Is biofeedback-assisted pelvic floor muscle training superior to pelvic floor muscle training alone in the treatment of dysfunctional voiding in women? A prospective randomized study

Do We Need to Re-Focus on Functional Female Urethral Disorders in Lower Urinary Tract Dysfunction? ICI-RS 2024

AIMS

Insights into the role of the urethra in maintaining continence and in normal voiding have been provided with advances in imaging techniques. Also, functional urethral testing is used to understand which treatments are optimal for women with functional bladder outlet obstruction (BOO), but which testing is better for which treatment? This review aims to describe our current understanding of female urethral function and dysfunction and to provide future research directions for treating functional female urethral disorders.

MATERIALS AND METHODS

This is a consensus report of the proceedings of a research proposal discussed at the annual International Consultation on Incontinence-Research Society (ICI-RS), 6th-8th June 2024 (Bristol, UK): "Do we need to re-focus on functional female urethral disorders in lower urinary tract dysfunction? ICI-RS 2024".

RESULTS

Regarding female urethral nomenclature, it was agreed that the same terminology should be used in the orientation of the female urethra as in the male. Also, functional MRI and computer modeling could aid further understanding of urethral function in women with voiding dysfunction and OAB symptoms. As for functional urethral assessment, options include video-urodynamics with leak point pressure (LPP) testing, urethral pressure profilometry (UPP), and striated urethral sphincter electromyography (EMG). Future testing may include the use of modalities (borrowed from cardiologic assessment of vascular structures such as resistive measures obtained with ultrasound) for the purpose of assessing urethral closure. UPP testing has limitations in measurement and reproducibility in assessing urethral pressure. Urethral sphincter EMG is difficult to perform and reproduce. LPP also has limitations related to testing and to patient effort, in addition to being influenced by factors such as bladder volume and compliance. When performing urethral surgery, it is imperative to dissect in tissue planes that preserve urethral function. Regarding therapeutic modalities for the treatment of functional female urethral dysfunction, conservative management includes pelvic floor muscle training with or without biofeedback, electrical stimulation, and extracorporeal magnetic stimulation. Furthermore, there was a robust discussion on the use of cognitive-behavioral therapy to address psychological comorbidities, thereby improving female LUTD. The evidence supporting long-term pharmacologic treatment of female urethral LUTD remains scarce. As for invasive management options, the evidence supporting the use of botulinum toxin in female LUTD is limited. Finally, the very existence of BNO and the validity of its diagnosis was discussed. Furthermore, bladder neck incision as a treatment of BNO was debated, and the indications for this procedure include a therapeutic decision balancing benefit to complications.

CONCLUSION

Improving the treatment of female functional storage and voiding disorders depends on optimal urethral function assessment. Functional MRI to better understand urethral function, expanding the use of UPP testing, LPP testing, and emerging modalities while maintaining urethral function during female urethral surgery, and addressing psychological comorbidities whilst pursuing both conservative and invasive options (for refractory symptoms) are all important considerations in treating functional female urethral disorders.

Is there evidence for pelvic floor muscle relaxation training in nonneurogenic female bladder outlet obstruction?-A narrative review

INTRODUCTION

Functional bladder outlet obstruction (BOO) in women is postulated to be caused by pelvic floor muscle (PFM) dyssynergia or increased tone. The aim of the present review was to investigate the effect of PFM relaxation training on PFM tone and female BOO symptoms.

MATERIALS AND METHODS

This was a narrative review using an open search strategy on PubMed with the search terms "Bladder outlet obstruction" AND "female" AND ("pelvic floor muscles" OR "Kegel"). The risk of bias of the randomized controlled trials (RCTs) was scored with the Physiotherapy Evidence Database (PEDro) scale (0-10).

RESULTS

Only three RCTs were found. All three RCTs compared different types of exercise, and no trial compared relaxation training with no or sham treatment. None of the trials reported the effect between groups on the reduction of PFM tone. There was a tendency toward positive effect of PFM relaxation training to improve BOO symptoms in women. PEDro score varied between 4 and 7. Few studies yielded information on the immediate effect of any type of PFM relaxation technique on PFM tone.

CONCLUSION

Few RCTs have been conducted on the effect of PFM relaxation training on PFM tone and functional female BOO symptoms. There is an urgent need for RCTs with high methodological and interventional quality in addition to basic research on mechanisms of different relaxation techniques on PFM activity.

A Reliable and Robust Method of Measuring Male Pelvic Floor Muscle Volume Using Three-dimensional Computed Tomography

Objectives

The pelvic floor muscle (PFM) plays a major role in sexual and urinary functions. No objective method exists to measure the PFM in male. This study evaluated the reliability of male PFM volume using three-dimensional computed tomography (3D-CT).

Methods

PFMs of five patients aged 43-83 years were selectively extracted from thin-slice CT using a workstation to reconstruct stereoscopic images and measure PFM volume. Two raters measured the PFM volume three times in all patients to confirm the reliability of PFM volume measurement. Intra- and inter-rater correlation coefficients, i.e., intraclass correlation coefficient, were determined. The CT attenuation of PFMs was also evaluated.

Results

Raters 1 and 2 reported an average PFM volume of 46.4 ± 11.5 cm3 and 46.1 ± 12.5 cm3, respectively. The intra- and inter-rater correlation coefficients were 0.99 and 0.98, respectively. The average CT value of PFMs had a minimum of 13.7 Hounsfield Unit (HU) in the eldest male and a maximum of 38.9 HU in the youngest male.

Conclusions

Male PFMs could be selectively extracted using a workstation to reconstruct a stereoscopic image. The PFM volume measurement is feasible and highly reproducible. To our knowledge, this is the first study that standardizes the method for measuring the male PFM volume using 3D-CT and examines its reliability.

Application of transperineal pelvic floor ultrasound in postpartum pelvic organ injury and prolapse in women

OBJECTIVE

To investigate SUI (stress urinary incontinence) and POP (pelvic organ prolapse) in women after childbirth by transperineal ultrasonography.

METHODS

In this retrospective study, 107 six-week postpartum primiparous mothers and 42 healthy nulliparous women were selected during the period from January 2021 to March 2023, in Pudong New Area People's Hospital. Among the postpartum mothers, 54 delivered vaginally and 53 underwent cesarean section. Various parameters such as bladder detrusor muscle thickness, urethrovesical angle, bladder neck mobility, puborectalis muscle hiatus area, and puborectalis muscle hiatus circumference were collected and analyzed.

RESULTS

During pregnancy and childbirth, several parameters underwent significant increases, including bladder detrusor muscle thickness, urethrovesical angle, bladder neck mobility, puborectalis muscle hiatus area, and puborectalis muscle hiatus circumference. Furthermore, vaginal delivery led to a notably more pronounced elevation in these indicators compared to other delivery methods (all P<0.05). Our findings revealed that the risk of pelvic organ prolapse (POP) escalated with an increasing number of pregnancies (P<0.05). Moreover, obese pregnant women, defined as having a body mass index (BMI) of 25 kg/m2 or higher, exhibited a heightened risk of developing POP.

CONCLUSIONS

Perineal ultrasound provides reliable imaging evidence, treatment theory basis, and evaluation value for women with pelvic floor dysfunction after childbirth.

The RISE FOR HEALTH study: Methods for in-person musculoskeletal assessment

OBJECTIVES

To describe the methods for the in-person musculoskeletal (MSK) assessment of the RISE FOR HEALTH (RISE) study, a population-based multicenter prospective cohort study designed to identify factors associated with bladder health (BH) conducted by the Prevention of Lower Urinary Tract Symptoms Research Consortium (PLUS).

METHODS

A subset of RISE participants who express interest in the in-person assessment are screened to ensure eligibility (planned n = 525). Eligible consenting participants are asked to complete a standardized MSK assessment to evaluate core stability (four component core stability test, lumbar spine pain (seated slump test), pelvic girdle pain, (sacroiliac joint, anterior superior iliac spine, pubic symphysis tenderness, and pelvic girdle pain provocation test), hip pain (flexion, abduction, internal rotation and flexion, adduction and external rotation) and pelvic girdle function (active straight leg raise). Participants are also asked to complete the Short Physical Performance Battery to measure balance, gait speed, lower extremity strength, and functional capacity.

RESULTS

Detailed online and in-person MSK training sessions led by physical therapy were used to certify research staff at each clinical center before the start of RISE in-person assessments. All evaluators exceeded the pre-specified pass rates.

CONCLUSIONS

The RISE in-person MSK assessment will provide further insight into the role of general body MSK health and dysfunction and the spectrum of BH.

The effect of pelvic floor muscle training in women with functional bladder outlet obstruction

INTRODUCTION AND HYPOTHESIS

Female voiding dysfunction is often due to bladder outlet obstruction (BOO). We investigated pelvic floor muscle training (PFMT) effectiveness in women with functional BOO.

METHODS

This is a prospective study recruiting 63 women functionally obstructed, over 18yo, maximum flow rate (Qmax) less than 12 ml/sec, naïve of voiding treatment. Exclusion criteria were anatomical BOO, neurological condition, pelvic intervention, psychiatric or anticholinergic medication, diabetes mellitus and affected upper urinary tract. At baseline, women underwent uroflow, post void residual (PVR) measurement, cystoscopy, cystogram and urodynamic study (UDS) with pelvic electromyography (EMG). Blaivas-Groutz nomogram has been used to define obstruction. After diagnosis, patients underwent six-month PFMT. Re-evaluation was offered four weeks after end of treatment. Data were analyzed with SPSSv22.0.

RESULTS

63 women were recruited and 48 finally included. At baseline, 20 reported 3 urinary tract infections (UTIs) during last year, and 12 had one episode of urine retention. Median Qmax was 7.5 ml/sec and median PVR 110 ml. 40 women were obstructed. 16 (40%) had mild, 16 (40%) moderate and 8 (20%) severe obstruction. All subjects had an overactive pelvic floor on EMG. Obstructed women were re-evaluated. Median Qmax was 8.5 ml/sec, close to baseline (p = 0.16). Median PVR was 65 ml, reduced to baseline (p = 0.02). 33 (82.5%) remained obstructed, 22 (66.67%) with mild, 8 (24.24%) moderate and 3 (9.09%) severe obstruction. 7 (17.5%) were non-obstructed. 4 patients reported one UTI episode with no cases of retention.

CONCLUSIONS

A 6 month PFMT reduced UTIs and PVR in women with functional BOO. Additionally, most patients had a de-escalation to milder obstruction.

The Efficacy of Combined Alarm Therapy Versus Alarm Monotherapy in the Treatment of Monosymptomatic Nocturnal Enuresis: A Review of Current Literature

Primary monosymptomatic nocturnal enuresis is a common clinical condition in childhood and affects the psychosocial development of the child. The management of this clinical condition, which includes the preschool and adolescence period, is very important for child development. Diagnostic evaluation should be performed in terms of diabetes mellitus, diabetes inspidus, neurogenic bladder, spinal anomalies, and congenital urogenital system anomalies. Treatment modalities in primary monosymptomatic nocturnal enuresis include enuretic alarm therapy, behavioral therapy, and pharmacological treatments such as desmopressin, tricyclic antidepressants, and anticholinergics. There are also experimental treatments such as percutaneous nerve stimulation, acupuncture, and manual therapy. In this study, we examined randomized controlled studies in the literature that included alarm monotherapy and combined therapy. We aimed to present the efficacy, advantages, and disadvantages of combined treatment with the results of the studies.