of carrying out PFMT was impacted by knowledge, understanding, and appropriate skill acquisition linked to self-efficacy. CONCLUSION Increasing opportunities and capabilities for engagement in PFMT are the most important factors in optimizing positive behavior changes. Ways to address these factors include clear patient communication to boost confidence in skill acquisition and using technology to encourage autonomy and improve convenience. Future research should address the impact of health professionals' beliefs about patient participation, assess the role of social values and gender roles, and explore the timing of the implementation of behavioral change strategies to improve PFMT. IMPACT This is believed to be the first systematic review and qualitative meta-synthesis to consider the enablers and barriers to participation in PFMT for all adult populations, purposes, and symptom complexes. Patient opportunities and capabilities are the greatest influencers on participation and self-efficacy. Individualized treatment approaches that acknowledge and address social influencers and competing demands will optimize self-efficacy and participation. LAY SUMMARY If you have pelvic floor muscle dysfunction, your opportunities and capabilities are the greatest influencers on participation and self-efficacy in PFMT. Your physical therapist can design individualized treatment approaches that acknowledge and address social influencers and competing demands to help you optimize participation.
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Affiliation(s)
- Alesha M Sayner
- Faculty of Health, University of Canberra, Bruce, Australian Capital Territory, Australia.,Chronic and Complex Care/Department of Physiotherapy, Western Health, St Albans, Victoria, Australia.,Prehabilitation, Activity, Cancer, Exercise and Survivorship (PACES) Research Group, Faculty of Health, University of Canberra, Bruce, Australian Capital Territory, Australia.,Allied Health Department, Ballarat Health Services, Ballarat, Victoria, Australia
| | - Clarice Y Tang
- Chronic and Complex Care/Department of Physiotherapy, Western Health, St Albans, Victoria, Australia.,School of Health Sciences, Western Sydney University, Penrith, New South Wales, Australia.,School of Allied Health, La Trobe University, Melbourne, Victoria, Australia
| | - Kellie Toohey
- Faculty of Health, University of Canberra, Bruce, Australian Capital Territory, Australia.,Prehabilitation, Activity, Cancer, Exercise and Survivorship (PACES) Research Group, Faculty of Health, University of Canberra, Bruce, Australian Capital Territory, Australia
| | - Chennelle Mendoza
- Chronic and Complex Care/Department of Physiotherapy, Western Health, St Albans, Victoria, Australia
| | - Irmina Nahon
- Faculty of Health, University of Canberra, Bruce, Australian Capital Territory, Australia.,Prehabilitation, Activity, Cancer, Exercise and Survivorship (PACES) Research Group, Faculty of Health, University of Canberra, Bruce, Australian Capital Territory, Australia
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7
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Ben Ami N, Feldman R, Dar G. Verbal Instruction for Pelvic Floor Muscle Contraction among Healthy Young Males. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:12031. [PMID: 36231333 PMCID: PMC9566287 DOI: 10.3390/ijerph191912031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 09/19/2022] [Accepted: 09/20/2022] [Indexed: 06/16/2023]
Abstract
Teaching Pelvic Floor Muscle (PFM) contraction is a challenging task for clinicians and patients, as these muscles cannot be directly visualized. Thus, this study's objective is to compare the effectiveness of six verbal instructions for contracting the PFM among young men, as observed with transabdominal ultrasound imaging. Thirty-five male physiotherapy students, mean age 25.9 ± 1.9 years, participated in the study. A 6 MHz 35-mm curved linear array ultrasound transducer (Mindray M5) was placed in the transverse plane, supra-pubically, and angled 15-30° from the vertical plane. During crook lying, participants received six verbal instructions for contracting the PFM, with bladder base displacement and endurance evaluated. Following the instructions, "squeeze your anus", "shorten the penis", and "elevate the scrotum", over 91% of the participants performed a cranial (upward) bladder base displacement. During instruction six, "draw in", which involves breathing, the PFM, and the transversus abdominis, only 25% performed cranial bladder base displacement (p < 0.001), and the endurance was the lowest (p < 0.001). Our findings suggest that several simple verbal instructions can be used for teaching PFM contraction to young males. Moreover, two instructions should be avoided: "draw in" and the general instruction "squeeze your PFM", as they did not produce effective elevation of the bladder base.
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Affiliation(s)
- Noa Ben Ami
- Department of Physiotherapy, Faculty of Health Sciences, Ariel University, Ariel 4077625, Israel
| | - Ron Feldman
- Department of Physiotherapy, Faculty of Health Sciences, Ariel University, Ariel 4077625, Israel
| | - Gali Dar
- Department of Physical Therapy, Faculty of Social Welfare & Health Sciences, University of Haifa, Mount Carmel, Haifa 3498838, Israel
- Ribstein Center for Research and Sports Medicine, Wingate Institute, Netanya 4290200, Israel
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8
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Cowley D, Stafford RE, Hodges PW. The influence of prostatectomy and body position on location and displacement of pelvic landmarks with pelvic floor muscle contraction. Neurourol Urodyn 2021; 41:203-210. [PMID: 34529870 DOI: 10.1002/nau.24794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 08/08/2021] [Accepted: 08/25/2021] [Indexed: 12/24/2022]
Abstract
AIMS To compare pelvic floor muscle (PFM) anatomy and function (i) between pre- and post-prostatectomy in standing, and (ii) between sitting and standing postprostatectomy. METHODS Thirty-two men scheduled to undergo a prostatectomy volunteered to participate. Transperineal ultrasound imaging was used to visualize five anatomical pelvic landmarks that have been validated to reflex anatomy and activity of PFMs (pubic symphysis, anorectal junction [ARJ], mid-urethra [MU], bulb of penis [BP], and urethrovesical junction [UVJ]). Both before and after prostatectomy, participants performed three submaximal PFM contractions in sitting and/or standing positions while ultrasound data were recorded. RESULTS Postprostatectomy the UVJ location was more caudal and dorsal, the ARJ (puborectalis) vector was longer, the BP was more ventral than preprostatectomy, and these landmarks moved less ventrally with contraction. After prostatectomy, the MU, BP, and ARJ were more ventral in standing than sitting. The UVJ was more caudal and elevated more with contraction in standing than sitting after prostatectomy. CONCLUSION These data demonstrate differences in the anatomy and mechanics of PFMs post- versus pre-prostatectomy, and between sitting and standing positions postprostatectomy. Findings are consistent with surgical changes to the bladder and urethral anatomy. Reduced passive support for the urethra and bladder are likely to may contribute to differences between standing and sitting postprostatectomy.
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Affiliation(s)
- David Cowley
- School of Health and Rehabilitation Sciences, Faculty of Health and Behavioural Sciences, The University of Queensland, Brisbane, Queensland, Australia
| | - Ryan E Stafford
- School of Health and Rehabilitation Sciences, Faculty of Health and Behavioural Sciences, The University of Queensland, Brisbane, Queensland, Australia.,School of Human Sciences, The University of Western Australia, Perth, Western Australia, Australia
| | - Paul W Hodges
- School of Health and Rehabilitation Sciences, Faculty of Health and Behavioural Sciences, The University of Queensland, Brisbane, Queensland, Australia
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9
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Cowley D, Stafford RE, Hodges PW. The repeatability of measurements of male pelvic floor anatomy and function made from transperineal ultrasound images of healthy men and those before and after prostatectomy. Neurourol Urodyn 2021; 40:1539-1549. [PMID: 34130355 DOI: 10.1002/nau.24701] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 04/20/2021] [Accepted: 05/03/2021] [Indexed: 11/09/2022]
Abstract
AIMS To investigate the inter- and intratester repeatability of measurement of the location and displacement of five pelvic landmarks related to pelvic floor muscles with transperineal ultrasound (TPUS) imaging recorded from healthy men and men before and after prostatectomy. METHODS TPUS images were selected from four different participant groups: healthy men, men awaiting prostatectomy, men 2 weeks after prostatectomy, and men 12 months after prostatectomy. On two separate occasions, two assessors with different levels of experience performed analysis of location and displacement of five pelvic landmarks in images made at rest and during voluntary contraction. A two-way mixed effects, single measurement, absolute agreement intraclass correlation coefficient (ICC) was used to investigate the repeatability. RESULTS Intertester reliability of all locations at rest for all groups was excellent (ICCs > 0.8) except for the craniocaudal coordinate of the ventral urethrovesical junction for men 2 weeks postprostatectomy and the anorectal junction for men with a cancerous prostate. Intertester reliability of the measurement of landmark displacement was acceptable (>0.5) for the dorsoventral axis of motion but not for the craniocaudal axis of motion for all landmarks across all groups. The more experienced assessor was consistently more repeatable. More deeply placed landmarks were more often excluded from analysis and had poorer reliability. CONCLUSIONS Analysis of TPUS images across clinical groups is repeatable for both location and displacement of pelvic landmarks related to pelvic floor muscles when measures are made twice. Analysis experience, landmark depth and optimization of ultrasound settings appear to be important factors in reliability.
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Affiliation(s)
- David Cowley
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
| | - Ryan E Stafford
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia.,Division of Exercise Science, School of Human Sciences, The University of Western Australia, Perth, Australia
| | - Paul W Hodges
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
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10
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Pané-Alemany R, Ramírez-García I, Carralero-Martínez A, Blanco-Ratto L, Kauffmann S, Sánchez E. Efficacy of transcutaneous perineal electrostimulation versus intracavitary anal electrostimulation in the treatment of urinary incontinence after a radical prostatectomy: randomized controlled trial study protocol. BMC Urol 2021; 21:12. [PMID: 33509164 PMCID: PMC7842059 DOI: 10.1186/s12894-020-00718-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 09/14/2020] [Indexed: 01/05/2023] Open
Abstract
Background Radical prostatectomy is the gold standard treatment for men with localized prostate cancer. This technique is associated with post-operative urinary incontinence. Pelvic floor physiotherapy is a conservative, painless and economical treatment for this specific situation. Kegel exercises and perineal electrostimulation are common techniques to train pelvic floor muscles. The perineal electrostimulation can be applied to the patient with surface electrodes or by an intra-cavitary anal probe. This study proposes that transcutaneous perineal electrostimulation is as effective as intra-cavitary electrostimulation in reducing urinary incontinence secondary to radical prostatectomy. The main objective is to compare the efficacy of the treatment with transcutaneous perineal electrostimulation versus the same intra-cavitary treatment to reduce the magnitude of urinary incontinence after radical prostatectomy, and the impact on the quality of life. Methods This single-blind equivalence randomized controlled trial will include 70 man who suffer urinary incontinence post radical prostatectomy. Participants will be randomized into surface electrodes group and intra-anal probe group. The groups will receive treatment for 10 consecutive weeks. Outcomes include changes in the 24-h Pad Test, and ICIQ-SF, SF-12 and I-QoL questionnaires. Clinical data will be collected at baseline, 6 and 10 weeks after the first session, and 6 months after the end of treatment. Discussion The results will allow us to prescribe the most beneficial perineal electrostimulation technique in the treatment of urinary incontinence derived from radical prostatectomy. Trial registration ClinicalTrials.gov Identifier: NCT03587402. 27/06/2018
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Affiliation(s)
- R Pané-Alemany
- Rehabilitación Abdomino-Pelviana (RAPbarcelona SL), Barcelona, Spain
| | - I Ramírez-García
- Rehabilitación Abdomino-Pelviana (RAPbarcelona SL), Barcelona, Spain. .,Servicio de Fisioterapia, Instituto Médico Tecnológico SL, Barcelona, Spain. .,Blanquerna School of Health Science-Universitat Ramon Llull, Barcelona, Spain. .,Universidad Internacional de Catalunya (UIC), Barcelona, Spain.
| | | | - L Blanco-Ratto
- Rehabilitación Abdomino-Pelviana (RAPbarcelona SL), Barcelona, Spain.,Fundació Universitària del Bages (FUB), Barcelona, Spain
| | - S Kauffmann
- Rehabilitación Abdomino-Pelviana (RAPbarcelona SL), Barcelona, Spain.,Fundació Universitària del Bages (FUB), Barcelona, Spain.,Servicio de Fisioterapia, Womens Salud Y Bienestar de La Mujer SL, Barcelona, Spain
| | - E Sánchez
- Blanquerna School of Health Science-Universitat Ramon Llull, Barcelona, Spain
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11
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Mungovan SF, Carlsson SV, Gass GC, Graham PL, Sandhu JS, Akin O, Scardino PT, Eastham JA, Patel MI. Preoperative exercise interventions to optimize continence outcomes following radical prostatectomy. Nat Rev Urol 2021; 18:259-281. [PMID: 33833445 PMCID: PMC8030653 DOI: 10.1038/s41585-021-00445-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2021] [Indexed: 01/31/2023]
Abstract
Urinary incontinence is a common and predictable consequence among men with localized prostate cancer who have undergone radical prostatectomy. Despite advances in the surgical technique, urinary continence recovery time remains variable. A range of surgical and patient-related risk factors contributing to urinary incontinence after radical prostatectomy have been described, including age, BMI, membranous urethral length and urethral sphincter insufficiency. Physical activity interventions incorporating aerobic exercise, resistance training and pelvic floor muscle training programmes can positively influence the return to continence in men after radical prostatectomy. Traditional approaches to improving urinary continence after radical prostatectomy have typically focused on interventions delivered during the postoperative period (rehabilitation). However, the limited efficacy of these postoperative approaches has led to a shift from the traditional reactive model of care to more comprehensive interventions incorporating exercise-based programmes that begin in the preoperative period (prehabilitation) and continue after surgery. Comprehensive prehabilitation interventions include appropriately prescribed aerobic exercise, resistance training and specific pelvic floor muscle instruction and exercise training programmes. Transperineal ultrasonography is a non-invasive and validated method for the visualization of the action of the pelvic floor musculature, providing real-time visual biofeedback to the patient during specific pelvic floor muscle instruction and training. Importantly, the waiting time before surgery can be used for the delivery of comprehensive prehabilitation exercise-based interventions to increase patient preparedness in the lead-up to surgery and optimize continence and health-related quality-of-life outcomes following radical prostatectomy.
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Affiliation(s)
- Sean F. Mungovan
- Westmead Private Physiotherapy Services, Westmead Private Hospital, Westmead, New South Wales Australia ,The Clinical Research Institute, Westmead, New South Wales Australia ,grid.1027.40000 0004 0409 2862Department of Professions, Faculty of Health, Arts and Design, Swinburne University of Technology, Hawthorn, Victoria Australia
| | - Sigrid V. Carlsson
- grid.51462.340000 0001 2171 9952Urology Service at the Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY USA ,grid.51462.340000 0001 2171 9952Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY USA ,grid.8761.80000 0000 9919 9582Institute of Clinical Sciences, Department of Urology, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Gregory C. Gass
- The Clinical Research Institute, Westmead, New South Wales Australia ,grid.420519.b0000 0000 9952 4517Physical Therapy Program, University of Jamestown, Fargo, ND USA
| | - Petra L. Graham
- grid.1004.50000 0001 2158 5405Department of Mathematics and Statistics, Macquarie University, Macquarie Park, New South Wales Australia
| | - Jaspreet S. Sandhu
- grid.51462.340000 0001 2171 9952Urology Service at the Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY USA
| | - Oguz Akin
- grid.51462.340000 0001 2171 9952Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY USA
| | - Peter T. Scardino
- grid.51462.340000 0001 2171 9952Urology Service at the Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY USA
| | - James A. Eastham
- grid.51462.340000 0001 2171 9952Urology Service at the Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY USA
| | - Manish I. Patel
- grid.1013.30000 0004 1936 834XSpecialty of Surgery, Sydney Medical School, The University of Sydney, Sydney, New South Wales Australia ,grid.413252.30000 0001 0180 6477Department of Urology, Westmead Hospital, Westmead, New South Wales Australia
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Stafford RE, Arkwright J, Dinning PG, van den Hoorn W, Hodges PW. Novel insight into pressurization of the male and female urethra through application of a multi-channel fibre-optic pressure transducer: Proof of concept and validation. Investig Clin Urol 2020; 61:528-537. [PMID: 32869566 PMCID: PMC7458876 DOI: 10.4111/icu.20200059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 03/31/2020] [Accepted: 04/28/2020] [Indexed: 11/29/2022] Open
Abstract
Purpose To confirm feasibility of recording pressure along the length of the urethra using a multi-sensor fibre-optic pressure catheter; to identify the spatial and temporal features of changes in pressure along the urethra at sites related to specific striated pelvic floor muscles; and to investigate the relationship between urethral pressures and activation of individual pelvic floor muscles estimated from ultrasound imaging. Materials and Methods Proof-of-concept study including one male (47 years old) and one female (33 years old). A multi-sensor fibre optic pressure catheter (10 mm sensor separation) was inserted into the urethra. Pressure data were recorded simultaneously with trans-perineal ultrasound imaging measures of pelvic floor muscle activity during sub-maximal and maximal voluntary contractions and evoked coughs. Results Pressure changes along the urethra were recorded in all tasks in both participants. Face validity of interpretation of pressure measures with respect to individual muscles was supported by correlation with ultrasound-measured displacements induced by the relevant muscles. Onset of pressure increase occurred in a distal to proximal sequence in the urethra of the male but not the female during voluntary contraction. Peak urethral pressures varied in location, timing and amplitude between tasks. Evoked cough induced in the greatest urethral pressure increase across all tasks for both participants. Conclusions The high spatial resolution pressure catheter provide viable and valid recordings of urethral pressure in a male and female. Data provide preliminary evidence of sex differences in spatial and temporal distribution of urethral pressure changes.
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Affiliation(s)
- Ryan E Stafford
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
| | - John Arkwright
- College of Science and Engineering, Flinders University, Adelaide, Australia
| | - Phil G Dinning
- Department of Gastroenterology and Surgery, Flinders Medical Centre, Adelaide, Australia
| | - Wolbert van den Hoorn
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
| | - Paul W Hodges
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia.
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Sayner A, Nahon I. Pelvic Floor Muscle Training in Radical Prostatectomy and Recent Understanding of the Male Continence Mechanism: A Review. Semin Oncol Nurs 2020; 36:151050. [PMID: 32674975 DOI: 10.1016/j.soncn.2020.151050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Pelvic floor muscle training (PFMT) is recommended as part of supportive care for patients with prostate cancer. It can assist in reducing treatment-related symptoms such as urinary incontinence. This literature review aims to discuss recent innovative findings on the pathophysiology of the male continence mechanism and implications for PFMT in radical prostatectomy. DATA SOURCES CINAHL, Embase, Web of Science, Emcare and PsycINFO were searched until January 2020. CONCLUSION Nurses providing supportive care for patients undergoing radical prostatectomy can engage in-clinic in the instruction and recommendation of pre- and postoperative PFMT and delivering guidance on home-based programs to promote motor learning. IMPLICATIONS FOR NURSING PRACTICE Optimal postoperative urinary incontinence outcomes are suggested to be promoted by preoperative PFMT. Training focused on the urethral and anterior pelvic floor muscle complex has been shown to facilitate mid urethral occlusion required for continence. Prescription of PFMT should be individualised, focusing on skill acquisition and motor learning, which is in line with recent knowledge developments in male pelvic floor anatomy.
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Affiliation(s)
- Alesha Sayner
- University of Canberra, Australian Capital Territory, Australia; Western Health, Chronic and Complex Care/Physiotherapy Department, Melbourne, Australia; Australian Prostate Centre, Melbourne, Australia.
| | - Irmina Nahon
- University of Canberra, Australian Capital Territory, Australia
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14
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Cowley D, Stafford RE, Hodges PW. Influence of body position on dynamics of the pelvic floor measured with transperineal ultrasound imaging in men. Neurourol Urodyn 2020; 39:954-961. [PMID: 32027772 DOI: 10.1002/nau.24301] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 01/23/2020] [Indexed: 11/12/2022]
Abstract
AIMS This paper aims to evaluate the feasibility of transperineal ultrasound imaging (TPUS) for visualizing the motion of pelvic landmarks associated with striated pelvic floor muscle contraction in men in standing; to compare the locations of pelvic landmarks between sitting and standing; and to compare the effects of different body positions on measures of pelvic floor muscle contraction. METHODS Thirty-five men awaiting prostatectomy volunteered to participate. Participants performed three repetitions of submaximal pelvic floor contraction in sitting and again in standing. Movement of pelvic landmarks with contraction was recorded using an ultrasound imaging transducer placed on the perineum. RESULTS The feasibility of TPUS in men in standing was demonstrated through the visualization of three out of four pelvic landmarks in more than 95% of images in the standing position. Analysis of pelvic landmarks and their respective relationships with muscle shortening demonstrated that the anorectal junction and urethrovesical junction were lower and the estimated length of puborectalis was shorter in standing than sitting. The mid-urethra (striated urethral sphincter) and anorectal junction (puborectalis) landmark displaced further cranially in standing than sitting. CONCLUSIONS TPUS can be used to visualize three pelvic landmarks in men with cancerous prostates. Puborectalis is shorter at rest in standing than sitting, and elevation of the mid-urethra and the anorectal junction is more in standing than sitting. Together these findings indicate that feedback for pelvic floor muscle training is possible in both positions, but the position needs to be standardized for a comparative assessment.
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Affiliation(s)
- David Cowley
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
| | - Ryan E Stafford
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia.,School of Human Sciences, The University of Western Australia, Perth, Australia
| | - Paul W Hodges
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
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15
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Hodges PW, Stafford RE, Hall L, Neumann P, Morrison S, Frawley H, Doorbar-Baptist S, Nahon I, Crow J, Thompson J, Cameron AP. Reconsideration of pelvic floor muscle training to prevent and treat incontinence after radical prostatectomy. Urol Oncol 2019; 38:354-371. [PMID: 31882228 DOI: 10.1016/j.urolonc.2019.12.007] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 11/08/2019] [Accepted: 12/02/2019] [Indexed: 01/20/2023]
Abstract
Urinary incontinence is common after radical prostatectomy. Pelvic floor muscle training provides a plausible solution. Although early trials provided promising results, systematic reviews have questioned the efficacy of this intervention. A major consideration is that most clinical trials in men have applied principles developed for pelvic floor muscle training for stress urinary incontinence in women, despite differences in anatomy between sexes and differences in the mechanisms for continence/incontinence. Literature regarding continence control in men has been conflicting and often based on erroneous anatomy. New understanding of continence mechanisms in men, including the complex contribution of multiple layers of striated pelvic floor muscles, and detailed consideration of the impact of radical prostatectomy on continence anatomy and physiology, have provided foundations for a new approach to pelvic floor muscle training to prevent and treat incontinence after prostatectomy. An approach to training can be designed to target the pathophysiology of incontinence. This approach relies on principles of motor learning and exercise physiology, in a manner that is tailored to the individual patient. The aims of this review are to consider new understanding of continence control in men, the mechanisms for incontinence after radical prostatectomy, and to review the characteristics of a pelvic floor muscle training program designed to specifically target recovery of continence after prostatectomy.
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Affiliation(s)
- Paul W Hodges
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia.
| | - Ryan E Stafford
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
| | - Leanne Hall
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
| | | | - Shan Morrison
- Women's and Men's Health Physiotherapy, Melbourne, Australia
| | | | | | | | - Jason Crow
- Active Rehabilitation, Brisbane, Australia
| | | | - Anne P Cameron
- Department of Urology, University of Michigan, Ann Arbor, MI
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16
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Comparison of dynamic features of pelvic floor muscle contraction between men with and without incontinence after prostatectomy and men with no history of prostate cancer. Neurourol Urodyn 2019; 39:170-180. [DOI: 10.1002/nau.24213] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 10/26/2019] [Indexed: 01/09/2023]
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17
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Costa Cruz DSLD, D Ancona CAL, Silva Filho WPD, Dornas MC, Baracat J, Moser DCU, Damião R. Parameters of 2-Dimensional Perineal Ultrasonography Before and After Male Sling Procedure for Urinary Incontinence After Radical Prostatectomy. Urology 2019; 136:257-262. [PMID: 31669134 DOI: 10.1016/j.urology.2019.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 10/06/2019] [Accepted: 10/09/2019] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To compare ultrasonographic patterns of 2-dimensional perineal ultrasonography in men in the preoperative and postoperative periods after transobturator sling deployment for the treatment of urinary incontinence after radical prostatectomy. Radiotherapy and radical prostatectomy are the primary treatments for localized prostate cancer. Studies comparing anatomic changes in men before and after radical prostatectomy based on perineal ultrasonography are scarce in the literature. METHODS Thirty-one patients from 2 centers were selected for examination and surgery. They were allocated into mild and/or moderate and severe incontinence groups who underwent the transobturator sling procedure between August 2014 and August 2018. Perineal ultrasonography was performed in the preoperative period for 21 of these patients and 3-6 months postoperatively after the transobturator sling procedure for 30 patients. Hypermobility of the proximal urethra and voluntary contraction of the pelvic floor were evaluated during the Valsalva maneuver, perineal contraction and at rest. RESULTS Clinical improvements of >50% were significantly more frequent in the mild and/or moderate vs severe incontinence group after male sling surgery (P = .035). Patients who demonstrated clinical improvement >50% showed a significantly greater displacement of the posterior portion of the bladder neck during contraction than those with clinical improvement <50% (P = .024). CONCLUSION The most important finding of this study was the significant difference in the posterior displacement of the bladder neck during contraction in patients who showed an improvement >50% compared with those with an improvement <50%. These data support the use of perineal ultrasonography in evaluating and selecting patients for the male sling procedure.
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Affiliation(s)
| | | | | | - Maria Cristina Dornas
- Hospital Universitário Pedro Ernesto-State University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Jamal Baracat
- Hospital de Clínicas-State University of Campinas, Rio de Janeiro, RJ, Brazil
| | | | - Ronaldo Damião
- Hospital Universitário Pedro Ernesto-State University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
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18
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Ha HK, Luiting HB, Graham PL, Patel MI, Sandhu JS, Akin O, Mungovan SF. Three novel methods to measure the postoperative displacement of lower urinary tract structures following radical prostatectomy in a sample of Korean patients. BMC Urol 2019; 19:54. [PMID: 31215416 PMCID: PMC6582582 DOI: 10.1186/s12894-019-0472-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 05/06/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND There is a change in the position of the remaining anatomical structures of the lower urinary tract system following radical prostatectomy. The aims of this investigation were to describe three novel methods used to measure the displacement of i) the vesico-urethral junction (VUJ), proximal membranous urethra (PMU) and anorectal junction (ARJ) and ii) the VUJ angle of displacement in men following radical prostatectomy and determine their intra- and interrater reliability. METHODS Retrospective comparative measurement of twenty pre- and postoperative MRI scans was undertaken by one observer on two separate occasions and on one occasion by another observer. Three standardized midsagittal pelvimetry reference lines were used to describe three X, Y axis measurement systems. The displacement (mm) of the VUJ, PMU and ARJ, and the angle of displacement (degrees) of the VUJ was measured for each of the three methods. Interrater reliability of VUJ, PMU and ARJ displacement and the VUJ angle of displacement measurements was assessed using a two-way mixed-effects agreement intra-class correlation coefficient (ICC) with 95% confidence intervals (CI). Test-retest (intrarater) reliability was calculated using a two-way random effects consistency ICC with 95% CI for all displacement measures of the VUJ, PMU and ARJ for one observer between two days. RESULTS The pubococcygeal line (PCL) axis measurement system demonstrated good to excellent intrarater and interrater reliability (ICC 95% interval lower bound > 0.75) for the VUJ and PMU displacement and the VUJ angle of displacement measurements. Other measurement systems were less reliable and more variable. CONCLUSIONS In this sample of 20 Korean patients with median prostate volume 27.5 mL and maximum volume 70 mL, the measurement methodology using the PCL consistently demonstrated good to excellent reliability and the lowest variability for the measurement of the displacement of the VUJ and PMU and the VUJ angle of displacement. The PCL methodology is recommended as the method of choice. Further studies should validate these results in patients with large prostate volumes.
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Affiliation(s)
- Hong Koo Ha
- Department of Urology, Pusan National University Hospital, Busan, South Korea.,Pusan National University School of Medicine, Busan, South Korea.,Biomedical Research Institute, Pusan National University Hospital, Busan, South Korea
| | - Henk B Luiting
- The Clinical Research Institute, Sydney, Australia.,Faculty of Medical Sciences, University of Groningen, Groningen, The Netherlands
| | - Petra L Graham
- Centre for Economic Impacts of Genomic Medicine (GenIMPACT), Macquarie University, Sydney, Australia
| | - Manish I Patel
- Department of Urology, Westmead Hospital, Sydney, Australia.,Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Jaspreet S Sandhu
- Urology Service, Department of Surgery, Memorial Sloan- Kettering Cancer Center, New York, USA
| | - Oguz Akin
- Department of Radiology, Memorial Sloan- Kettering Cancer Center, New York, USA
| | - Sean F Mungovan
- The Clinical Research Institute, Sydney, Australia. .,Westmead Private Physiotherapy Services, Westmead Private Hospital, Suite 6, 16-18 Mons Road, Westmead, NSW, 2145, Australia. .,Department of Health Professions, Faculty of Health, Arts and Design, Swinburne University of Technology, Melbourne, Australia.
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19
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Hodges P, Stafford R, Coughlin GD, Kasza J, Ashton-Miller J, Cameron AP, Connelly L, Hall LM. Efficacy of a personalised pelvic floor muscle training programme on urinary incontinence after radical prostatectomy (MaTchUP): protocol for a randomised controlled trial. BMJ Open 2019; 9:e028288. [PMID: 31061057 PMCID: PMC6502040 DOI: 10.1136/bmjopen-2018-028288] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION Prostate cancer is the most common cancer in men. Prostatectomy is the most common treatment. Morbidity from prostatectomy is high-80% of men experience urinary incontinence which negatively impacts the quality of life. Postsurgical pelvic floor muscle training is commonly prescribed but recent systematic reviews found no evidence of efficacy. We propose a new treatment that commences preoperatively and targets functional training of specific pelvic floor muscles that contribute to urinary continence. Assessment and biofeedback using transperineal ultrasound imaging assists in training. This will be compared against conventional training (maximal pelvic floor muscle contraction assessed by digital rectal examination) and no training. Embedded physiological studies will allow the investigation of moderation and mediation of the treatment effect on the outcomes. METHODS AND ANALYSIS This randomised clinical trial will include 363 men scheduled to undergo radical prostatectomy for prostate cancer. Participants will be randomised into urethral training, conventional training and no training groups. Clinical data will be collected at baseline (1-2 weeks presurgery) and postsurgery after catheter removal, weekly to 3 months (primary endpoint) and monthly to 12 months. Outcomes include 24-hour pad weight test (primary), incontinence, quality of life and cost-effectiveness data. Neuromuscular control measures of pelvic floor muscles will be measured at baseline, postsurgery, 6 weeks, 3 and 12 months. Study assessors and statisticians will be blinded to the group allocation. ETHICS AND DISSEMINATION This study is registered with the Australian New Zealand Clinical Trials Registry and has ethical approval from the university and host hospital ethics committees. Trial outcomes will be shared via national/international conference presentations and peer-reviewed journal publications. TRIAL REGISTRATION NUMBER ACTRN12617000788370; Pre-results.
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Affiliation(s)
- Paul Hodges
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia
| | - Ryan Stafford
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia
| | - Geoff D Coughlin
- Renal Medicine, Royal Brisbane & Women’s Hospital, Brisbane, Queensland, Australia
- Wesley Urology Clinic, Wesley Hospital, Brisbane, Queensland, Australia
| | - Jessica Kasza
- Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - James Ashton-Miller
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan, USA
| | - Anne P Cameron
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan, USA
| | - Luke Connelly
- Centre for the Business and Economics of Health, University of Queensland, Brisbane, Queensland, Australia
- Poche Centre for Indigenous Health, University of Queensland, Brisbane, Queensland, Australia
| | - Leanne M Hall
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia
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20
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Mungovan SF, Luiting HB, Graham PL, Sandhu JS, Akin O, Chan L, Patel MI. The measurement of membranous urethral length using transperineal ultrasound prior to radical prostatectomy. Scand J Urol 2018; 52:263-268. [PMID: 30041561 DOI: 10.1080/21681805.2018.1484509] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To compare preoperative membranous urethral length (MUL) measurements using magnetic resonance imaging (MRI) with two-dimensional transperineal ultrasound imaging (TPUS) in two supine positions on two separate days in men prior to radical prostatectomy. MATERIALS AND METHODS MUL was prospectively measured in 18 male volunteers using MRI and on two separate occasions in two different patient positions using TPUS; the patient supine with the knees extended (Supine) and supine with the knees flexed to 70 degrees (Supine KF). Agreement between TPUS and MRI measurements of MUL was assessed using Bland-Altman method comparison techniques and a two-way mixed-effects single measures intraclass correlation (ICC). Test-retest reliability was assessed using a two-way random effects single measures ICC. RESULTS The mean difference in MUL measurements between MRI and i) TPUS Supine was -0.8 mm (95% limits of agreement (LOA): -3.2, 1.7) and ii) TPUS Supine KF was -0.8mm (95% LOA: -3.5, 1.9). ICC indicated a point estimate of excellent agreement between MRI and TPUS Supine ICC 0.93 (95% CI: 0.76, 0.98) and TPUS Supine KF ICC 0.91 (95%CI 0.79, 0.97). There was excellent agreement between TPUS Supine and TPUS Supine KF (ICC 0.98, 95% CI: 0.96, 0.99) with a mean difference of 0.3mm (95% LOA: -1.2 to 1.3mm). CONCLUSIONS Preoperative MUL can be reliably measured using TPUS and demonstrates excellent agreement with MRI measurements of MUL. TPUS provides clinicians with an accessible non-invasive alternative to MRI for the measurement of MUL that can be used in outpatient urological settings and for patients where MRI is contraindicated.
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Affiliation(s)
- Sean F Mungovan
- a Westmead Private Physiotherapy Services, Westmead Private Hospital Sydney , Australia.,b The Clinical Research Institute , Sydney , Australia.,c Department of Physiotherapy, Faculty of Medicine, Dentistry and Health Sciences , The University of Melbourne , Melbourne , Australia
| | - Henk B Luiting
- b The Clinical Research Institute , Sydney , Australia.,d Faculty of Medical Sciences , University of Groningen , Groningen , The Netherlands
| | - Petra L Graham
- e Department of Statistics , Macquarie University , Australia
| | - Jaspreet S Sandhu
- f Urology Service, Department of Surgery , Memorial Sloan-Kettering Cancer Center , New York
| | - Oguz Akin
- g Department of Radiology , Memorial Sloan-Kettering Cancer Center , New York
| | - Lewis Chan
- h Discipline of Surgery , Sydney Medical School, The University of Sydney , Australia.,i Department of Urology , Concord Hospital , Sydney , Australia
| | - Manish I Patel
- h Discipline of Surgery , Sydney Medical School, The University of Sydney , Australia.,j Department of Urology , Westmead Hospital , Sydney , Australia
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S FC, C CL, A GM, JL AB. 2nd Rehabilitative Ultrasound Imaging Symposium in Physiotherapy – Madrid, Spain, 3–5 June 2016. Br J Sports Med 2018. [DOI: 10.1136/bjsports-2018-099763.1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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22
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Perineal Ultrasound: a Review in the Context of Ejaculatory Dysfunction. Sex Med Rev 2018; 6:419-428. [DOI: 10.1016/j.sxmr.2017.12.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 12/11/2017] [Accepted: 12/15/2017] [Indexed: 01/23/2023]
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23
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The Role of Preoperative Puborectal Muscle Function Assessed by Transperineal Ultrasound in Urinary Continence Outcomes at 3, 6, and 12 Months After Robotic-Assisted Radical Prostatectomy. Int Neurourol J 2018; 22:114-122. [PMID: 29991233 PMCID: PMC6059918 DOI: 10.5213/inj.1836026.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 04/02/2018] [Indexed: 11/08/2022] Open
Abstract
PURPOSE The efficacy of pelvic floor muscle training (PFMT) for men with postprostatectomy incontinence (PPI) after robotic-assisted radical prostatectomy (RARP) is controversial and the mechanism for its possible effect remains unclear. The aim of this study was to investigate the relationship between bladder neck (BN) displacement, as a proxy for puborectal muscle activation, and continence outcomes after RARP. METHODS Data were extracted from the South Australian Prostate Cancer Clinical Outcomes Collaborative database for men undergoing RARP by high volume surgeons who attended preoperative pelvic floor physiotherapy for pelvic floor muscle (PFM) training between 2012 and 2015. Instructions were to contract the PFM as if stopping the flow of urine. BN displacement was measured with 2-dimensional transperineal ultrasound, without digital rectal examination. Urinary continence status was assessed preoperatively and at 3, 6, and 12 months using the Expanded Prostate Cancer Index Composite 26. Data were analysed using logistic regression and mixed effects linear modelling. Confounding variables considered were baseline continence, age at diagnosis, margin status, nerve sparing procedures and pathological stage. RESULTS Of 671 eligible men, 358 met the inclusion criteria and were available for analysis, with 136 complete datasets at 12-month follow-up. While BN movement was associated with preoperative continence, there was no significant effect of BN displacement on the change in urinary continence at 12 months postprostatectomy (P=0.81) or on the influence of time on continence over 3-12 months. Conclusions Continence outcomes were not associated with BN displacement, produced by activity of the puborectal portion of the levator ani muscle, at 3, 6, or 12 months after RARP. These results suggest that the puborectal muscle does not play a role in the recovery of continence after RARP and may help to explain the negative findings of many studies of PFMT for PPI.
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Stafford RE, van den Hoorn W, Coughlin G, Hodges PW. Postprostatectomy incontinence is related to pelvic floor displacements observed with trans-perineal ultrasound imaging. Neurourol Urodyn 2017; 37:658-665. [PMID: 28745804 DOI: 10.1002/nau.23371] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 06/30/2017] [Indexed: 11/07/2022]
Abstract
AIMS To investigate the relationship between post-prostatectomy incontinence and dynamic features of activation of specific pelvic floor muscles in addition to anatomical parameters of the urethra. METHODS Forty-two men aged 66 (7) years (incontinent [N = 19] and continent [N = 23]) who had undergone prostatectomy participated. Transperineal ultrasound imaging was used to record sagittal images of pelvic structures during involuntary coughing and sustained maximal voluntary contractions. Imaging data were analyzed to calculate displacements of pelvic floor landmarks associated with activation of the puborectalis, striated urethral sphincter, and bulbocavernosus muscles. Anatomical features of functional urethral length and the resting position of the ano-rectal and urethra-vesical junctions were calculated. A principal component analysis and multiple logistic regression were used to consider which combinations of variables best distinguish between men with and without incontinence. RESULTS Five principal components were identified that together explained 72.0% of the data. Two principal components that represented (i) striated urethral sphincter activation and (ii) bulbocavernosus and puborectalis muscle activation were significantly different between participants with and without incontinence. Together these components correctly identified 88.1% of incontinent men, with a specificity and sensitivity of 91.3% and 84.2%, respectively. Poor function of the bulbocavernosus and puborectalis muscles could be compensated by good striated urethral sphincter function, but the bulbocavernosus and puborectalis muscles had less potential to compensate for poor striated urethral sphincter function. CONCLUSIONS Dynamic features of pelvic floor muscle activation, particularly shortening of the striated urethral sphincter during cough and voluntary contraction, are related to continence status after prostatectomy.
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Affiliation(s)
- Ryan E Stafford
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
| | - Wolbert van den Hoorn
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
| | - Geoff Coughlin
- Department of Urology, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Paul W Hodges
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
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25
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Doorbar-Baptist S, Adams R, Rebbeck T. Ultrasound-based motor control training for the pelvic floor pre- and post-prostatectomy: Scoring reliability and skill acquisition. Physiother Theory Pract 2017; 33:296-302. [DOI: 10.1080/09593985.2017.1290171] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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26
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Stafford RE, Aljuraifani R, Hug F, Hodges PW. Application of shear-wave elastography to estimate the stiffness of the male striated urethral sphincter during voluntary contractions. BJU Int 2016; 119:619-625. [DOI: 10.1111/bju.13688] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Ryan E. Stafford
- Centre for Clinical Research Excellence in Spinal Pain, Injury and Health; School of Health and Rehabilitation Sciences; The University of Queensland; Brisbane Qld Australia
| | - Rafeef Aljuraifani
- Centre for Clinical Research Excellence in Spinal Pain, Injury and Health; School of Health and Rehabilitation Sciences; The University of Queensland; Brisbane Qld Australia
| | - François Hug
- Centre for Clinical Research Excellence in Spinal Pain, Injury and Health; School of Health and Rehabilitation Sciences; The University of Queensland; Brisbane Qld Australia
- Laboratory ‘Movement, Interactions, Performance’; Faculty of Sport Sciences; University of Nantes; Nantes France
| | - Paul W. Hodges
- Centre for Clinical Research Excellence in Spinal Pain, Injury and Health; School of Health and Rehabilitation Sciences; The University of Queensland; Brisbane Qld Australia
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Stafford RE, Coughlin G, Lutton NJ, Hodges PW. Validity of Estimation of Pelvic Floor Muscle Activity from Transperineal Ultrasound Imaging in Men. PLoS One 2015; 10:e0144342. [PMID: 26642347 PMCID: PMC4671687 DOI: 10.1371/journal.pone.0144342] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 11/17/2015] [Indexed: 11/18/2022] Open
Abstract
PURPOSE To investigate the relationship between displacement of pelvic floor landmarks observed with transperineal ultrasound imaging and electromyography of the muscles hypothesised to cause the displacements. MATERIALS AND METHODS Three healthy men participated in this study, which included ultrasound imaging of the mid-urethra, urethra-vesical junction, ano-rectal junction and bulb of the penis. Fine-wire electromyography electrodes were inserted into the puborectalis and bulbocavernosus muscles and a transurethral catheter electrode recorded striated urethral sphincter electromyography. A nasogastric sensor recorded intra-abdominal pressure. Tasks included submaximal and maximal voluntary contractions, and Valsalva. The relationship between each of the parameters measured from ultrasound images and electromyography or intra-abdominal pressure amplitudes was described with nonlinear regression. RESULTS Strong, non-linear relationships were calculated for each predicted landmark/muscle pair for submaximal contractions (R2-0.87-0.95). The relationships between mid-urethral displacement and striated urethral sphincter electromyography, and bulb of the penis displacement and bulbocavernosus electromyography were strong during maximal contractions (R2-0.74-0.88). Increased intra-abdominal pressure prevented shortening of puborectalis, which resulted in weak relationships between electromyography and anorectal and urethravesical junction displacement during all tasks. CONCLUSIONS Displacement of landmarks in transperineal ultrasound imaging provides meaningful measures of activation of individual pelvic floor muscles in men during voluntary contractions. This method may aid assessment of muscle function or feedback for training.
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Affiliation(s)
- Ryan E. Stafford
- The University of Queensland, Centre for Clinical Research Excellence in Spinal Pain, Injury and Health, School of Health and Rehabilitation Sciences, Brisbane, Australia
| | - Geoff Coughlin
- Department of Urology, Royal Brisbane and Women’s Hospital, Brisbane, Australia
| | - Nicholas J Lutton
- Department of Colorectal Surgery, Princess Alexandra Hospital, Brisbane, Australia
| | - Paul W. Hodges
- The University of Queensland, Centre for Clinical Research Excellence in Spinal Pain, Injury and Health, School of Health and Rehabilitation Sciences, Brisbane, Australia
- * E-mail:
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Stafford RE, Ashton-Miller JA, Constantinou C, Coughlin G, Lutton NJ, Hodges PW. Pattern of activation of pelvic floor muscles in men differs with verbal instructions. Neurourol Urodyn 2015; 35:457-63. [PMID: 25727781 DOI: 10.1002/nau.22745] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Accepted: 01/14/2015] [Indexed: 11/08/2022]
Abstract
AIMS To investigate the effect of instruction on activation of pelvic floor muscles (PFM) in men as quantified by transperineal ultrasound imaging (US) and to validate these measures with invasive EMG recordings. METHODS Displacement of pelvic floor landmarks on transperineal US, intra-abdominal pressure (IAP) recorded with a nasogastric transducer, and surface EMG of the abdominal muscles and anal sphincter were recorded in 15 healthy men during sub-maximal PFM contractions in response to different verbal instructions: "tighten around the anus," "elevate the bladder," "shorten the penis," and "stop the flow of urine." In three men, fine-wire EMG recordings were made from puborectalis and bulbocavernosus, and trans-urethral EMG recordings from the striated urethral sphincter (SUS). Displacement data were validated by analysis of relationship with invasive EMG. Displacement, IAP, and abdominal/anal EMG were compared between instructions. RESULTS Displacement of pelvic landmarks correlated with the EMG of the muscles predicted anatomically to affect their locations. Greatest dorsal displacement of the mid-urethra and SUS activity was achieved with the instruction "shorten the penis." Instruction to "elevate the bladder" induced the greatest increase in abdominal EMG and IAP. "Tighten around the anus" induced greatest anal sphincter activity. CONCLUSIONS The pattern of urethral movement measured from transperineal US is influenced by the instructions used to teach activation of the pelvic floor muscles in men. Efficacy of PFM training may depend on the instructions used to train activation. Instructions that optimize activation of muscles with a potential to increase urethral pressure without increasing abdominal EMG/IAP are likely ideal. Neurourol. Urodynam. 35:457-463, 2016. © 2015 Wiley Periodicals, Inc.
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Affiliation(s)
- Ryan E Stafford
- The University of Queensland, Centre for Clinical Research Excellence in Spinal Pain, Injury and Health, School of Health and Rehabilitation Sciences, Brisbane, Australia
| | - James A Ashton-Miller
- Departments of Mechanical and Biomedical Engineering, Institute of Gerontology, The University of Michigan, Ann Arbor, Michigan
| | - Chris Constantinou
- Department of Urology, School of Medicine, Stanford University, Palo Alto, California
| | - Geoff Coughlin
- Department of Urology, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Nicholas J Lutton
- Department of Colorectal Surgery, Princess Alexandra Hospital, Brisbane, Australia
| | - Paul W Hodges
- The University of Queensland, Centre for Clinical Research Excellence in Spinal Pain, Injury and Health, School of Health and Rehabilitation Sciences, Brisbane, Australia
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Roll SC, Rana M, Sigward SM, Yani MS, Kirages DJ, Kutch JJ. Reliability of superficial male pelvic floor structural measurements using linear-array transperineal sonography. ULTRASOUND IN MEDICINE & BIOLOGY 2015; 41:610-7. [PMID: 25444690 PMCID: PMC4297525 DOI: 10.1016/j.ultrasmedbio.2014.09.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Revised: 08/29/2014] [Accepted: 09/02/2014] [Indexed: 05/08/2023]
Abstract
This study evaluated reliability of measures for superficial structures of the male pelvic floor (PF) obtained via transperineal sonography. Two embalmed cadavers were dissected to identify positioning of muscles on and around the bulb of the penis and to confirm the PF protocol. Cross-sectional area (CSA) and linear thickness of the bulb of the penis, urethra, bulbospongiosus (BS) muscles, and ischiocavernosus (IC) muscles were measured on 38 transverse images from 20 male patients by three raters with varied study knowledge and sonographic experience. Intra- and inter-rater reliability were calculated with two-way, mixed effects intra-class correlation coefficients. Measures of the bulb of the penis had the best reliability. CSA of all muscles and sagittal thickness of the BS near the central tendon had good reliability. Reliability varied for rater-identified thickest muscle region and measures of the urethra. Our study suggests that structures of the male PF can be reliably evaluated using a transperineal sonographic approach.
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Affiliation(s)
- Shawn C Roll
- Division of Occupational Science and Occupational Therapy, University of Southern California, Los Angeles, CA, USA.
| | - Manku Rana
- Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA, USA
| | - Susan M Sigward
- Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA, USA
| | - Moheb S Yani
- Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA, USA
| | - Daniel J Kirages
- Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA, USA
| | - Jason J Kutch
- Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA, USA
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Cruz DSLDC, D’Ancona CAL, Baracat J, Alves MAD, Cartapatti M, Damião R. Parameters of two-dimensional perineal ultrasonography for evaluation of urinary incontinence after Radical Prostatectomy. Int Braz J Urol 2014; 40:596-604. [DOI: 10.1590/s1677-5538.ibju.2014.05.03] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 07/04/2014] [Indexed: 11/22/2022] Open
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Stafford RE, Mazzone S, Ashton-Miller JA, Constantinou C, Hodges PW. Dynamics of male pelvic floor muscle contraction observed with transperineal ultrasound imaging differ between voluntary and evoked coughs. J Appl Physiol (1985) 2014; 116:953-60. [PMID: 24526580 DOI: 10.1152/japplphysiol.01225.2013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Coughing provokes stress urinary incontinence, and voluntary coughs are employed clinically to assess pelvic floor dysfunction. Understanding urethral dynamics during coughing in men is limited, and it is unclear whether voluntary coughs are an appropriate surrogate for spontaneous coughs. We aimed to investigate the dynamics of urethral motion in continent men during voluntary and evoked coughs. Thirteen men (28-42 years) with no history of urological disorders volunteered to participate. Transperineal ultrasound (US) images were recorded and synchronized with measures of intraabdominal pressure (IAP), airflow, and abdominal/chest wall electromyography during voluntary coughs and coughs evoked by inhalation of nebulized capsaicin. Temporal and spatial aspects of urethral movement induced by contraction of the striated urethral sphincter (SUS), levator ani (LA), and bulbocavernosus (BC) muscles and mechanical aspects of cough generation were investigated. Results showed coughing involved complex urethral dynamics. Urethral motion implied SUS and BC shortening and LA lengthening during preparatory and expulsion phases. Evoked coughs resulted in greater IAP, greater bladder base descent (LA lengthening), and greater midurethral displacement (SUS shortening). The preparatory inspiration cough phase was shorter during evoked coughs, as was the latency between onset of midurethral displacement and expulsion. Maximum midurethral displacement coincided with maximal bladder base descent during voluntary cough, but followed it during evoked cough. The data revealed complex interaction between muscles involved in continence in men. Spatial and temporal differences in urethral dynamics and cough mechanics between cough types suggest that voluntary coughing may not adequately assess capacity of the continence mechanism.
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Affiliation(s)
- Ryan E Stafford
- Centre for Clinical Research Excellence - Spinal Pain, Injury and Health, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
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