Evaluation of pelvic floor muscle function in a random group of adult women in Austria

Effects of hypopressive exercises on pelvic floor and abdominal muscles in adult women: A systematic review of randomized clinical trials

INTRODUCTION

Hypopressive exercises (HE) are postural and breathing exercises that activate deep muscles in the abdomen and pelvic floor. Despite this, there is still no consensus in the literature on its real effectiveness. The objective was to analyze the effects of HE on the abdominal and pelvic floor muscles in women with or without dysfunctions in these regions.

METHODS

This is a systematic review of randomized clinical trials found in the PEDro, PubMed, Cochrane, LILACS, and Embase databases. We include studies that evaluate the effects of HE (with or without other techniques) on the pelvic floor and abdominal region for 8 weeks or more, in women over 18 years old, with or without dysfunction in these regions, with the presence of a control group (active or passive).

RESULTS

HE were effective in improving strength, tone, and reducing symptoms of pelvic floor dysfunctions, in magnitude less than (in two studies) or equal (in one study) to the pelvic floor muscle training (PFMT). When HE were performed with PFMT in the same group, no additional benefits were found. Only one study evaluated abdominal muscles activation, where HE were effective in improving postural control and activation of the transversus abdominis muscle.

CONCLUSIONS

The HE presented positive results to the evaluated parameters. However, the information is still preliminary and scarce. There are methodological divergences regarding the execution, follow-up and standardization of the method, which could affect the results. According to the existing information, HE cannot yet be reliably indicated for the treatment of the pelvic floor, despite pointing out relevant results in some studies. More randomized clinical trials and long-term studies are needed to analyze the effects of HE not only for pelvic floor, but also for other regions, such as abdominal muscles and related dysfunctions.

Portable Dynamometer-Based Measurement of Pelvic Floor Muscle Force

OBJECTIVE

In attempts to improve the quality of life of women, continuous projects are sought between rehabilitation intervention and engineering. Using the knowledge of the pelvic floor muscle (PFM) physiology, assessment and training methods are developed to reduce lower urinary tract symptoms such as urinary incontinence. Therefore, this paper covers the design and implementation of a portable vaginal dynamometer.

METHODS

A PFM probe is designed, 3D printed, assembled, and tested in ten women to assess its acceptability and usability. The feedback from the usability study is used to optimize the PFM probe design. A vaginal dynamometer is developed based on the designed PFM probe, then tested for linearity, repeatability, hysteresis, noise and heat effect, and power consumption. The variability between the different produced PFM probe prototypes is evaluated.

RESULTS

Force measurements are made using a load cell. Wireless communication is performed through a Bluetooth low energy transceiver v5.0, with a corresponding interface on both computer and smartphone. The device operates at a 3.3V supply and achieves a power consumption of 49.5 mW in operating mode. Two PFM probe sizes are designed to accommodate different vaginal hiatus sizes, based on usability study feedback. The proposed system allows the physiotherapist to wirelessly monitor variation in pelvic floor muscle force during assessment and/or training.

DISCUSSION/CONCLUSION

The testing results showed that the newly designed system has the potential to measure the PFM function in functional conditions such as the standing position.

The Perception of Pelvic Floor Muscle Function amongst Exercising Women Who Are Repeatedly Instructed to Contract Their Pelvic Floor Muscles

In this study, the self-perception of pelvic floor muscle (PFM) contractions amongst women receiving repeated verbal instructions during exercise classes was examined. The prevalence and severity of urinary stress incontinence were also assessed. This cross-sectional observational study included 46 women (mean age 48 (±8.6)), who regularly participated in Pilates classes where repeated instruction was given to contract PFM (“instruction group”; N = 22) or not (controls, N = 24). PFM function was evaluated using transabdominal ultrasound. Simultaneously, the participant described her personal evaluation of her PFM contraction ability. The International Consultation on Incontinence Questionnaire–Short Form was also utilized. Most women (80%) correctly contract PFM; however, 95% did not perform a voluntary contraction during leg movement, without differences observed between groups. A higher perception of PFM contraction was found in the “instruction group” when performing knee flexion towards the chest without specific verbal instruction. Women who were instructed to contract their PFM suffered less incontinence and had a lower degree of severity than the controls. Most women performing Pilates exercises correctly contracted their PFM. However, there was no PFM voluntary contraction during leg movement. Exposure to repeated verbal instructions to contract PFM, over time, might lead to an improvement in women’s perception of their ability to contract PFM. Verbal instructions for PFM contraction were found to be effective in reducing urinary incontinence.

Urinary Incontinence in Competitive Women Powerlifters: A Cross-Sectional Survey

Background

Urinary incontinence (UI) can negatively affect a woman’s quality of life, participation in sport and athletic performance. The objectives of this study were to determine the prevalence of UI in competitive women powerlifters; identify possible risk factors and activities likely to provoke UI; and establish self-care practices.

Methods

This international cross-sectional study was conducted using an online survey completed by 480 competitive women powerlifters aged between 20 and 71 years. The Incontinence Severity Index (ISI) was used to determine the severity of UI.

Results

We found that 43.9% of women had experienced UI within the three months prior to this study. The deadlift was the most likely, and the bench-press the least likely exercise to provoke UI. ISI scores were positively correlated with parity (τ = 0.227, p < 0.001), age (τ = 0.179, p < 0.001), competition total (τ = 0.105, p = 0.002) and body mass index score (τ = 0.089, p = 0.009). There was no significant correlation between ISI and years strength training (τ = − 0.052, p = 0.147) or years powerlifting (τ = 0.041, p = 0.275). There was a negative correlation between ISI score with having a pelvic floor assessment (η = 0.197), and the ability to correctly perform pelvic floor exercises (η = 0.172).

Conclusion

The prevalence of UI in this cohort was at the upper limit experienced by women in the general population. Women who had undergone a pelvic floor examination or were confident in correctly performing pelvic floor exercises experienced less severe UI.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40798-021-00387-7.

Is there a correlation between a 20-min pad-test and subjective urine leakage amount?

INTRODUCTION AND HYPOTHESIS

The quantification of urinary incontinence (UI) is widely used in clinical practice to guide the prognosis and treatment, and the pad test is an inexpensive, quick, and easy tool to assess UI that has been used in studies in the literature. Another way to evaluate UI is the subjective urine leakage amount, but no studies have tried to correlate it with the 20-min pad test. Therefore, this study aimed to assess the correlation of the 20-min pad test with the subjective urine leakage amount and compare it with the pelvic floor function.

METHODS

This is a cross-sectional study with a sample size of 72 participants. It evaluated pelvic floor muscle strength as well as the duration of symptoms and pad weight. It used mean, standard deviation, median, and 95% confidence interval. In addition, ANOVA, Kruskal-Wallis, and Spearman's correlation coefficient were used. The significance level was fixed at 5% (significant if P < 0.05).

RESULTS

Only age was different between leakage volumes; participants who report greater UI volume were older than the participants who leaked less urine. There were no differences related to the duration of symptoms between different UI volumes and pad weights according to the subjective volume reported. Spearman's coefficient between pad weight and subjective volume of urine leakage was r_s = 0.558 (P ≤ 0.0001), demonstrating a moderate positive correlation.

CONCLUSIONS

There was a moderate correlation between the UI volume reported and the 20-min pad test. Additionally, no differences related to pelvic floor function were detected.

Effect of Paula exercise method on functional outcomes of women with post fistula repair incontinence: a protocol for randomized controlled trial

BACKGROUND

Post-fistula-repair incontinence (PFRI) is a common complication of vesicovaginal fistula (VVF) surgeries. It entails continuous leakage of urine after successful VVF closure. Pelvic Floor Muscle Training (PFMT) plays a vital role in the management of PFRI, however, an evolving exercise approach is the Paula Exercise Method (PEM) which has shown a promising effect in stopping urinary incontinence, but there is no data on its effect on PFRI. This study therefore, proposes to primarily investigate the effect of PEM on urine leakage and secondarily, pelvic floor strength (PFS), quality of life (QoL), sexual function (SF), and mental health (MH) in women with PFRI.

METHODS

This is a study protocol for a randomized controlled trial. A total of 182 participants are expected to participate in the study after satisfying the inclusion criteria. The participants will be randomized into either PEM or PFMT study groups. The demographic data of all the participants will be recorded. Each participant will be assessed for urine leakage, PFS, QoL, SF, and MH at baseline and subsequently, at four, eight and 12 weeks of intervention. Demographic parameters will be summarized using descriptive statistics. Continuous data will be computed for differences using inferential statistic of Analysis of variance, t-test and Man Whitney U as appropriate. All analyses will be performed using SPSS version 22.0 with probability set at 0.05 alpha level.

DISCUSSION

It is hoped that the outcome of this study will determine the effect of the Paula exercise method on urine leakage, pelvic floor strength, quality of life, sexual function, and mental health among women with post-fistula-repair incontinence and also provide evidence for the use of the Paula method in urinary incontinence.

TRIAL REGISTRATION

Pan African Clinical Trials Registry ( www.pactr.org ), identifier PACTR201906515532827.

The effect of parity on the function of pelvic floor musculature in the long term: cross-sectional study

Objective

Parity is associated with an increased risk of pelvic floor muscle dysfunction. The aim of this study was to evaluate the long-term effects of parity on this musculature.

Methods

This cross-sectional study was completed at the Department of Physical Therapy, Federal University of São Carlos, Brazil. In total, 143 women participated in the study and were classified into three groups according to parity: nulliparae, primiparae, and secundiparae women. All parous participants had last given birth between 1 and 6 years prior. Pelvic floor muscle function was assessed through unidigital vaginal palpation using the PERFECT scheme, with the contraction grade classified according to the Modified Oxford Scale and through manometry.

Results

There was no difference in scores on the Modified Oxford Scale (the means and standard deviations were 2.5±0.8 in nulliparae women, 2.3±0.9 in primiparae women, and 2.2±0.9 in secundiparae women; P=0.482) and manometry findings (the means and standard deviations were 42.3±22.7 in nulliparae women, 35.0±21.8 in primiparae women, and 33.2±20.0 in secundiparae women; P=0.144) among the assessed groups.

Conclusion

Parity had no effect, regardless of mode of birth, on the function of pelvic floor muscles and the presence of urinary symptoms, such as long-term urinary incontinence after birth.

Linking Pelvic Floor Muscle Function Terminology to the International Classification of Functioning, Disability and Health

OBJECTIVE

A previous systematic review on pelvic floor muscle function (PFMF) identified a miscellaneity of terms. The lack of consensual terminology might have come from the complexity of neuromusculoskeletal function itself. This study sought to link the previously identified PFMF terms to the International Classification of Functioning, Disability and Health (ICF) terminology.

METHODS

In this secondary analysis study, 10 linkage rules were applied to link 196 previously identified PFMF terms to the ICF. Two researchers performed the linking process independently. Disagreements were solved by open dialogue with a third researcher. Percentage agreement was computed for main outcome.

RESULTS

A total of 184 (93.9%) PFMF terms were subsumed into the following 6 ICF terms: tone, involuntary movement reaction, control, coordination, strength, and endurance. The most frequently investigated PFMF was strength (25.5%), followed by involuntary movement reaction (22.9%), endurance (17.2%), control (14.1%), coordination (9.9%), and tone (4.2%). Only 6.2% PFMF could not be linked to ICF terminology. A wide variation of instruments/methods was used to measure PFMF. Vaginal palpation was the only method employed to measure all 6 PFMF. Percentage agreement between raters was 100%.

CONCLUSIONS

Linking PFMF terminology to the ICF was feasible and valid. It allowed the identification of the most investigated PFMF and their measuring methods. ICF terminology to describe PFMF should be used since it may improve communication, data gathering, and the advance in scientific knowledge.

IMPACT

Standardized terminology anchored in a theoretical framework is crucial to data gathering, communication, and dissemination of evidence-based practice. PFMF terminology based on ICF can be used to improve data pooling and communication.

Ability to contract the pelvic floor muscles and association with muscle function in incontinent women

INTRODUCTION AND HYPOTHESIS

Many women with pelvic floor dysfunction are unable to perform pelvic floor muscle (PFM) contraction. We aimed to assess the ability to contract the PFM and to evaluate the association with muscle function in Brazilian women with urinary incontinence.

METHODS

We conducted a retrospective cross-sectional study including incontinent women over the age of 18. The assessment of PFM contraction was carried out by bidigital palpation via the PERFECT scheme. We categorized our population as: group absent: women not able to contract the PFM with verbal instructions; group 1 (1st command): women able to contract their PFM after verbal instructions; group 2 (2nd command): women who needed additional training on PFM anatomy and functioning to contract them. We compared the groups regarding their PFM functionality. We used ANOVA for demographic data and Mann-Whitney test for association analyses and P value < 0.05 for statistical significance.

RESULTS

Among 139 women included, 21 (15.1%) were not able to perform the contraction of the PFM. Sixty-five (46.7%) contracted their PFM voluntarily at the first command and 53 (38.1%) at the second command. There was a significant reduction in the PFM function in group 2 in terms of power (p < 0.001), endurance (p < 0.001) and fast contraction (p < 0.001) compared to group 1.

CONCLUSION

A high percentage (53.2%) of women were not able to contract their PFM voluntarily without training in PFM anatomy and functioning. Those women had impaired muscle function compared to women able to perform PFM after receiving exclusively oral instructions.

Urinary Incontinence in Women: Modern Methods of Physiotherapy as a Support for Surgical Treatment or Independent Therapy

Urinary incontinence (UI) is a common health problem affecting quality of life of nearly 420 million people, both women and men. Pelvic floor muscle (PFM) training and other physiotherapy techniques play an important role in non-surgical UI treatment, but their therapeutic effectiveness is limited to slight or moderate severity of UI. Higher UI severity requires surgical procedures with pre- and post-operative physiotherapy. Given that nearly 30%-40% of women without dysfunction and about 70% with pelvic floor dysfunction are unable to perform a correct PFM contraction, therefore, it is particularly important to implement physiotherapeutic techniques aimed at early activation of PFM. Presently, UI physiotherapy focuses primarily on PFM therapy and its proper cooperation with synergistic muscles, the respiratory diaphragm, and correction of improper everyday habits for better pelvic organ support and continence. The purpose of this work is a systematic review showing the possibilities of using physiotherapeutic techniques in the treatment of UI in women with attention to the techniques of PFM activation. Evidence of the effectiveness of well-known (e.g., PFM training, biofeedback, and electrostimulation) and less-known (e.g., magnetostimulation, vibration training) techniques will be presented here regarding the treatment of symptoms of urinary incontinence in women.

The Effect of Pelvic Floor Muscle Strengthening Exercise on Urinary Incontinence and Quality of Life in Patients after Prostatectomy: a Randomized Clinical Trial

Introduction: Urinary incontinence is a common problem after Prostatectomy that affects patients' life. Nurses can assist patients in improving urinary problems. This study aimed to assess the effects of pelvic floor muscle exercises on urinary incontinence and the quality of life in patients after Prostatectomy. Methods: This randomized clinical trial was performed on 60 patients with suprapubic prostatectomy and urinary incontinence who had referred to urology department of Vali-e-Asr Hospital in Tehran. The subjects were selected and randomly divided into control and intervention groups. The control and intervention groups received standard care and pelvic floor muscles exercises after surgery, respectively. The data were gathered in the course of seven days; one, two and three months after surgery, using three questionnaires and a check list for the evaluation of urinary incontinence and assessing Quality of Life. The data were then analyzed, using SPSS ver.13, and statistical tests such as t-test, ANOVA and Chi- square. Results: The quality of life and urinary incontinence score before intervention were not significant between two groups. The findings showed that there was a statistically significant difference between two groups in the average scores of urinary incontinence and the quality of life after intervention. Conclusion: Pelvic muscles exercises reduced urinary incontinence and enhanced quality of life. It's recommended as a non-pharmacologic, non-invasive way to control urinary incontinence. Patients with adequate cognitive and mental abilities can easily be trained on pelvic floor muscle exercises.

Reliability of different electromyographic normalization methods for pelvic floor muscles assessment

AIMS

To evaluate the reliability of different methods to normalize pelvic floor muscles (PFM) electromyography (EMG).

METHODS

Thirty nulliparous women (23.9 ± 3.2 years), free from PFM dysfunction, completed two test sessions 7 days apart. For EMG normalization, signals were acquired during four different tasks using a vaginal probe in situ: PFM maximal voluntary contraction (MVC) and three daily activities with increased intra-abdominal pressure (coughing, Valsalva maneuver, and abdominal contraction). The intraclass correlation coefficients (ICC), standard error of measurement (SEM), relative standard error of measurement (%SEM), and minimal detectable change (MDC) were calculated for each variable.

RESULTS

ICC values for test-retest reliability of normalization methods ranged from 0.61 to 0.95. The highest values were obtained for mean root mean square (RMS) of the abdominal contraction and peak RMS of PFM-MVC. Normalization using RMS of PFM-MVC showed the lowest values of SEM and MDC.

CONCLUSIONS

The normalization of EMG data is considered a fundamental part of EMG investigations. These findings suggest that the normalization of PFM-EMG by either peak RMS of PFM-MVC or mean and peak RMS of abdominal contraction has excellent reliability and it can be applied in studies involving the evaluation of young women.

Comparação entre oxibutinina, eletroestimulação do nervo tibial posterior e exercícios perineais no tratamento da síndrome da bexiga hiperativa

RESUMO Objetivou-se avaliar a eficácia dos exercícios perineais, da eletroestimulação transcutânea do nervo tibial posterior (ETNTP) e da oxibutinina em mulheres com síndrome da bexiga hiperativa, que é a segunda causa mais comum de incontinência urinária, com sintomas urinários extremamente incômodos que prejudicam a qualidade de vida. Foram randomizadas 65 mulheres, das quais 57 completaram o tratamento. Formaram-se três grupos: o de exercícios perineais, ETNTP e o grupo controle, que utilizou oxibutinina. Os exercícios foram realizados em grupo, nas posições em pé, supino e sentado, duas vezes por semana, com duração de 30 minutos cada sessão, totalizando 12 sessões. Na ETNTP utilizou-se eletrodo transcutâneo posicionado em maléolo medial e outro 10cm acima, com frequência de 10Hz e largura de pulso de 200 microssegundos, por 30 minutos, duas vezes por semana, totalizando 12 sessões. Na medicação as pacientes receberam oxibutinina de 10mg/dia de liberação imediata divididos e duas doses de 5mg/dia, durante 12 semanas consecutivas. Antes e depois dos tratamentos, as pacientes passaram por uma avaliação composta pela análise do diário miccional, avaliação funcional do assoalho pélvico e aplicação de questionário de qualidade de vida OAB-V8. Houve redução da incontinência de urgência em 50%, 70,5% e 41% nos grupos de exercício, ETNTP e oxibutinina, respectivamente, com significância estatística somente da eletroestimulação. As três modalidades de tratamento foram eficazes na melhora da qualidade de vida para a terapêutica em curto prazo, estatisticamente semelhantes entre si.

Reliability and validity of pelvic floor muscle displacement measurements during voluntary contractions

INTRODUCTION AND HYPOTHESIS

Understanding the functioning of pelvic floor muscles (PFM) is crucial in female PFM rehabilitation. The aim of this study was to determine the intra-session retest reliability and validity to evaluate the quantity of PFM displacement.

METHODS

This cross-sectional observational study examined the PFM displacement of 17 young healthy nulliparous women in the midsagittal plane. Three maximal voluntary contractions (MVCs) and five fast voluntary contractions (FVCs) were simultaneously examined with an electromagnetic tracking system (ETS) and transabdominal ultrasound (TAUS) and expressed in millimeters (mean, SD). To evaluate reliability and validity, the analysis of variance, intraclass coefficient (2,1), standard error of measurement (SEM), and minimal detectable difference (MDD) were calculated.

RESULTS

Maximal voluntary contractions and FVCs in supine position measured by an ETS (TAUS) showed a displacement of MVC: 3.5 ± 1.9 mm (7.8 ± 4.5 mm), FVC: 3.5 ± 2.4 mm (7.6 ± 5.3 mm), and during standing of MVC: 5.2 ± 1.6 mm (9.4 ± 3.8 mm) and FVC: 4.8 ± 2.5 mm (9.7 ± 4.1 mm). Intraclass correlation for the ETS (TAUS) measurement varied between 0.79 and 0.89 (0.61 and 0.74), SEM 0.52 and 1.03 mm (1.54 and 3.2 mm), and MDD 1.54 and 3.2 mm (6.64 and 7.53 mm). The correlation between an ETS and TAUS varied between 0.53 and 0.67.

CONCLUSIONS

For MVC and FVC, ETS measurements are highly reliable and TAUS measurements are moderately reliable for both contraction types. The correlation between the TAUS and ETS measurements is moderate. An ETS seems to be a reliable and valid measurement tool for evaluating PFM displacement during voluntary contractions. In future studies, the reproducibility and validity of ETS measurements need to be investigated in impact activities.

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.

Evaluation of the pelvic floor muscles training in older women with urinary incontinence: a systematic review

Background:

Urinary incontinence (UI) is defined as any involuntary urine loss that predominantly affects older women. There is evidence that pelvic floor muscles training (PFMT) program is effective on the treatment of pelvic floor (PF) dysfunctions and is considered to be first-line treatment. The evaluation of pelvic floor muscles (PFM) function and strength is central to validate the effectiveness of the training protocol in UI decrease. The Oxford Grading Scale and manometry are fundamental to evaluate the PFM function and strength.

Objective:

The aim of the study was to systematize the scientific evidence about the effects of PFMT in older women, assessing the PF function and strength through Oxford Grading Scale and manometry.

Methods:

The research of randomized controlled clinical trials was performed through B-on, EBSCO, PEDro, Pubmed, and SciELO data carried out from 2003 to 2016.

Results:

A total of 35 studies were identified, 26 of these were selected and fully analyzed. From the analyzed studies (n = 26), 20 were excluded for not meeting the criteria for inclusion, and only 6 studies were classified as high methodological quality, scoring an overall 4 points according the PEDro scale.

Conclusion:

The PFMT seems to be effective in treating UI in older women; the Oxford Grading Scale and manometry are considered the most reliable in the random and controlled clinical trials results. However, future investigations with high methodological quality with older women are necessary to support these results.

Test-retest reliability of the different dynamometric variables used to evaluate pelvic floor musculature during the menstrual cycle

OBJECTIVE

The aim of this study was to evaluate the reliability of different dynamometric variables of the pelvic floor muscles (PFM) in healthy women during different periods of menstrual cycle.

MATERIALS AND METHODS

Vaginal dynamometric equipment was developed by the authors and its reproducibility was tested. The PFM contractions of 20 healthy women were collected by two independent examiners over three consecutive weeks, always on the same day, with a seven-day interval between readings, starting from the first day after the end of the menstrual period. For the measurements, the branch of the dynamometer was positioned first on the sagittal plane and then on the frontal plane. Baseline, peak time, maximum PFM strength, impulse contraction, and average contraction force were calculated. Reproducibility was tested using the intra-class correlation coefficient (ICC) and standard error of measurement. Repeated-measures ANOVA was used to compare the data from different days.

RESULTS

For intra-day and inter-day reliability between examiners, all the parameters collected on the sagittal plane presented good and excellent reproducibility (ICC_2,1  = 0.60 to 0.98), whereas reproducibility on the frontal plane was respectively poor and excellent (ICC_2,1  = 0.23 to 0.97). The ANOVA revealed significant differences between sessions only for the impulse of contraction for the sagittal (P = 0.005) and frontal (P = 0.03) planes.

CONCLUSIONS

Time and contraction force parameters of the PFM are not influenced by hormonal alterations that occur during the menstrual cycle. The impulse of contraction was the only variable to demonstrate a significant difference between the first and second week of the data collection protocol. The baseline, maximum strength value, impulse of contraction, and average contraction force variables presented good to excellent reproducibility and can be safely used as a method of PFM evaluation.

Effects of three interventions in facilitating voluntary pelvic floor muscle contraction in women: a randomized controlled trial

OBJECTIVE

To evaluate the effect of vaginal palpation, vaginal palpation associated with posterior pelvic tilt, and intravaginal electrical stimulation in facilitating voluntary contraction of the pelvic floor muscles in women.

METHODS

A randomized controlled trial in which 132 women with pelvic floor muscles function graded at 0 or 1 using the Modified Oxford Scale were randomized into four groups: vaginal palpation (n=33); vaginal palpation with posterior pelvic tilt (n=33); intravaginal electrical stimulation (n=33) and a control group (n=33) that only received verbal instructions. The primary outcome was evaluated by the Modified Oxford Scale and the secondary using the ICIQ-UI-SF. The assessment was performed at baseline with follow-up assessment after eight weeks.

RESULTS

A total of 69.7% of the women from posterior pelvic tilt; 63.6% from vaginal palpation; 33.3% from intravaginal electrical stimulation; and 18.2% from control group (p<0.001) were able to attain Modified Oxford Scale greater than or equal to 2 after eight weeks. In comparison with control group, the posterior pelvic tilt (OR=10.35; 95% CI=3.26-32.84) and vaginal palpation (OR=7.87; 95% CI=2.53-24.47) had the most significant improvement as opposed to intravaginal electrical stimulation (OR=2.25; 95% CI=0.72-7.06). There was significant improvement among all of the groups in UI. The largest changes respectively were noted in the vaginal palpation, posterior pelvic tilt, intravaginal electrical stimulation and control group. There were no reports of adverse effects.

CONCLUSION

Vaginal palpation with posterior pelvic tilt and vaginal palpation were more effective interventions to facilitate pelvic floor muscles contraction when compared with intravaginal electrical stimulation and controls. Vaginal palpation was the most effective in improving urinary incontinence. Clinical Trials Identifier: ClinicalTrial.gov: NCT02062242.

Physiotherapy methods to facilitate pelvic floor muscle contraction: A systematic review

AIM

To undertake a systematic review of the literature on physical therapy methods to facilitate voluntary pelvic floor muscles (PFM) contraction.

METHODS

The databases consulted were PubMed, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, PEDro and CINHAL. The study included randomized controlled trials, quasi-experimental trials and systematic reviews. The GRADE scale was used to assess methodological quality.

RESULTS

Six manuscripts were included. The methods investigated included instruction regarding the anatomy and function of the PFM, vaginal palpation, palpation on the central perineal tendon, interruption of urinary flow, biofeedback using a perineometer, vaginal cones, hypopressive exercise, PFM contraction associated with diaphragmatic breathing; and coactivation of abdominal muscles. The studies showed improvement in PFM contraction, but most were of low methodological quality. Only one study was characterized as being of high methodological quality.

CONCLUSION

All the studies observed improvement in PFM contraction using various methods, but none were superior over the others. The studies revealed no adverse effects of the interventions used. Patient preferences should be taken into account in clinical decision-making. More studies of high methodological quality on this topic are needed.

Residual defects after repair of obstetric anal sphincter injuries and pelvic floor muscle strength are related to anal incontinence symptoms

INTRODUCTION AND HYPOTHESIS

The aim was to analyze the correlation between residual anal sphincter (AS) defects and pelvic floor muscle (PFM) strength on anal incontinence (AI) in patients with a history of obstetric AS injuries (OASIS).

METHODS

From September 2012 to February 2015, an observational study was conducted on a cohort of females who underwent repair of OASIS intrapartum. The degree of OASIS was scored intrapartum according to Sultan's classification. Participants were assessed at 6 months postpartum. Incontinence symptoms were evaluated using Wexner's score and PFM strength using the Modified Oxford Scale (MOS). 3D-endoanal ultrasound was performed to classify AS defects according to Starck's system. Correlation between Sultan's and Starck's classifications was calculated using Cohen's kappa and Spearman's rho (R_s) test. The impact of residual AS defects and PFM strength on AI was analyzed using a multiple regression model.

RESULTS

A total of 95 women were included in the study. Good correlation (κ= 0.72) was found between Sultan's and Starck's classifications. Significant positive correlation was observed between Wexner's score and both Sultan's (p = 0.023, R_s =0.212) and Starck's (p < 0.001, R_s =0.777) scores. The extent of the residual AS defect was the most relevant factor correlating with AI symptoms. In patients with severe AS injuries, higher MOS values were associated with lower Wexner's score.

CONCLUSIONS

The degree of AS tear measured intrapartum was the most important factor related to AI after primary repair of OASIS. PFM strength was associated with lower incontinence symptoms in the postpartum period.

Correct performance of pelvic muscle exercises in women reporting prior knowledge

OBJECTIVES

This study aimed to assess correct performance of pelvic muscle exercises (PMEs) in women presenting for urogynecologic care who express prior PME knowledge and to identify optimal instruction.

METHODS

New patients referred to urogynecology clinic reporting knowledge of PME or Kegels were asked to complete a questionnaire concerning knowledge, prior instruction, and current use of PME. During examination, the participants were asked to perform their PME or Kegel. Initial levator strength was documented by Oxford Scale. Randomized-order instructions were then given to educate women who contracted incorrectly. The participants completed a postexamination questionnaire. Analyses described percentage of women who were able to perform a correct contraction on initial attempt and factors associated with correct performance. Standard statistical methods were used to assess factors associated with correct PME performance and initial strength.

RESULTS

Two hundred fifty eligible participants completed the questionnaires. Sixty (24%) participants were unable to correctly perform a PME initially. Of the 83 participants reporting current practice of PME, 23% performed them incorrectly. Prior instruction (odds ratio, 3.0; 95% confidence interval, 1.6-5.7; P < 0.01) and prior feedback (odds ratio, 3.5; 95% confidence interval, 1.0-12.0; P < 0.05) were associated with correct PME performance. In women who performed PME incorrectly at the initial assessment, "Squeeze the vaginal muscles you use to hold your urine" resulted in correct PME performance most often.

CONCLUSIONS

Women reporting prior knowledge of PME may still perform them incorrectly. Providing instruction and feedback is strongly associated with correct performance and can be easily incorporated into pelvic examination. This may improve PME use and effectiveness to control symptoms of pelvic floor disorders.

Is there a difference in the electromyographic activity of the pelvic floor muscles across the phases of the menstrual cycle?

[Purpose] To evaluate the electrical activity of the pelvic floor muscle in women during the follicular, ovulatory, and luteal phases of the menstrual cycle and its correlation with estradiol and total testosterone levels. [Subjects and Methods] This cross-sectional study involved 30 women with ovulatory menstrual cycles. Total testosterone and estradiol levels were measured and the muscle tone and maximum voluntary contraction of the pelvic floor muscles were evaluated using surface electromyography. [Results] Muscle tone was significantly lower during the follicular (21.1±3.3 μV) and ovulatory (27.1±5.9 μV) phases than the luteal phase (30.4±4.1 μV). The maximum voluntary contraction was not different across phases. The estradiol level on the 7th day of the menstrual cycle showed a strong positive correlation with muscle tone and maximum voluntary contraction, and the testosterone level was positively correlated with muscle tone on the 21st day. [Conclusion] Women have better muscle tone during the luteal phase. The muscle tone and maximum voluntary contraction were strongly correlated with the estradiol level on the 7th day, and the muscle tone was correlated with the testosterone level on the 21st day of the menstrual cycle. These findings suggest that hormonal fluctuations during the menstrual cycle alter pelvic floor muscle activity.

Relationship among vaginal palpation, vaginal squeeze pressure, electromyographic and ultrasonographic variables of female pelvic floor muscles

Background:

The proper evaluation of the pelvic floor muscles (PFM) is essential for choosing the correct treatment. Currently, there is no gold standard for the assessment of female PFM function.

Objective:

To determine the correlation between vaginal palpation, vaginal squeeze pressure, and electromyographic and ultrasonographic variables of the female PFM.

Method:

This cross-sectional study evaluated 80 women between 18 and 35 years of age who were nulliparous and had no pelvic floor dysfunction. PFM function was assessed based on digital palpation, vaginal squeeze pressure, electromyographic activity, bilateral diameter of the bulbocavernosus muscles and the amount of bladder neck movement during voluntary PFM contraction using transperineal bi-dimensional ultrasound. The Pearson correlation was used for statistical analysis (p<0.05).

Results:

There was a strong positive correlation between PFM function and PFM contraction pressure (0.90). In addition, there was a moderate positive correlation between these two variables and PFM electromyographic activity (0.59 and 0.63, respectively) and movement of the bladder neck in relation to the pubic symphysis (0.51 and 0.60, respectively).

Conclusions:

This study showed that there was a correlation between vaginal palpation, vaginal squeeze pressure, and electromyographic and ultrasonographic variables of the PFM in nulliparous women. The strong correlation between digital palpation and PFM contraction pressure indicated that perineometry could easily be replaced by PFM digital palpation in the absence of equipment.

Pelvic floor awareness and the positive effect of verbal instructions in 958 women early postdelivery

INTRODUCTION AND HYPOTHESIS

It is uncertain how reliable a personal belief is about the ability to do pelvic floor muscle (PFM) contractions early postdelivery and how instructional feedback affects pelvic floor muscle contraction (PFMC) performance. We hypothesize that many women do not have a reliable idea about PFMC and that instructional feedback can help improve their control.

METHODS

Prospective observational study in 958 women (median 30 years) early postdelivery PFMC was evaluated with visual observation: an inward movement of the perineum was accepted as sign of good contraction. The women who could not show PFMC three consecutive times got verbal instructions, and re-evaluation was afterward.

RESULTS

In 500 women, no inward movement of the perineum was observed: 275 women (29%) showed no movement at all, and 225 women (24%) showed some movement but no inward displacement. In 33.4%, the personal conviction to be able or not to perform PFMC proved false. After verbal instructions, 74% improved their PFMC.

CONCLUSIONS

The belief of doing correct PFM contraction was false in at least one of five postpartum women. Verbal instructions have a positive effect on performing PFMC in 73.6% of women.

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.

Pain and Psychological Outcomes After Rehabilitative Treatment for a Woman With Chronic Pelvic Pain With Stage III Cervical Cancer: A Case Report

BACKGROUND

Chronic pelvic pain and sexual dysfunction are adverse effects of treatment of cervical cancer. Surgery and radiation therapies may result in soft tissue pain and dysfunction, including spasms and trigger points of the pelvic floor muscles that result in pain. In addition to physical restrictions, negative mood associated with pain is believed to intensify and prolong the pain experience.

STUDY DESIGN

The purpose of this case report was to describe outcomes of pelvic physical therapy in a 58-year-old woman with chronic pelvic pain after medical treatments for cervical cancer.

CASE DESCRIPTION

The patient reported dyspareunia, hip pain, and lower abdominal, pelvic pain, and fatigue with activities lasting greater than 30 minutes. Interventions included pelvic floor massage, dilator use, and patient education. Symptoms were assessed at baseline and completion of physical therapy, using the Female Sexual Function Index, Fear of Pain Questionnaire-III, Pain Catastrophizing Scale, and Numerical Pain Rating Scale.

OUTCOMES

The Female Sexual Function Index score decreased from 7.8 to 2.8, the Fear of Pain Questionnaire- III score decreased from 85 to 73, the Pain Catastrophizing Scale score decreased from 18 to 8, and lower abdominal and pelvic pain decreased from 4 of 10 to 0 of 10, while bilateral hip pain remained at 4 of 10. In addition, she exhibited increased tolerance to mechanical pressure, evidenced by progression in size of a vaginal dilator.

DISCUSSION

These results suggest that pelvic physical therapy may be useful in treating chronic pelvic pain after cervical cancer treatments and may also help decrease the magnitude of negative mood aspects such as pain-related fear and catastrophizing.

Pelvic floor muscle exercise for chronic low back pain

Objective

To assess the effect of pelvic floor muscle exercise in patients with chronic low back pain.

Methods

Adults (aged ≥18 years) with chronic low back pain (with or without radiculopathy) were randomized to undergo either routine treatment (ultrasonography, short wave diathermy and lumbar strengthening exercises; control group) or routine treatment with pelvic floor exercises (intervention group) for 24 weeks. Pain, disability (Oswestry Disability Index [ODI] score) and trunk muscle function were assessed at baseline and after completion of treatment.

Results

The study included 47 patients (control group n = 24; intervention group n = 23). Pain severity and ODI scores were significantly lower in the intervention group than in the control group after 24 weeks. There were no significant between-group differences in trunk muscle function.

Conclusion

Pelvic floor exercise in combination with routine treatment provides significant benefits in terms of pain relief and disability over routine treatment alone.

Fisioterapia para consciência perineal: uma comparação entre as cinesioterapias com toque digital e com auxílio do biofeedback

INTRODUÇÃO: Grande parte das mulheres (cerca de 30 a 50%) não consegue contrair corretamente seus músculos perineais quando isso lhes é solicitado. Provavelmente, a parte mais importante e também a mais delicada de toda avaliação fisioterapêutica é a conscientização da região perineal das pacientes incontinentes. OBJETIVO: Este trabalho teve como objetivo comparar os efeitos das cinesioterapias com toque digital e com biofeedback para consciência perineal de mulheres com incontinência urinária de esforço. METODOLOGIA: Foi realizado um ensaio clínico randomizado, composto por dois grupos intervencionais, formados por cinco mulheres cada, com incontinência urinária de esforço e com ausência de consciência perineal. RESULTADOS: Inicialmente, o grupo de biofeedback seria composto de seis mulheres e o grupo de cinesioterapia com toque bidigital seria formado por cinco mulheres, porém uma paciente foi excluída do grupo biofeedback no decorrer da pesquisa. Observou-se que houve melhora estatisticamente significativa em ambos os grupos em relação a Power, Endurance, Fast e conhecimentos acerca da região perineal, porém não houve diferença significativa entre os dois grupos, ou seja, ambos os recursos são igualmente eficazes. CONCLUSÃO: Diante dos resultados apresentados, podemos concluir que tanto a cinesioterapia com uso do biofeedback quanto a cinesioterapia com toque digital são excelentes opções de tratamento para ganho de consciência perineal.

Recognition and management of nonrelaxing pelvic floor dysfunction

Nonrelaxing pelvic floor dysfunction is not widely recognized. Unlike in pelvic floor disorders caused by relaxed muscles (eg, pelvic organ prolapse or urinary incontinence, both of which often are identified readily), women affected by nonrelaxing pelvic floor dysfunction may present with a broad range of nonspecific symptoms. These may include pain and problems with defecation, urination, and sexual function, which require relaxation and coordination of pelvic floor muscles and urinary and anal sphincters. These symptoms may adversely affect quality of life. Focus on the global symptom complex, rather than the individual symptoms, may help the clinician identify the condition. The primary care provider is in a position to intervene early, efficiently, and effectively by (1) recognizing the range of symptoms that might suggest nonrelaxing pelvic floor dysfunction, (2) educating patients, (3) performing selective tests when needed to confirm the diagnosis, and (4) providing early referral for physical therapy.

Effects of multidimensional pelvic floor muscle training in healthy young women

PURPOSE

Cross-sectional and interventional study to assess pelvic floor muscle (PFM) function in healthy young nulliparous women and to determine the effects of a 3-month PFM training program with emphasis on co-contraction of PFM and anterolateral abdominal muscles and on correctly performed coughing patterns.

METHODS

PFM function was assessed by digital vaginal palpation in 40 volunteers and graded according to the 6-point Oxford grading scale. The PFM training program was comprised theoretical instruction, as well as verbal feedback during hands-on instruction and repeated training sessions focussing on strengthening PFM and anterolateral abdominal muscle co-contraction during forced expiration and coughing.

RESULTS

At baseline, 30 women (75%) were able to perform normal PFM contractions at rest (Oxford scale score ≥ 3); only 4 of them (10%) presented additional involuntary PFM contractions before and during coughing. The remaining 10 women (25%) were unable to perform voluntary or involuntary PFM contractions. Mean Oxford scale score in the whole group was 3.3 ± 1.7. After completing the PFM training program, 29 women (72.5%) performed cough-related PFM contractions and group mean Oxford scale score increased significantly to 4.2 ± 1.0.

CONCLUSIONS

The study shows that PFM dysfunction may be detected even in healthy young women. Multidimensional training, however, may significantly improve PFM function.

Pelvic floor muscle function in a general female population in relation with age and parity and the relation between voluntary and involuntary contractions of the pelvic floor musculature

Introduction and hypothesis

The objective of this study is to describe pelvic floor muscle function (PFMF) in relation to age and parity in a general female population and to test whether strength/endurance measurements represent all functions of the pelvic floor musculature.

Methods

A cross-sectional study was performed on 95% of the women aged 45–85 years from a small Dutch town. Validated questionnaires were used to obtain general information, and vaginal examination to test PFMF was performed on 649 women. Chi-square tests were used to analyse the relation between PFMF versus age and parity. Analysis of variance was used to compare muscle strength and endurance to the other PFMF items.

Results

Response rate to the questionnaire was 62.7% (1,869/2,979). PFM strength and endurance are not positively associated with the effective involuntary muscle contractions during coughing.

Conclusions

Voluntary muscle contractions decreased with age, but there was no relation with parity. Muscle strength and endurance measurements alone are not sensitive enough to determine PFMF.

Validation of new ultrasound parameters for quantifying pelvic floor muscle contraction

OBJECTIVE

To determine the reliability and validity of new ultrasound parameters, measured in the polar coordinate system, for quantifying pelvic floor muscle action.

METHODS

This was a prospective study, from January 2005 to December 2007, in 209 women with urodynamic stress incontinence, to validate new ultrasound parameters for quantifying pelvic floor muscle contraction. The examination of each patient included intravaginal digital palpation of voluntary pelvic floor muscle contractility and an ultrasound assessment of the positions of the bladder neck and anorectal junction at rest and during pelvic floor muscle contraction. The position of the bladder neck was expressed by bladder neck angle and bladder neck distance from the lower border of the pubic symphysis, and the position of the anorectal junction was expressed by the levator hiatal angle and sagittal hiatal diameter. The vector lengths of the motion of the bladder neck and anorectal junction during pelvic floor muscle contraction were calculated from the positions at rest and during pelvic floor muscle contraction by mathematical formulae.

RESULTS

There was good inter- and intraobserver reliability of measurement of ultrasound parameters on stored volumes. During pelvic floor muscle contraction, elevated bladder neck distance and shortened sagittal hiatal diameter were valid parameters representing stronger pelvic floor muscle contractility, with shortened sagittal hiatal diameter having the best correlation (r = - 0.348, P < 0.001).

CONCLUSION

The methods used in this study appear to be reliable for quantifying pelvic floor muscle action. The bladder neck distance with respect to the lower border of the pubic symphysis and the sagittal hiatal diameter were both valid parameters reflecting PFM contractility.

Pelvic floor muscle function in women presenting with pelvic floor disorders

INTRODUCTION AND HYPOTHESIS

This observational study was undertaken to determine knowledge, prior instruction, frequency of performance, and ability to perform pelvic floor muscle exercises in a group of women presenting for evaluation of pelvic floor disorders.

METHODS

Three hundred twenty-five women presenting for evaluation of pelvic floor disorders were questioned concerning knowledge and performance of pelvic floor muscle exercises (PMEs) and then examined to determine pelvic floor muscle contraction strength.

RESULTS

The majority of women (73%) had heard of PMEs, but only 42% had been instructed to perform them and 62.5% stated they received verbal instruction only. Only 23.4% of patients could perform pelvic muscle contractions with Oxford Scale 3, 4, or 5 strengths. Increased age, parity, and stage of prolapse were associated with lower Oxford scores.

CONCLUSIONS

Although most women with pelvic floor disorders are familiar with PMEs, less than one fourth could perform adequate contractions at the time of initial evaluation.

Urinary incontinence and pelvic organ prolapse: diagnosis and treatment for the primary care physician

This article outlines a simplified approach to diagnosis and treatment of women with urinary incontinence or pelvic organ prolapse that can be used by primary care physicians to identify patients with these conditions and initiate treatment for basic problems.