External anal sphincter contraction during cough: Not a simple spinal reflex

Assessment of Involuntary PFM Contractions in Comparison with Existing Literature and IUGA/ICS Terminology Reports

INTRODUCTION AND HYPOTHESIS

Involuntary pelvic floor muscle (PFM) contractions are thought to occur during an increase in intra-abdominal pressure (IAP). Although no studies have assessed their presence in women with normal pelvic floor (PF) function, existing literature links the absence of involuntary PFM contractions to various PF dysfunctions. This study rectifies this lacuna by evaluating involuntary PFM contractions during IAP in healthy nulliparous women with no PF dysfunction, using visual observation and vaginal palpation. Results were compared with the literature and the IUGA/ICS Terminology Reports.

METHODS

Nulliparous (n=149) women performed three sets of three maximal coughs. Visual observation and vaginal palpation were conducted in the standing and supine positions. The women were not instructed to contract their PFMs. Occurrence rates were calculated for each assessment method and position; differences between positions were analyzed using the Chi-squared test.

RESULTS

Rates of occurrence of involuntary PFM contraction were low across both assessments and positions (5-17%). Significant differences were found between standing (5%) and supine (15%) positions for visual observation, but not vaginal palpation (15%, 17% respectively). Occurrence rates also differed compared with the literature and terminology reports.

CONCLUSIONS

Contrary to clinical expectations, rates of occurrence of involuntary PFM contraction among our cohort of nulliparous women were extremely low. Digital palpation results showed high agreement with the terminology reports, but only partial agreement was observed for the visual observation results. Our study underscores the need for more research aimed at defining normal involuntary PF functions, a review of our understanding of involuntary PFM contractions, and better standardized guidelines for involuntary PFM assessment methods.

Novel insights into physiological mechanisms underlying fecal continence

The machinery maintaining fecal continence prevents involuntary loss of stool and is based on the synchronized interplay of multiple voluntary and involuntary mechanisms, dependent on cooperation between motor responses of the musculature of the colon, pelvic floor, and anorectum, and sensory and motor neural pathways. Knowledge of the physiology of fecal continence is key toward understanding the pathophysiology of fecal incontinence. The idea that involuntary contraction of the internal anal sphincter is the primary mechanism of continence and that the external anal sphincter supports continence only by voluntary contraction is outdated. Other mechanisms have come to the forefront, and they have significantly changed viewpoints on the mechanisms of continence and incontinence. For instance, involuntary contractions of the external anal sphincter, the puborectal muscle, and the sphincter of O'Beirne have been proven to play a role in fecal continence. Also, retrograde propagating cyclic motor patterns in the sigmoid and rectum promote retrograde transit to prevent the continuous flow of content into the anal canal. With this review, we aim to give an overview of primary and secondary mechanisms controlling fecal continence and evaluate the strength of evidence.

Comparing the efficacy of the Knack maneuver on pelvic floor muscle function and urinary symptoms using different teaching methods: a prospective, nonrandomized study

INTRODUCTION AND HYPOTHESIS

This study was aimed at comparing the efficacy of Knack maneuver training taught using different techniques on pelvic floor muscle (PFM) function, urinary symptoms, and perception of improvement in women with stress urinary incontinence (SUI).

METHODS

We conducted a prospective nonrandomized study of 46 women with SUI. Assessments included: PFM functions (secondary outcome, SO) using a Myomed 932 EMG biofeedback device, urinary incontinence symptoms using the International Consultation on Incontinence Questionnaire Urinary Incontinence-Short Form (ICIQ-SF; primary outcome), the Urogenital Distress Inventory-6 (UDI-6; SO), and the Incontinence Severity Index (ISI; SO), and perception of improvement using the Global Perceived Impact scale. The women were divided into three groups according to their preference: group 1 (Knack maneuver training with electromyography biofeedback), group 2 (Knack maneuver training with verbal instruction), and group 3 (Knack maneuver training with vaginal palpation). An education program was also given to all women individually. The training program was 1 day per week for 4 weeks.

RESULTS

There was an improvement in UDI-6, ICIQ-SF, and ISI scores in all groups (p<0.05). The maximum voluntary contraction (MVC) of the PFMs increased in group 2 (p=0.002), whereas both the MVC of PFMs and PFM contraction during Valsalva increased in group 3 (p=0.011 and p=0.042).

CONCLUSIONS

Regardless of the teaching methods, the Knack maneuver and education programs were effective on urinary symptoms in women with mild to moderate SUI. The Knack maneuver training with vaginal palpation and verbal instruction improved MVC of PFMs. All three different teaching methods might be used in SUI treatment programs.

Urethral function and failure: A review of current knowledge of urethral closure mechanisms, how they vary, and how they are affected by life events

INTRODUCTION

A critical appraisal of the literature regarding female urethral function and dysfunction is needed in light of recent evidence showing the urethra's role in causing stress and urge urinary incontinence.

METHODS

An evidence assessment was conducted using selected articles from the literature that contained mechanistic data on factors affecting urethral function and failure.

RESULTS

Maximal urethral closure pressure (MUCP) is 40% lower in stress urinary incontinence (SUI) than normal controls. Evidence from five women shows relatively equal contributions to MUCP from striated/smooth muscle, vascular-plexus, connective tissue. MUCP varies twofold in individuals of similar age and declines 15% per decade even in nulliparous women. Age explains 57% of the variance in MUCP. This parallels with striated/smooth muscle loss and reduced nerve density. Factors influencing pressure variation minute-to-minute and decade-to-decade are poorly understood. Connective tissue changes have not been investigated. MUCP in de novo SUI persisting 9-months postpartum is 25% less than in age and parity-matched controls. Longitudinal studies do not show significant changes in urethral function after vaginal birth suggesting that changes in urethral support from birth may unmask pre-existing sphincter weakness and precipitate SUI. Mechanisms of interaction between support injury, pre-existing urethral weakness, and neuropathy are unclear.

CONCLUSION

Urethral failure is the predominant cause of SUI and a contributing factor for UUI; potentially explaining why mixed symptoms predominate in epidemiological studies. Age-related striated muscle loss and differences between women of similar age are prominent features of poor urethral closure. Yet, connective tissue changes, vasculature function, and complex interactions among factors are poorly understood.

An International Continence Society (ICS) report on the terminology for pelvic floor muscle assessment

INTRODUCTION

The terminology for female and male pelvic floor muscle (PFM) assessment has expanded considerably since the first PFM function and dysfunction standardization of terminology document in 2005. New terms have entered assessment reports, and new investigations to measure PFM function and dysfunction have been developed. An update of this terminology was required to comprehensively document the terms and their definitions, and to describe the assessment method and interpretation of the finding, to standardize assessment procedures and aid diagnostic decision making.

METHODS

This report combines the input of members of the Standardisation Committee of the International Continence Society (ICS) Working Group 16, with contributions from recognized experts in the field and external referees. A logical, sequential, clinically directed assessment framework was created against which the assessment process was mapped. Within categories and subclassifications, each term was assigned a numeric coding. A transparent process of 12 rounds of full working group and external review was undertaken to exhaustively examine each definition, plus additional extensive internal development, with decision making by collective opinion (consensus).

RESULTS

A Terminology Report for the symptoms, signs, investigations, and diagnoses associated with PFM function and dysfunction, encompassing 185 separate definitions/descriptors, has been developed. It is clinically based with the most common assessment processes defined. Clarity and user-friendliness have been key aims to make it interpretable by clinicians and researchers of different disciplines.

CONCLUSION

A consensus-based Terminology Report for assessment of PFM function and dysfunction has been produced to aid clinical practice and be a stimulus for research.

Pelvic floor muscle activation in stress urinary incontinent women: Impact of a distraction task

AIMS

Our purpose was to explore the involvement of cognition in voluntary and involuntary pelvic floor muscle (PFM) contraction in stress urinary incontinent women.

METHODS

PFM contraction monitored by surface electromyography (EMG) was measured without a mental distraction task (DT), and with a DT called "paced auditory serial additional test" (PASAT). Forty stress incontinent women performed voluntary contractions of the external anal sphincter (EAS), and reflex EAS contractions induced by means of coughing were studied using the external intercostal muscle (EIC) EMG pattern.

RESULTS

A DT altered PFM pre-activation when coughing: the reaction time between EIC muscle contraction and EAS contraction (called RT3) was respectively -54.94 ms (IQR -87.12; 3.12) without the PASAT and -3.99 ms (IQR: -47.92; 18.69) with a DT (P = 0.02, Wilcoxon's test). Concerning voluntary contraction, women activated their PFM sooner without than with a DT.

CONCLUSION

The PASAT altered voluntary and reflex contractions of the PFM in stress urinary incontinent women. Our study suggests that cognition plays a role in urinary pathophysiology. Future studies should investigate rehabilitation programs that consider the role of cognition in stress urinary incontinent women.

Prevalence of Fecal Incontinence in Adults with Cystic Fibrosis

BACKGROUND

Patients with cystic fibrosis (CF) are deemed at risk of developing urinary incontinence (UI) due to repeated coughing and other factors causing increased pressure on the pelvic floor. Fecal incontinence (FI) is probably derived from the same mechanism, but only very few data are available on its frequency.

AIMS

The aim of this study was to determine the prevalence of FI in an adult population with CF.

METHODS

This retrospective study was conducted from January 2012 to June 2014. Patients were recruited from Marseille referral center for adult CF. They were asked to fill in a self-completed anonymous questionnaire for symptom assessment of UI and FI. Clinical data and a detailed history of CF were also recorded.

RESULTS

A total of 155 out of 190 patients (92 females) of mean age 30.5 ± 11 years completed the survey. Seventy-three patients (47%) were lung transplanted. Forty patients (25.8%) reported FI with a mean St Mark's score of 4.9 ± 2. Thirty-five patients (22.6%) reported UI. Eighteen patients (11.6%) reported both FI and UI. FI was significantly more frequent in older patients (34.27 vs. 29.54 years, p = 0.03) and in patients with associated UI (p = 0.001). No relationship was found between respiratory, bacterial, nutritional status, transplantation, pancreatic status, practice of physiotherapy, delivery history, and FI.

CONCLUSIONS

The high prevalence of FI in CF and its negative impacts need to integrate this symptom in the overall treatment of this pathology. The systematic early detection of FI may allow its rapid management and limit their consequences.

Cough-Anal Reflex May Be the Expression of a Pre-Programmed Postural Action

When coughing, an involuntary contraction of the external anal sphincter occurs, in order to prevent unwanted leakages or sagging of the pelvis muscular wall. Literature originally described such cough-anal response as a reflex elicited by cough, therefore identifying a precise cause-effect relationship. However, recent studies report that the anal contraction actually precedes the rise in abdominal pressure during cough expiratory effort, so that the sphincter activity should be pre-programmed. In recent years, an important family of pre-programmed muscle activities has been well documented to precede voluntary movements: these anticipatory actions play a fundamental role in whole body and segmental postural control, hence they are referred to as anticipatory postural adjustments (APAs). On these basis, we searched in literature for similarities between APAs and the cough-anal response, observing that both follow the same predictive homeostatic principle, namely that anticipatory collateral actions are needed to prevent the unwanted mechanical consequences induced by the primary movement. We thus propose that the cough-anal response also belongs to the family of pre-programmed actions, as it may be interpreted as an APA acting on the abdominal-thoracic compartment; in other words, the cough-anal response may actually be an Anticipatory Sphincter Adjustment, the visceral counterpart of APAs.

Pelvic floor muscle reflex activity during coughing - an exploratory and reliability study

OBJECTIVES

Activities that provoke stress urinary incontinence (SUI) rapidly increase the intra-abdominal pressure and the impact loading on the pelvic floor muscles (PFMs). Coughing can cause urinary leakage and is often used to test SUI. However, PFM characteristics during coughing, including their reliability, have not been investigated. Here, we used electromyography (EMG) to describe PFM pre-activity and reflexivity during coughing and examined the reliability of the measurements.

METHODS

This was an exploratory and reliability study including 11 young healthy women to characterize EMG reflex activity in PFMs during coughing. We describe 6 variables, averaged over 3 coughs per subject, and tested their reliability (intraclass correlation coefficient 3,1 [ICC(3,1)] and ICC(3,k), related standard error of measurement (SEM) and minimal difference [MD]). The variables represented the mean EMG activity for PFMs during 30-ms time intervals of pre-activity (initial time point of coughing [T0] and minus 30ms) and reflex activity (T0-30, 30-60, 60-90, 90-120 and 120-150ms after T0) of stretch-reflex latency responses.

RESULTS

The mean %EMG (normalized to maximal voluntary PFM contraction) for EMG variables was 35.1 to 52.2 and was significantly higher during coughing than for PFM activity at rest (mean 24.9±3.7%EMG; P<0.05). ICC(3,k) ranged from 0.67 to 0.91 (SEM 6.1-13.3%EMG and MD 16.7-36.8%EMG) and was higher than ICC(3,1) (range 0.40-0.77; SEM 9.0-18.0%EMG, MD 24.9-50.0%EMG).

CONCLUSIONS

PFM activity during reflex latency response time intervals during coughing was significantly higher than at rest, which suggests PFM pre-activity and reflex activity during coughing. Although we standardized coughing, EMG variables for PFM activity showed poor reliability [good to excellent ICC(3,k) and fair to excellent ICC(3,1) but high SEM and MD]. Therefore, coughing is expected to be heterogeneous, with low reliability, in clinical test situations. Potential crosstalk from other muscles involved in coughing could limit the interpretation of our results.

Influence of a distraction task on the involuntary reflex contraction of the pelvic floor muscles following cough

AIMS

To explore the involvement of a distraction task in involuntary reflex pelvic floor muscle contraction following cough.

METHODS

Informed consent was obtained from 33 healthy volunteers. Involuntary contraction of the external anal sphincter (EAS) was induced by means of coughing. Cough efforts were elicited by electronic order. The electromyographic (EMG) activity of the EAS was recorded during involuntary contraction elicited by coughing. The trials were carried out twice: combined (or not) with a mental distraction task; the paced auditory serial additional test (PASAT). Reaction time (RT) defined as latency between the stimulus and maximum EAS EMG activity (RT1), latency between the stimulus and external intercostal (EIC) muscle EMG activity (RT2), latency between EIC EMG activity and EAS EMG activity (RT3), duration of the contraction, and the area under the EAS EMG activity curve (perineal contraction) were measured.

RESULTS

The distraction task altered anticipation of the PFM contraction: RT3 was -80.00 ms (IQR -107; -56) without the PASAT versus -56.67 ms (IQR: -94; -2) with the distraction task (ratio 0.71, P = 0.0045, Wilcoxon test). RT2 was altered during the distraction task: 583.33 ms (IQR: 344-775) without PASAT versus 652.71 ms (503-790) during PASAT (ratio 1.12, P = 0.031, Wilcoxon test). Finally, when the two conditions (respectively with and without the mental distraction task) were compared, there was a significant difference between the area under the EAS EMG activity curve (0.0115 mv sec vs. 0.0103 mv sec, ratio 0.90, P = 0.023).

CONCLUSIONS

The mental distraction task altered involuntary reflex contraction of the pelvic floor muscles. Neurourol. Urodynam. 36:160-165, 2017. © 2015 Wiley Periodicals, Inc.

Anorectal manometric dysfunctions in newly diagnosed, early-stage Parkinson's disease

BACKGROUND AND PURPOSE

Anorectal dysmotility is common in advanced Parkinson's disease (PD), but there have been few evaluations in newly diagnosed PD patients.

METHODS

We conducted anorectal manometric evaluations in 19 newly diagnosed, drug-naïve, early-stage PD patients. All of the PD patients were questioned regarding the presence of anorectal symptoms.

RESULTS

Anorectal manometry was abnormal in 12 of the 19 patients. These abnormalities were more common in patients with more severe anorectal symptoms, as measured using a self-reported scale. However, more than 40% of patients with no or minimal symptoms also exhibited manometric abnormalities.

CONCLUSIONS

These results suggest that anorectal dysmotility manifests in many early-stage PD patients, which this represent evidence for the involvement of neuronal structures in such nonmotor manifestations in PD.

Activation of the striated urethral sphincter to maintain continence during dynamic tasks in healthy men

AIMS

Function of the striated urethral sphincter (SUS) in men is debated. Current evidence is limited to electromyographic (EMG) recordings made with concentric needle electrodes in supine. Understanding of SUS function requires investigation of SUS EMG activity using new recording techniques in dynamic tasks. The aim of this study was to evaluate timing and amplitude of SUS EMG at rest and during dynamic tasks that challenge continence by increasing intra-abdominal pressure (IAP).

METHODS

Investigative study of five healthy men aged 25-39 years. Measurements included SUS, anal sphincter (AS), and transversus abdominus (TrA) EMG, and IAP (recorded with a nasogastric pressure catheter). Participants performed four tasks that challenged postural control in standing (single and repetitive arm movement, stepping and load catching).

RESULTS

IAP amplitude and SUS activity were linearly correlated during repetitive arm movement (R(2): 0.67-0.88). During stepping SUS EMG onset preceded the IAP increase, but followed it with rapid arm movements. When the trunk was loaded unpredictably onset of SUS generally followed the increase in IAP. The modest sample size meant only younger men were tested. Future studies might investigate healthy older men or those with certain pathologies.

CONCLUSIONS

Data show that SUS activity increases proportionally with IAP. This provided evidence that SUS contributes to continence when IAP is increased, and that postural control of the trunk involves activation of this muscle.

Anorectal dysfunctions in Parkinson's disease

Anorectal symptoms are frequently found in patients with Parkinson's disease (PD), mainly manifested as diffuse lower abdominal discomfort, constipation, and fecal incontinence. Among these symptoms, constipation may precede by years the motor manifestations of PD. Research has focused for decades on selection of a measurement method for detection of abnormalities and support of clinometric instruments for anorectal symptoms. We review those manifestations and their contribution to evaluation of the anorectal symptoms in patients with PD.

Halothane-anesthetized rabbit: a new experimental model to test the effects of besipirdine and duloxetine on lower urinary tract function

INTRODUCTION

The effects of besipirdine and its main metabolite, HP-748, as well as duloxetine and tomoxetine in the lower urinary tract (LUT) were studied using in vitro and in vivo techniques.

MATERIALS AND METHODS

For in vivo studies, besipirdine or duloxetine effects on cystometric parameters and striated sphincter electromyographic (SS-EMG) activity were investigated. On the isolated urethra, norepinephrine (NE) concentration-response curves (CRC) were performed in the presence of besipirdine, duloxetine or tomoxetine. Moreover, CRC to HP-748 were constructed in the absence or presence of prazosin. Potency (pEC(50)) and maximal responses (E(max)) were determined.

RESULTS

Besipirdine at 1, 3 and 5 mg/kg intravenously (i.v.) induced a significant increase in SS-EMG activity (250, 273 and 241%, respectively), bladder capacity (172, 197, and 235%, respectively), intercontraction interval (ICI; 208, 242, and 400%, respectively), and residual volume (181, 191, and 236%, respectively). Duloxetine at 2 mg/kg i.v. increased significantly SS-EMG activity (219%), micturition volume (222%), and ICI (205%). In the isolated urethra, besipirdine, tomoxetine and duloxetine significantly displaced to the left the NE CRC. In addition, HP-748 induced contraction of the isolated urethra with a pEC(50) of 5.89 and an E(max) of 37%.

CONCLUSIONS

These data support the potential of besipirdine as a new drug for LUT dysfunctions such as stress and mixed urinary incontinence.