Effects of PFM rehabilitation on PFM function and morphology in older women

Does combining two evidence-based exercise programs in elderly people with incontinence have a triple effect on incontinence symptoms, balance and functional status?

BACKGROUND

Improving pelvic floor muscle training (PFMT), balance and functional activity is recommended in the treatment of urinary incontinence (UI) in the elderly people. The aim of this study is to examine whether PFMT combined with Otago exercises is effective on symptoms, balance and functional status in elderly people with UI compared to PFMT alone.

METHODS

This study is an assessor-blinded, randomized controlled trial. Participants with UI aged 65 and over living in a nursing home were randomly assigned to the intervention (IG) and control groups (CG). The intervention group attended an exercise program that included Otago exercises combined with PFMT. The control group was included in the PFMT program with different positions. The duration of exercise for both groups was 45-60 min per session three times a week for 12 weeks. UI symptoms and severity (Pelvic Floor Distress Inventory-20, bladder diary), PFM muscle function (superficial electromyography), balance (Berg Balance Scale), functional status (Senior Fitness Test) and fear of falling (Falls Efficacy Scale) were measured at baseline and after the intervention.

RESULTS

The median age of the IG (n: 22) and CG (n: 21) was 73.5 and 77 years, respectively. At baseline and after the intervention within the group, a significant improvement was observed in the PTDE-20 score (IG and CG, p: 0.00) and the 2-min step test in the IG (p: 0.02) and CG (p: 0.01). A significant decrease was found in the 2.45 m get up-and-go test, PFM work average onset, and PFM rest MVC EMG values (p: 0.01, p: 0.01, p: 0.00) in the IG. The PFM rest average value decreased (p: 0.04) in the CG.

CONCLUSION

The findings of this study show that combining PFMT with Otago exercises, two evidence-based interventions, is beneficial for effectively treating incontinence symptoms, balance and functional status in elderly people. Thus, a triple effect can be achieved with a single exercise training in the same treatment session and for the same duration.

CLINICAL TRIAL NUMBER

Clinical trial number: NCT06331039.

Accuracy and Reliability of Different Approaches for the Assessment of Pelvic Floor Muscle Strength: A Systematic Review

There had been various methods employed for the evaluation of pelvic floor muscle (PFM) strength. The aim of the study was to do a systemic review of these methods for a better understanding of these techniques and to find the best appropriate method. A systemic review of the literature was done using three databases that included: PubMed, Scopus and Web of Science using the keywords "pelvic floor anatomy" and "functional anatomy of pelvic floor muscles" from 1985 to 2022. All the studies involved were analyzed for the methodologies used by the researcher, advantages, disadvantages, and the conclusion of the study. A total of 1,876 studies were found, out of which only 64 met the criteria of inclusion. In these studies, seven methods were used for the determination of PFM strength. These methods included: clinical palpation, perineometer, electromyography, dynamometer, ultrasonography, magnetic resonance imaging, and vaginal cones. The PFM cannot be calculated accurately using any one measuring technique. There is therefore no "gold standard" approach to PFM assessment. However, combining these methods will result in the best outcomes. According to the literature review, the most often employed procedures were digital palpation, perineometry, and Ultrasonography (USG).

Pelvic floor muscle rehabilitation for genitourinary syndrome of menopause: why, how and when?

Genitourinary syndrome of menopause (GSM) is caused by chronic deprivation of estrogen and other sex steroids during the postmenopausal period, which leads to changes in the vulvovaginal tissues. These changes cause bothersome symptoms, such as vaginal dryness, pruritus, dyspareunia, increased daytime urinary frequency, urgency and urinary incontinence, which have considerable negative effects on women's quality of life and sexual function. Recent studies have investigated a novel treatment approach for GSM. Pelvic floor muscle (PFM) rehabilitation, a low-cost conservative management with no side-effects, has been studied alone or in combination with other treatment modalities to reduce the signs and symptoms of GSM. The aim of this article is to discuss why PFM rehabilitation could be useful for women with GSM, how it may help improve signs and symptoms of GSM and when this treatment should be recommended.

Examining the Role of Nonsurgical Therapy in the Treatment of Geriatric Urinary Incontinence

OBJECTIVE

To examine the role of physical function impairments on the change in urinary incontinence (UI) symptoms after pelvic floor muscle training in older women.

METHODS

This is a prospective cohort study of 70 community-dwelling participants, older than age 70 years, with at least moderate incontinence symptoms. A comprehensive pelvic floor and physical function assessment was done at baseline. Individualized pelvic floor muscle training prescriptions with behavioral management strategies to reduce incontinence episodes were provided for 12 weeks. Baseline physical function was determined using the SPPB (Short Physical Performance Battery). A total score of 9 or lower out of 12 indicated impaired physical function, and scores higher than 9 indicated normal physical function. A 3-day bladder diary established daily incontinence episodes. The between-group difference in the change in number of UI episodes, from baseline to 6 weeks, was our primary outcome. Descriptive analyses compared important demographic and clinical characteristics. Longitudinal mixed model linear regression analyses determined the change in incontinence episodes and estimates of improvement based on the presence of impaired physical function and adjusted for age, race, and body mass index (BMI).

RESULTS

Participants' mean±SD age was 76.9±5.4 years, and 15.7% identified as African American, with no significant differences in age or race between groups. Participants with impaired physical function had higher mean±SD BMI (33.6±14.5 vs 27.4±5.8; P=.03) and more baseline incontinence episodes (4.5±2.9 vs 2.7±2.1 episodes per day; P=.005) than in women without functional impairment. After 6 weeks of pelvic floor exercises, the change in number of incontinence episodes per day was not different between participants with physical functional impairment compared with women with normal physical function (mean [95% CI] -1.2 [-2.0 to -0.5] vs -0.4 [-1.1 to 0.3], P=.31). Overall, after 12 weeks of pelvic floor muscle training, complete satisfaction with incontinence symptom improvement was low for both groups (41.8% with physical function impairments vs 44.8% with normal physical function; P=.90).

CONCLUSION

Behavioral therapy including pelvic floor muscle training may not significantly decrease UI symptoms to a degree that is satisfactory in women who are older than 70 years and are seeking treatment for UI, regardless of the presence of physical function impairments.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT03057834.

Mechanisms of pelvic floor muscle training for managing urinary incontinence in women: a scoping review

BACKGROUND

Pelvic floor muscle training is recommended as first line treatment for urinary incontinence in women based on three proposed theorized mechanisms: 'Enhanced Pelvic Floor Muscle Strength,' 'Maximized Awareness of Timing,' and 'Strengthened Core Muscles'. The purpose of this scoping review was to systematically map evidence for and against theorized mechanisms through which pelvic floor muscle training interventions work to reduce urinary incontinence in women.

METHODS

The scoping review is based upon a comprehensive search of relevant literature published from 1990 to 2020 in PubMed, CINAHL, PsycINFO, ClinialTrials.gov, reference lists from review articles, and hand searches of articles by known researchers in the field. We included English-language, peer-reviewed articles on pelvic floor muscle training as an intervention for adult women if they provided empirical evidence to testing the theorized intervention mechanisms. Two independent reviewers screened articles for inclusion and extracted data to describe details of each study (author, year, country, design, sampling), measures of pelvic floor muscle strength and urinary incontinence, statistical analysis of linkage between changes in the measures, and pelvic floor muscle training regimens. Data were summarized to facilitate the integration of diverse evidence to draw conclusions on supporting or refuting the three proposed theorized mechanisms for managing urinary incontinence in women.

RESULTS

Of the 278 articles identified with the search, 13 (4.7%) met inclusion criteria. There was weak to no evidence for the mechanism of enhanced pelvic floor muscle strength, equivocal support for maximized awareness of timing, and no evidence for strengthened core muscles.

CONCLUSIONS

This review revealed extremely limited data supporting the proposed theorized mechanisms underlying pelvic floor muscle training programs to manage urinary incontinence in women. Such evidence is needed to help women and clinicians understand how, why and when a woman benefits from pelvic floor muscle training. Future studies should specifically state and report statistical analysis that relates the theorized mechanisms to the training outcomes observed.

The geriatric incontinence syndrome: Characterizing geriatric incontinence in older women

OBJECTIVES

Among older women, the clinical presentation of urinary incontinence (UI) is heterogeneous; presenting as a pelvic floor condition or geriatric syndrome. We aimed to characterize the geriatric incontinence syndrome (GIS) to establish its foundation in clinical practice.

DESIGN

Prospective study.

SETTING

Geriatric Clinical Research Unit.

PARTICIPANTS

Sixty-one community-dwelling women aged 70 and older with bothersome UI symptoms.

MEASUREMENTS

UI symptom type and severity were determined by 3-day bladder diary. UI severity was defined; moderate UI defined as <2 UI episodes/day and severe UI defined as ≥2 UI episodes/day. Subjective assessment of physical performance was determined using the Short Physical Performance Battery (SPPB) score. Total SPPB scores >9 define normal physical performance and scores ≤9 defined impaired physical performance.

RESULTS

The average age was 77.1 ± 5.8 (mean ± SD) years; 69% of women had severe UI and 31% had moderate UI. Demographic characteristics were similar between groups. Daytime voiding frequency was 7.1 ± 2.9 and nocturia was present equally between groups. The majority of women (59%) with severe UI had SPPB ≤9 compared with 26% among women with moderate UI (p = 0.02); featuring significantly slower chair stand scores (2.3 ± 1.4 vs 3.3 ± 0.9, p = 0.007) and gait speed (0.08 ± 0.2 m/s compared with 1.0 ± 0.2 in women with moderate UI).

CONCLUSIONS

A multifactorial GIS may be present in older women evidenced by the co-existence of severe UI, physical disability, slower chair stand pace, and gait speed. Prospective studies are needed to understand how these clinical features may impact the clinical care of older incontinent women.

Comprehensive reporting of pelvic floor muscle training for urinary incontinence: CERT-PFMT

AIM

To produce a pelvic floor muscle training variation of the Consensus on Exercise Reporting Template (CERT-PFMT).

METHODS

Qualitative methods were used to explore the perspectives of physiotherapists who have postgraduate continence and pelvic floor rehabilitation qualifications on using research evidence to implement pelvic floor muscle training for urinary incontinence. The same experienced facilitator guided the discussions with questions derived from systematic reviews and content experts. The face-to-face focus groups were audio-recorded and verbatim transcripts were thematically analysed. For each CERT item the authors collated participant quotations that identified required explanation or elaboration for the CERT-PFMT. Systematic reviews of pelvic floor muscle training for urinary incontinence were searched by the research team for examples of good reporting.

RESULTS

Twenty- nine continence physiotherapists participated in one of seven focus groups. Participants agreed that all key elements they needed for replicating pelvic floor muscle training interventions from a research report were provided in the published CERT checklist. CERT items 2 (qualifications), 6 (motivation), 7 (progression rules), 8 (exercise description), 13 (intervention description) and 15 (starting level) required additional explanations for pelvic floor muscle training. Clinicians reported that original CERT explanations for items 1, 3-5, 8-12, 14 and 16 could be used without modification.

CONCLUSIONS

The CERT-PFMT reporting guideline has been designed with clinician input to inform how to document pelvic floor muscle training to enable replication in clinical practice. It can be used for research protocols, to construct manuscripts reporting pelvic floor muscle training for urinary incontinence and by journal editors and reviewers.

Design and validation of an automated dual-arm instrumented intravaginal dynamometer

AIMS

(1) To present the design of a novel intravaginal dynamometer (IVD) capable of measuring vaginal closure force on both the anterior and posterior arms, (2) to use bench testing to validate the force, speed of arm opening, and positional accuracy of load measurement along the IVD arms, and (3) to present in vivo force measurements made with this device, comparing forces measured by the anterior and posterior arms.

METHODS

IVD load measurements were validated against an Instron® Universal Tester, arm opening speeds were validated using video analysis, and position-load accuracy was validated against calibration weights. In vivo IVD data were acquired from female volunteers during passive opening and pelvic floor muscle contraction tasks. Anterior and posterior IVD arm force outcomes were compared.

RESULTS

Forces measured by the IVD and Instron® exhibited a strong linear relationship with excellent model fit. The speed control system was valid when tested under physiological loading conditions, however smaller antero-posterior opening diameters (25 and 30 mm) exhibited some error. The loading position along the IVD arms had no effect on force outcomes. In vivo data exhibited differences between force outcomes measured at the anterior and posterior aspects of the vagina during active contraction and passive elongation of the pelvic floor muscles.

CONCLUSIONS

This IVD design demonstrates valid load measurement and speed control during bench testing. Active and passive forces measured are consistent with the literature. With dual instrumented arms, this device allows for further investigation into the source of measured vaginal closure forces.

Pelvic floor morphometrical and functional changes immediately after pelvic floor muscle training and at 1-year follow-up, in older incontinent women

AIMS

To compare the effects of group-based and individual physiotherapy for stress or mixed urinary incontinence (UI) on pelvic floor morphometry, pelvic floor muscle (PFM) function, and related self-efficacy, immediately after treatment and at 1 year.

METHODS

This is a planned secondary analysis of the group rehabilitation or individual physiotherapy study, an assessor-blinded, randomized, noninferiority trial. Eligible participants included 362 community-dwelling older women with symptoms of stress/mixed UI. After learning how to contract PFMs, participants completed 12 weeks of PFM training, either individually (one-on-one) or as part of a group (eight women). Pelvic floor transperineal ultrasound volumes (morphometry), PFM intravaginal dynamometric data (function), and self-efficacy in performing PFM exercises were acquired at baseline, posttreatment, and at 1 year.

RESULTS

Groups were comparable at all time points. Immediately posttreatment, both groups demonstrated significant changes in pelvic floor morphometry during coughs, and in PFM function during contractions and coughs. Participants also reported improved self-efficacy in performing PFM exercises. Results were sustained at 1 year. When participants coughed, pelvic floor structures were better supported (reflected by less caudal movement of the puborectalis sling and a smaller opening of the levator hiatus) in a pattern consistent with the "knack" strategy. Furthermore, both interventions resulted in stronger, faster, more coordinated, and more endurant PFMs.

CONCLUSION

In older women with stress or mixed UI, both individual and group-based PFM training resulted in comparable improvements in overall PFM function, pelvic floor morphometry during coughs, and related self-efficacy in performing PFM exercises, which were sustained at 1 year.

Pelvic floor muscle training: mechanisms of action for the improvement of genitourinary syndrome of menopause

Objective: This study aims to investigate the mechanism of action of pelvic floor muscle training (PFMT) for the improvement of the signs and symptoms of genitourinary syndrome of menopause (GSM) in postmenopausal women with GSM and urinary incontinence (UI).Methods: Twenty-nine women were included in the secondary analysis of a single-arm feasibility study. Using color Doppler ultrasound, the peak systolic velocity, time-averaged maximum velocity, and pulsatility index of the internal pudendal and dorsal clitoral arteries were measured at rest and after a pelvic floor muscle (PFM) contraction task. PFM function was assessed by dynamometry, and vulvovaginal tissue elasticity was measured using the Vaginal Atrophy Index.Results: PFMT significantly improved blood flow parameters in both arteries (p < 0.05) and significantly increased the speed of PFM relaxation after a contraction (p = 0.003). After the intervention, a marginally significant decrease in PFM tone was observed, as well as an increase in PFM strength (p = 0.060 and p = 0.051, respectively). Finally, improvements in skin elasticity and introitus width were observed as measured by the Vaginal Atrophy Index (p < 0.007).Conclusion: Our findings suggest that PFMT improves blood flow in vulvovaginal tissues, PFM relaxation capacity, and vulvovaginal tissue elasticity in postmenopausal women with GSM and UI.

Physical Therapy Intervention for Women With Dyspareunia: A Randomized Clinical Trial

Dyspareunia negatively affects women´s quality of life, and is a frequent complaint during the peri- and postmenopausal period. A randomized trial evaluated sexual function, quality of life, pain, and pelvic floor muscle function of climacteric women aged between 40 and 60 years old who were sexually active and had complaints of dyspareunia for at least six months. They were assessed before and after their randomization in one of the following interventions: the first group (n = 21) received five one-hour sessions of thermotherapy for relaxation of pelvic floor muscles, myofascial release, and pelvic training (pelvic floor muscle training-PFMT group). The second group (n = 21) received five one-hour sessions during which heat was applied to the lower back with myofascial release of abdominal diaphragm, piriformis, and iliopsoas muscles, with no involvement of pelvic training (lower back-LB group). Forty-two climacteric women with dyspareunia (mean ± SD, PFMT group: 51.9 ± 5.3 years, LB group: 50.6 ± 4.7 years, Student's t-test, p = 0.397) were studied. Pain scores (mean ± SEM) in the PFMT group decreased from 7.77 ± 0.38 to 2.25 ± 0.30; and in the LB group from 7.62 ± 0.29 to 5.58 ± 0.49 (generalized estimating equation-GEE model, p ≤ 0.001 for group, time, and interaction pairwise comparisons). Conclusion: The proposed pelvic floor muscle training protocol was effective to improve pain, quality of life, sexual function, and pelvic floor muscle function in climacteric women with dyspareunia.

The impact of a familiarization session on the magnitude and stability of active and passive pelvic floor muscle forces measured through intravaginal dynamometry

AIMS

The aim of this study was to investigate the impact of task familiarization on (1) the magnitude and (2) the repeatability of active and passive properties of the female pelvic floor muscles (PFMs) measured using automated intra-vaginal dynamometry.

METHODS

Women attended three laboratory sessions at one-week intervals. After receiving initial task instruction and feedback at the start of the first session, standardized instructions were given while women performed maximal effort voluntary contractions of their PFMs with the dynamometer arms open at two different diameters and kept their PFMs relaxed while the dynamometer arms opened to 40 mm at two speeds. Outcomes included baseline force, peak force, relative peak forces (N), rate of force development (N/s) and stiffness. Between session effects were tested for all outcomes using one-way ANOVAs. Intra-class correlation coefficients (ICCs) and minimal detectable change values were computed within each session and between sessions 1 and 2 and sessions 2 and 3.

RESULTS

Twenty nulliparous women (mean age = 35 ± 15 years) participated. No differences in the mean values were found across the three visits for any outcomes. Within sessions, neither ICC nor minimal detectable change differed among sessions and between-session ICC values were not different between visits 1 and 2 and visits 2 and 3.

CONCLUSIONS

There is no evidence of a familiarization effect over a two-week period on the amplitude nor repeatability of dynamometric measures of active or passive PFM properties recorded from nulliparous women.

Effectiveness of Intra-anal Biofeedback and Electrical Stimulation in the Treatment of Children With Refractory Monosymptomatic Nocturnal Enuresis: A Comparative Randomized Controlled Trial

Purpose

To compare the effects of intra-anal biofeedback (BF) and intra-anal electrical stimulation (ES) on pelvic floor muscles (PFMs) activity, nocturnal bladder capacity, and frequency of wet night episodes in children with refractory primary monosymptomatic nocturnal enuresis (PMNE).

Methods

Ninety children of both sexes aged 8–12 years with refractory PMNE participated in this study. They were randomly assigned to 3 groups of equal number: control group (CON) that underwent behavioral therapy and PFM training, and 2 study groups (BF and ES) that underwent the same program in addition to intra-anal BF training and intra-anal ES, respectively. PFMs activity was assessed using electromyography, nocturnal bladder capacity was evaluated by measuring the first morning voided volume, and a nocturnal enuresis diary was used for documenting wet night episodes before treatment and after 3 months of treatment.

Results

After training, all groups showed statistically significant improvements in all measured outcomes compared to their pretreatment findings. The ES group showed significantly greater improvements in all measured outcomes than the CON and BF groups.

Conclusions

Both intra-anal BF training and ES combined with behavioral therapy and PFMs training were effective in the treatment of PMNE, with intra-anal ES being superior to BF training.

Terminology of Pelvic Floor Muscle Function in Women With and Without Urinary Incontinence: A Systematic Review

BACKGROUND

Pelvic floor muscle function (PFMF) is a target of the physical therapist intervention for women with urinary incontinence (UI). However, possible variations in PFMF terminology might hamper communication among researchers and health care professionals in Women's Health.

OBJECTIVE

The objective of this study was to investigate the terminology of PFMF regarding clear terms, conceptual definitions, and operational definitions.

DATA SOURCES

Data sources include PUBMED, CINAHL, LILACS, and SCIELO.

STUDY SELECTION

Observational studies investigating any PFMF in women with or without UI, published in English, Spanish, or Portuguese from 2005 through 2017, were considered.

DATA EXTRACTION

The risk of bias was assessed by a questionnaire on the quality of observational studies. Data on terminology were extracted as terms, conceptual definitions, and operational definitions of PFMF and were synthesized according to key words, key ideas, and key operationalization, respectively. Consistencies and variations were identified for the most frequently investigated PFMF.

DATA SYNTHESIS

Sixty-four studies were included, and a low risk of bias was identified. All studies presented terms and operational definitions of PFMF, but only 29.7% presented conceptual definitions of those terms. One hundred ninety-six different terms referred to PFMF. According to similarities in terminology, 161 PFMF terms could be grouped under 26 terms; the other 35 were left ungrouped. Therefore, a total of 61 different PFMF terms were identified in the literature.

LIMITATIONS

A limitation in the study was that only observational studies were included.

CONCLUSIONS

A large variation in PFMF terminology was identified, precluding data gathering and meta-analysis. The lack of use of standardized terminology delays the progress of scientific knowledge and evidence-based practice dissemination. Efforts toward creating a collaborative, consensual terminology based on a sound framework are necessary.

Group physiotherapy compared to individual physiotherapy to treat urinary incontinence in aging women: study protocol for a randomized controlled trial

Background

Urinary incontinence (UI), one of the most prevalent health concerns confronting women aged over 60 years, affects up to 55% of older community-dwelling women—20–25% with severe symptoms. Clinical practice guidelines recommend individualized pelvic floor muscle training (PFMT) as a first-line treatment for stress or mixed UI in women, although lack of human and financial resources limits delivery of this first-line treatment. Preliminary data suggest that group-based treatments may provide the answer. To date, no adequately powered trials have evaluated the effectiveness or cost-effectiveness of group compared to individual PFMT for UI in older women. Given demographic projections, high prevalence of UI in older women, costly barriers, and group PFMT promising results, there is a clear need to rigorously compare the short- and long-term effectiveness and cost-effectiveness of group vs individual PFMT.

Methods/Design

The study is designed as a non-inferiority randomized controlled trial, conducted in two facilities (Montreal and Sherbrooke) in the Canadian province of Quebec. Participants include 364 ambulatory, community-dwelling women, aged 60 years and older, with stress or mixed UI. Randomly assigned participants will follow a 12-week PFMT, either in one-on-one sessions or as part of a group, under the supervision of a physiotherapist. Blinded assessments at baseline, immediately post intervention, and at one year will include the seven-day bladder diary, the 24-h pad test, symptoms and quality of life questionnaires, adherence and self-efficacy questionnaire, pelvic floor muscle function, and cost assessments. Primary analysis will test our main hypothesis that group-based treatment is not inferior to individualized treatment with respect to the primary outcome: relative (%) reduction in the number of leakages.

Discussion

Should this study find that a group-based approach is not less effective than individual PFMT, and more cost-effective, this trial will impact positively continence-care accessibility and warrant a change in clinical practice.

Trial registration

ClinicalTrials.gov, NCT02039830. Registered on 12 December 2013; Study protocol version 2; 21 November 2013.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2261-4) contains supplementary material, which is available to authorized users.

Characterizing the Functional Decline of Older Women With Incident Urinary Incontinence

OBJECTIVE

To characterize change in physical performance and differential prevalence of low skeletal muscle mass and strength (sarcopenia) and lower 25-hydroxyvitamin D concentrations among older women who developed urinary incontinence (UI) symptoms.

METHODS

This is a secondary analysis of the Health, Aging, and Body Composition Study. Urinary incontinence symptoms were assessed using validated questions. The Short Physical Performance Battery measured physical performance. Sarcopenia, defined by low muscle mass and strength, was determined using validated cutoffs for gait speed, grip strength, and appendicular skeletal muscle mass. All parameters were evaluated at baseline and year 4. Serum 25-hydroxyvitamin D concentrations were assessed at year 2. The primary outcome was change in Short Physical Performance Battery total scores. Sarcopenia and lower serum 25-hydroxyvitamin D concentrations have been independently associated with poor physical performance and UI and were therefore included as secondary outcomes. Univariate and multivariate analyses were used to characterize the associations of change in physical performance from baseline to year 4, incidence of sarcopenia, and lower serum 25-hydroxyvitamin D on the development of UI symptoms.

RESULTS

Of the 1,583 women enrolled, 910 were excluded (730 had baseline UI; 180 with missing data). Six hundred seventy-three women were continent at baseline; 223 (33%) developed UI symptoms at year 4. SPPB total scores significantly declined in women with UI versus continent women (mean difference continent-incident UI 0.32, 95% CI 0.04-0.60, P=.02). Of subscale measures, standing balance showed the greatest decline at 0.20 (0.05-0.36; continent-incident UI, respectively; P=.009). Sarcopenia developed at a higher rate with incident UI (adjusted odds ratio [OR] 1.7, 95% CI 1.0-2.9). Low 25-hydroxyvitamin D was not associated with incident UI (adjusted OR 1.1, 95% CI 0.7-1.6 and 1.1, 95% CI 0.7-1.6 for deficient or insufficient versus sufficient status, respectively).

CONCLUSION

We observed a significant decline in standing balance among older women who developed UI symptoms. This decline may be associated with coinciding development of sarcopenia.

The effects of training by virtual reality or gym ball on pelvic floor muscle strength in postmenopausal women: a randomized controlled trial

Objective

To evaluate the effectiveness of abdominopelvic training by virtual reality compared to pelvic floor muscle training (PFMT) using a gym ball (a previously tested and efficient protocol) on postmenopausal women’s pelvic floor muscle (PFM) strength.

Method

A randomized controlled trial was conducted with 60 postmenopausal women, randomly allocated into two groups: Abdominopelvic training by virtual reality – APT_VR (n=30) and PFMT using a gym ball – PFMT_GB (n=30). Both types of training were supervised by the same physical therapist, during 10 sessions each, for 30 minutes. The participants’ PFM strength was evaluated by digital palpation and vaginal dynamometry, considering three different parameters: maximum strength, average strength and endurance. An intention-to-treat approach was used to analyze the participants according to original groups.

Results

No significant between-group differences were observed in most analyzed parameters. The outcome endurance was higher in the APT_VR group (p=0.003; effect size=0.89; mean difference=1.37; 95% CI=0.46 to 2.28).

Conclusion

Both protocols have improved the overall PFM strength, suggesting that both are equally beneficial and can be used in clinical practice. Muscle endurance was higher in patients who trained using virtual reality.

Pelvic floor morphometry: a predictor of success of pelvic floor muscle training for women with stress and mixed urinary incontinence

INTRODUCTION AND HYPOTHESIS

The aim of this study was to determine if pelvic floor muscle (PFM) morphometry at baseline, as measured by MRI, can predict response to PFM training in women with stress or mixed urinary incontinence (UI).

METHODS

This study was a prospective quasi-experimental pre-test, post-test cohort study of women with UI, aged 60 years and older. All participants completed a baseline assessment of UI severity and impact, using the 72-h bladder diary and the Incontinence Impact Questionnaire. They underwent a pelvic MRI examination to assess the PFM anatomy. Women then participated in a 12-week PFM training program. Finally, they attended a post intervention assessment of UI severity and impact. The association between morphometry and PFM training response was assessed by univariate analysis, multivariate analysis, and receiver operating characteristic (ROC) curve analysis.

RESULTS

The urethro-vesical junction height at rest, as measured by MRI before treatment, was associated with response to PFM training both on univariate (p ≤ 0.005) and multivariate analyses (p = 0.007). The area under the ROC curve was 0.82 (95% confidence interval [CI]: 0.67-0.96). Using a cut-off point of 11.4 mm, participants' response to PFM training was predicted with a sensitivity of 77% and a specificity of 83%. Incontinent women with a urethro-vesical junction height above this threshold were 35% more likely to respond to PFM training (OR 1.35; 95% CI: 1.08-1.67).

CONCLUSION

In older women with UI, a urethro-vesical junction height at rest of at least 11.4 mm appears to be predictive of PFM training response.

Physical therapy for urinary incontinence in postmenopausal women with osteoporosis or low bone density: a randomized controlled trial

OBJECTIVE

To assess the effectiveness of 12 weekly physical therapy sessions for urinary incontinence (UI) compared with a control intervention, for reducing the number of UI episodes measured with the 7-day bladder diary, at 3 months and 1 year postrandomization.

METHODS

A single parallel-group randomized controlled trial was conducted at one outpatient public health center, in postmenopausal women aged 55 years and over with osteoporosis or low bone density and UI. Women were randomized to physical therapy (PT) for UI or osteoporosis education. The primary outcome measure was number of leakage episodes on the 7-day bladder diary, assessed at baseline, after treatment and at 1 year. The secondary outcome measures included the pad test and disease-specific quality of life and self-efficacy questionnaires assessed at the same timepoints.

RESULTS

Forty-eight women participated (24 per group). Two participants dropped out of each group and one participant was deceased before 3-month follow-up. Intention-to-treat analysis was undertaken. At 3 months and 1 year, there was a statistically significant difference in the number of leakage episodes on the 7-day bladder diary (3 mo: P = 0.04; 1 y: P = 0.01) in favor of the PT group. The effect size was 0.34 at 1 year. There were no harms reported.

CONCLUSIONS

After a 12-week course of PT once per week for UI, PT group participants had a 75% reduction in weekly median number of leakage episodes, whereas the control group's condition had no improvement. At 1 year, the PT group participants maintained this improvement, whereas the control group's incontinence worsened.

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.

Insulin Resistance Is Associated with Prevalence of Physician-Diagnosed Urinary Incontinence in Postmenopausal Non-Diabetic Adult Women: Data from the Fourth Korea National Health and Nutrition Examination Survey

Objective

To investigate the association between insulin resistance (IR) and urinary incontinence in Korean adult women by analyzing the data from the Korea National Health and Nutrition Examination Survey IV (KNHANES) 2007–2009

Methods

A nationally representative sample of 5318 non-diabetic Korean women ≥19-years-of-age (3043 premenopausal and 2275 postmenopausal women) was included from KNHANES 2008–2010. IR was measured using the homeostasis model assessment of IR (HOMA-IR). Participants in the highest and lowest quartile of HOMA-IR were defined as insulin-resistant and insulin-sensitive respectively. Women who have current physician-diagnosed urinary incontinence were classified as having urinary incontinence.

Results

Incontinence was found in 9.18% of the total population, 8.51% of the premenopausal population, and 10.86% of the postmenopausal population. The prevalence of incontinence increased with age, reaching a peak at 60-69-years-of-age. The prevalence of urinary incontinence increased significantly with higher HOMA-IR quartiles in pre- and post-menopausal women (p for linear association = 0.0458 and 0.0009 respectively). Among post-menopausal women, those in the highest quartile of HOMA-IR were significantly more likely to have urinary incontinence compared to those in the lowest quartile [adjusted odds ratio, 1.72; 95% confidence interval, 1.07–2.77]. However premenopausal population exhibited no association between incontinence and HOMA-IR quartiles

Conclusion

Our results suggest that the prevalence of incontinence increased across HOMA-IR in non-diabetic adult women, and especially, IR might be a risk factor for incontinence in postmenopausal non-diabetic women.

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.

Intra and inter-rater reliability study of pelvic floor muscle dynamometric measurements

OBJECTIVE:

The aim of this study was to evaluate the intra and inter-rater reliability of pelvic floor muscle (PFM) dynamometric measurements for maximum and average strengths, as well as endurance.

METHOD:

A convenience sample of 18 nulliparous women, without any urogynecological complaints, aged between 19 and 31 (mean age of 25.4±3.9) participated in this study. They were evaluated using a pelvic floor dynamometer based on load cell technology. The dynamometric evaluations were repeated in three successive sessions: two on the same day with a rest period of 30 minutes between them, and the third on the following day. All participants were evaluated twice in each session; first by examiner 1 followed by examiner 2. The vaginal dynamometry data were analyzed using three parameters: maximum strength, average strength, and endurance. The Intraclass Correlation Coefficient (ICC) was applied to estimate the PFM dynamometric measurement reliability, considering a good level as being above 0.75.

RESULTS:

The intra and inter-raters' analyses showed good reliability for maximum strength (ICC_intra-rater1=0.96, ICC_intra-rater2=0.95, and ICC_inter-rater=0.96), average strength (ICC_intra-rater1=0.96, ICC_intra-rater2=0.94, and ICC_inter-rater=0.97), and endurance (ICC_intra-rater1=0.88, ICC_intra-rater2=0.86, and ICC_inter-rater=0.92) dynamometric measurements.

CONCLUSIONS:

The PFM dynamometric measurements showed good intra- and inter-rater reliability for maximum strength, average strength and endurance, which demonstrates that this is a reliable device that can be used in clinical practice.

A pelvic floor muscle training program in postmenopausal women: A randomized controlled trial

OBJECTIVES

The purpose of this study was to investigate if a specific pelvic floor muscle training (PFMT) program effectively increases pelvic floor muscle (PFM) contractility and decreases anterior pelvic organ prolapse (POP) as well as urogynecological symptoms, in postmenopausal women. The mean outcome measure of this study was the pelvic floor surface electromyography (sEMG) activity.

STUDY DESIGN

A clinical, randomized, blinded-assessor and controlled study was conducted with 46 postmenopausal women. Thirty women completed this study (mean age of 65.93 years), divided into two groups: Treatment Group - TG (n=18) and Control Group - CG (n=12). The evaluation was carried out using digital palpation, sEMG, pelvic organ prolapse quantification (POP-Q) as well as validated questionnaires by the International Consultation on Incontinence Questionnaires to investigate urogynecological symptoms. The treatment protocol consisted of 12 group sessions, twice a week, with 30 min of duration each. These data were then submitted to statistical analyses by the Statistical Analysis System for Windows software, with a significance level of 5%.

RESULTS

The pelvic floor muscle contractility increased after PFMT, evaluated by sEMG (p=0.003) and digital palpation (p=0.001), accompanied by a decrease in urinary symptoms (p<0.001 for ICIQ-OAB scores e 0.036 for ICIQ UI-SF) as well as anterior pelvic organ prolapse (p=0.03).

CONCLUSION

This preliminary study suggests that the applied PFMT program could be an effective way to increase PFM contractility, as well as to decrease both anterior pelvic organ prolapse and urinary symptoms, in postmenopausal women.

Does pelvic floor muscle training abolish symptoms of urinary incontinence? A randomized controlled trial

OBJECTIVE

To determine whether symptoms of urinary incontinence is reduced by pelvic floor muscle training, to determine whether urinary incontinence can be totally eliminated by strengthening the pelvic floor muscle to grade 5 on the Oxford scale.

DESIGN

Prospective randomized controlled clinical trial.

SETTING

Outpatient urogynecology department.

SUBJECTS

One hundred thirty cases with stress and mixed urinary incontinence.

INTERVENTION

All participants were randomly allocated to the pelvic floor muscle training group or control group. A 12-week home based exercise program, prescribed individually, was performed by the pelvic floor muscle training group.

MAIN MEASURES

Urinary incontinence symptoms (Incontinence Impact Questionnaire-7, Urogenital Distress Inventory-6, bladder diary, stop test and pad test) were assessed, and the pelvic floor muscle strength was measured for (PERFECT testing, perineometric and ultrasound) all participants before and after 12 weeks of treatment.

RESULTS

The pelvic floor muscle training group had significant improvement in their symptoms of urinary incontinence (P=0.001) and an increase in pelvic floor muscle strength (P=0.001, by the dependent t test) compared with the control group. All the symptoms of urinary incontinence were significantly decreased in the patients that had reached pelvic floor muscle strength of grade 5 and continued the pelvic floor muscle training (P<0.05).

CONCLUSION

The study demonstrated that pelvic floor muscle training is effective in reducing the symptoms of stress and mixed urinary incontinence and in increasing pelvic floor muscle strength.

Pelvic floor muscle function in women with pelvic floor dysfunction: a retrospective chart review, 1992-2008

INTRODUCTION AND HYPOTHESIS

The objectives of this study were to investigate the level of pelvic floor muscle (PFM) function in women with pelvic floor dysfunction (PFD) referred by gynaecologists and urologists for in-hospital pelvic floor muscle training (PFMT), and to identity associated factors for a low level of PFM function.

METHODS

Data of women with PFD referred to a PFMT programme were included in a retrospective chart review. Measurement of PFM function performed by digital vaginal palpation included: voluntary PFM contraction, PFM strength (Modified Oxford Grading Scale) and PFM static endurance.

RESULTS

Data of 998 women, mean age 56 (SD 13) years, with PFD (urinary incontinence, n = 757, anal incontinence, n = 36, pelvic organ prolapse, n = 111, other PFD, n = 94) were analysed. In all, 690 women (70%) were, at baseline, unable to perform correct voluntary PFM contraction, mean PFM strength was 1.5 (SD 1.0) points, mean PFM static endurance was 16.7 (SD 16.1) seconds. Age ≥ 65 years and year of referral > 2000 were significantly (p < 0.01) associated with the ability to perform correct PFM contraction. Likewise, year of referral was significantly associated with high PFM strength (p < 0.01).

CONCLUSIONS

The majority of the women were unable to perform correct voluntary PFM contraction and almost all had low PFM strength. The most important factor associated with a low level of PFM function was age.