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Hilde G, Stær-Jensen J, Siafarikas F, Engh ME, Bø K. Postpartum pelvic floor muscle training, levator ani avulsion and levator hiatus area: a randomized trial. Int Urogynecol J 2023; 34:413-423. [PMID: 36418566 PMCID: PMC9870957 DOI: 10.1007/s00192-022-05406-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 10/18/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Vaginal delivery may lead to tearing of the levator ani (LA) muscle from its bony insertions (complete LA avulsion) and increased levator hiatus (LH) area, both risk factors for pelvic floor dysfunctions. Early active rehabilitation is standard treatment after musculo-skeletal injury. We hypothesized that pelvic floor muscle training (PFMT) early postpartum would reduce the presence of LA avulsions and reduce LH area. METHODS We carried out a planned secondary analysis from a randomized controlled study. Primiparous women (n=175) giving birth vaginally were included 6 weeks postpartum, stratified on complete LA avulsion, and thereafter randomized to PFMT or control. The training participants (n=87) attended a supervised PFMT class once a week and performed home-based PFMT daily for 16 weeks. The control participants (n=88) received no intervention. Presence of complete LA avulsion, LH area at rest, maximal contraction, and maximal Valsalva maneuver were assessed by transperineal ultrasound. Between-group comparisons were analyzed by analysis of covariance for continuous data, and relative risk (RR) for categorical data. RESULTS Six months postpartum, the number of women who had complete LA avulsion was reduced from 27 to 14 within the PFMT group (44% reduction) and from 28 to 17 within the control group (39% reduction). The between-group difference was not significant, RR 0.85 (95% CI 0.53 to 1.37). Further, no significant between-group differences were found for LH area at rest, during contraction, or Valsalva. CONCLUSIONS Supervised PFMT class combined with home exercise early postpartum did not reduce the presence of complete LA avulsion or LH area more than natural remission.
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Affiliation(s)
- Gunvor Hilde
- Department of Rehabilitation Science and Health Technology, Faculty of Health Sciences, OsloMet – Oslo Metropolitan University, Pilestredet, P.O. Box 4, St. Olavs plass, NO-0130 Oslo, Norway
| | - Jette Stær-Jensen
- Department of Obstetrics and Gynecology, Akershus University Hospital, Lørenskog, Norway
| | - Franziska Siafarikas
- Department of Obstetrics and Gynecology, Akershus University Hospital, Lørenskog, Norway ,Division Akershus University Hospital, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Marie Ellström Engh
- Department of Obstetrics and Gynecology, Akershus University Hospital, Lørenskog, Norway ,Division Akershus University Hospital, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Kari Bø
- Department of Obstetrics and Gynecology, Akershus University Hospital, Lørenskog, Norway ,Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
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Serrano S, Henriques A, Valentim-Lourenço A, Pereira I. Levator ani muscle avulsion in patients with pelvic floor dysfunction – does it help in understanding pelvic organ prolapse? Eur J Obstet Gynecol Reprod Biol 2022; 279:140-145. [DOI: 10.1016/j.ejogrb.2022.09.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 09/22/2022] [Accepted: 09/26/2022] [Indexed: 11/16/2022]
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Alouini S, Memic S, Couillandre A. Pelvic Floor Muscle Training for Urinary Incontinence with or without Biofeedback or Electrostimulation in Women: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19052789. [PMID: 35270480 PMCID: PMC8910078 DOI: 10.3390/ijerph19052789] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 02/15/2022] [Accepted: 02/21/2022] [Indexed: 12/18/2022]
Abstract
To determine the effectiveness of pelvic floor muscle training (PFMT) with or without biofeedback or electrostimulation in reducing urinary incontinence and pelvic floor muscle con-traction in non-pregnant women with urinary incontinence. Methods: The following electronic databases were searched: PubMed, Cochrane Central, ClinicalTrials.gov, EU Clinical Trials Register, and sources from NICE, FDA, EMA, and SMC (articles only in English, 2000–2021). Search terms were: urinary incontinence, pelvic floor muscle training or exercises, biofeedback, electrostimulation. We used the PRISMA statement (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) for this systematic review. Relevant articles were selected, data were extracted, and quality was assessed. Data were extracted in predesigned form, followed by narrative synthesis. Results: Following the search, 15 RCTs were retrieved using the strict inclusion and exclusion criteria, assessing 2441 non-pregnant women with urinary incontinence. Of the 15 studies, 7 were low risk, 5 were medium risk, and 3 were high-risk studies. Of the 2441 patients, 970 were in PFMT, 69 were in extracorporeal magnetic innervation (ExMi) or with PFMT + BF, 30 were in electrostimulation (ES), 21 were in whole body vibration training (WBVT), 23 were in pelvic floor muscle + abdominal muscle therapy (PFM + AMT), 326 were in PFMT + biofeedback, 93 were in vaginal cones (VC), 362 were in PFMT + education, 318 were in education, and 229 were in control groups. The most often measures employed were pad tests, bladder diary, and questionnaire on the quality of life. Stress, urge and mixed urinary incontinence were studied. In all RCT, PFMT significantly reduced urinary incontinence, essentially SIU and MUI, when compared with the control group before and after treatment. Overall, out of 997 PFMT or PFMT + education patients, 504 patients (50.5%) showed improvement in urinary incontinence, and 218 became continent (21.8%) (negative pad test). In total, 62% of patients significantly reduced their urinary incontinence or cured it and improved their pelvic floor muscle contraction. All other physiotherapist techniques also significantly reduced urinary leakages, e.g., vaginal cones, biofeedback, ExMI, and WBVT when compared with the control group. There were no significant differences between these methods in reducing the severity of urinary incontinence. Conclusion: PFMT alone or with bio-feedback or electrostimulation was effective in reducing urinary incontinence and improving pelvic floor muscle contraction. PFMT when compared with other interventions such as bio-feedback, VC, and WBVT did not show significant differences but was superior to the control group. RCT studies with similar parameters used for measuring the outcomes need to be included.
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Affiliation(s)
- Souhail Alouini
- Center Hospitalier Regional d’Orléans, Departement of Gynecologic Surgery, 14 Avenue de L’hôpital, 45100 Orleans, France
- EUKCVL, Université d’Orléans, 45100 Orleans, France; (S.M.); (A.C.)
- Correspondence:
| | - Sejla Memic
- EUKCVL, Université d’Orléans, 45100 Orleans, France; (S.M.); (A.C.)
| | - Annabelle Couillandre
- EUKCVL, Université d’Orléans, 45100 Orleans, France; (S.M.); (A.C.)
- Laboratoire CIAMS, Université Paris—Sud, EA 4532, 91400 Orsay, France
- Laboratoire en Neurosciences, Physiologie et Psychologie, LINP2, Université Paris Nanterre, 92001 Nanterre, France
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Yune Y, Jeong HY, Park DH, Lee JK. Three-Dimensional Pelvic Floor Ultrasound Assessment of Pelvic Organ Prolapse: Minimal Levator Hiatus and Levator Ani Deficiency Score. Ann Coloproctol 2021; 37:291-297. [PMID: 34376023 PMCID: PMC8566146 DOI: 10.3393/ac.2020.01095.0156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 03/16/2021] [Indexed: 11/17/2022] Open
Abstract
Purpose The purpose of this study was to determine whether levator ani deficiency (LAD) scores and minimal levator hiatus (MLH) areas affect Pelvic Organ Prolapse Quantification (POP-Q) stage. Methods This study was a retrospective chart review of patients with pelvic organ prolapse (POP) at Seoul Songdo Hospital between August 2019 and August 2020. Three-dimensional (3D) pelvic floor ultrasound, preoperative anal manometry, and other physiological tests were performed in 78 patients with POP symptoms. We divided the patients into mild prolapse and severe prolapse groups based on the POP-Q. We examined the LAD and MLH areas. LAD scores were categorized as mild, moderate, or severe. Results There were 32 patients (41.0%) in the mild prolapse group (POP-Q stage I and II) and 46 (59.0%) in the severe prolapse group (POP-Q stage III and IV). The mean LAD score was significantly higher in severe prolapse group (13.33±2.49 vs. 8.19±2.92, P<0.001), and the rate of severe deficiency was also significantly higher in the severe prolapse group (29 [63.0%] vs. 2 [6.3%], P<0.001). The mean MLH was also significantly larger in the severe prolapse group (17.91±2.74 cm2 vs. 14.95±2.60 cm2, P<0.001). In addition, both MLH and LAD scores tended to increase at each stage. Conclusion There is a strong positive correlation between the POP-Q stage and the MLH and LAD scores that can be seen on 3D pelvic floor ultrasound. The findings of this study, by objectively demonstrating LAD and MLH in women with POP, are an important contribution to POP.
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Affiliation(s)
- Yongwoo Yune
- Department of Surgery, Seoul Songdo Hospital, Seoul, Korea
| | | | - Duk Hoon Park
- Department of Surgery, Seoul Songdo Hospital, Seoul, Korea
| | - Jong Kyun Lee
- Department of Surgery, Seoul Songdo Hospital, Seoul, Korea
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Rodrigues MP, Paiva LL, Mallmann S, Bessel T, Ramos JGL. Can the inability to contract the pelvic floor muscles influence the severity of urinary incontinence symptoms in females? Int Urogynecol J 2021; 33:1193-1197. [PMID: 34170343 DOI: 10.1007/s00192-021-04880-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 05/24/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION AND HYPOTHESIS The objective was to analyze if the inability to perform a maximal voluntary contraction (MVC) of the pelvic floor muscles (PFMs) in a first assessment can influence the severity of urinary incontinence symptoms in women. METHODS A cross-sectional study was carried out using the medical records of women with UI who were referred for pelvic floor physiotherapy after undergoing a gynecological evaluation between May 2013 and December 2019. Records included data referring to age, body mass index (BMI), obstetric history, Modified Oxford Scale (MOS), and the final score of the International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF) from a baseline assessment. Data were divided into women who were unable and those who were able to voluntarily perform an MVC of the PFMs. Statistical analysis was conducted using SPSS version 21. RESULTS A total of 498 medical records were analyzed and 36.3% of those women were not able to perform a PFM MVC after verbal command and digital stimulus. Homogeneity was observed among groups and no significant difference was found regarding the severity of UI symptoms when the groups were compared. CONCLUSIONS No association was found between the inability to contract the PFMs and the severity of UI symptoms. Other studies should be developed to better understand why some women are incapable of performing a voluntary PFM contraction. Also, it would be relevant to compare women with PFM dysfunction who are not able to contract the PFMs with healthy women with the same PFM condition to analyze whether this muscle condition could be related to dysfunctions such as UI or pelvic organ prolapse.
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Affiliation(s)
- Marina Petter Rodrigues
- Graduate Program in Health Sciences: Gynecology and Obstetrics, Hospital de Clínicas de Porto Alegre, School of Medicine, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2400, Porto Alegre, RS, 90035-003, Brazil.
| | - Luciana Laureano Paiva
- School of Physical Education, Physiotherapy and Dance, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Suzana Mallmann
- School of Physical Education, Physiotherapy and Dance, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Thaise Bessel
- School of Physical Education, Physiotherapy and Dance, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - José Geraldo Lopes Ramos
- Graduate Program in Health Sciences: Gynecology and Obstetrics, Hospital de Clínicas de Porto Alegre, School of Medicine, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2400, Porto Alegre, RS, 90035-003, Brazil
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Saltiel F, Miranda-Gazzola APG, Vitória RO, Sampaio RF, Figueiredo EM. Linking Pelvic Floor Muscle Function Terminology to the International Classification of Functioning, Disability and Health. Phys Ther 2020; 100:1659-1680. [PMID: 32201881 DOI: 10.1093/ptj/pzaa044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Accepted: 02/11/2020] [Indexed: 02/09/2023]
Abstract
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.
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El-Haieg DO, Madkour NM, Basha MAA, Ahmad RA, Sadek SM, Al-Molla RM, Tantwy EF, Almassry HN, Altaher KM, Mahmoud NEM, Aly SA. Magnetic resonance imaging and 3-dimensional transperineal ultrasound evaluation of pelvic floor dysfunction in symptomatic women: a prospective comparative study. Ultrasonography 2019; 38:355-364. [PMID: 31466142 PMCID: PMC6769195 DOI: 10.14366/usg.19007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 05/06/2019] [Indexed: 12/15/2022] Open
Abstract
Purpose The purpose of this study was to investigate magnetic resonance imaging (MRI) and 3-dimensional transperineal ultrasound (3D-TPUS) features of pelvic floor dysfunction (PFD) in symptomatic women in correlation with digital palpation and to define cut-offs for hiatal dimensions predictive of muscle dysfunction. Methods This prospective study included 73 women with symptoms suggesting PFD. 3D-TPUS, MRI, and digital palpation of the levator ani muscle were performed in all patients. Levator hiatal antero-posterior (LHap) diameter and area (LH area) were measured at rest and at maximum muscle contraction. Results The reduction in LHap diameter and LH area during contraction was significantly less in women with underactive pelvic floor muscle contraction (UpfmC) than in those who had normal pelvic floor muscle contraction by digital palpation (P<0.001). Statistically significant positive correlations (P<0.001) were found between the Modified Oxford Score and 3D-TPUS and MRI regarding the reduction in the LHap diameter (r=0.80 and r=0.82, respectively) and LH area (r=0.60 and r=0.70, respectively). A reduction in LHap of <6.5% on 3D-TPUS and <7.6% on MRI predicted UpfmC with sensitivities of 46.2% and 82.7%, respectively. A reduction in LH area of <3.4% on 3D-TPUS and <3.8% on MRI predicted UpfmC with sensitivities of 75.0% and 88.5%, respectively. MRI was more sensitive in detecting levator avulsion (63.4%) than 3D-TPUS (27.1%). Conclusion MRI and 3D-TPUS had strong positive correlations with findings on palpation, and at certain cut-offs for hiatal dimensions, they can be used as complementary and objective tools to improve the accuracy of diagnosis and management planning of PFD.
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Affiliation(s)
- Dahlia O El-Haieg
- Department of Obstetrics and Gynecology, Zagazig University, Zagazig, Egypt
| | - Nadia M Madkour
- Department of Obstetrics and Gynecology, Zagazig University, Zagazig, Egypt
| | | | - Reda A Ahmad
- Department of Obstetrics and Gynecology, Zagazig University, Zagazig, Egypt
| | - Somayya M Sadek
- Department of Obstetrics and Gynecology, Zagazig University, Zagazig, Egypt
| | - Rania M Al-Molla
- Department of Radiodiagnosis, Zagazig University, Zagazig, Egypt
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Sheng Y, Low LK, Liu X, Ashton-Miller JA, Miller JM. Association of index finger palpatory assessment of pubovisceral muscle body integrity with MRI-documented tear. Neurourol Urodyn 2019; 38:1120-1128. [PMID: 30848840 DOI: 10.1002/nau.23967] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 12/07/2018] [Accepted: 02/03/2019] [Indexed: 12/27/2022]
Abstract
AIMS Pubovisceral (PV) muscle tears are associated with pelvic floor disorders. The goal of this study was to determine whether index finger palpatory assessment of PV muscle body integrity through the lateral vaginal wall is a reliable indicator of PV muscle tear severity diagnosed by magnetic resonance imaging (MRI). METHODS We studied 85 women, 7 weeks after vaginal birth. All had at least one risk factor for obstetric-related PV muscle tear. The ordinal outcome measure of MRI-documented PV muscle tear was defined as: none, less than 50% unilateral tear, 50% or greater unilateral tear or less than 50% bilateral tear, and 50% or greater bilateral tear. PV muscle body integrity by palpatory assessment was scored on a matrix, with each side scored independently and classified as PV muscle body "present" (assuredly felt), "equivocal" (not sure if felt), or "absent" (assuredly not felt). Proportional odds models were constructed to estimate the relationship between PV muscle body integrity palpatory assessment and MRI-documented PV muscle tears. RESULTS Thirty-five percent of study participants exhibited varying degrees of MRI-documented PV muscle tears. Using palpatory assessment, we identified "PV muscle body present bilaterally" in 20%, "equivocal unilaterally or present contralaterally" in 8%, "equivocal or absent unilaterally" or "equivocal bilaterally" in 62%, and "absent bilaterally" in 9%. The odds ratio for estimating MRI results from palpatory assessment was 3.62 (95% confidence interval = 1.70-7.73, P = 0.001). CONCLUSIONS A rapid and inexpensive palpatory assessment in the clinic was highly associated with the risk of MRI-documented PV muscle tear and is a useful component of a clinical assessment.
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Affiliation(s)
- Ying Sheng
- University of Michigan School of Nursing, Ann Arbor, Michigan
| | - Lisa Kane Low
- University of Michigan School of Nursing, Ann Arbor, Michigan.,Department of Women's Studies, University of Michigan, Ann Arbor, Michigan.,Department of Obstetrics and Gynecology, School of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Xuefeng Liu
- University of Michigan School of Nursing, Ann Arbor, Michigan
| | - James A Ashton-Miller
- Department of Mechanical Engineering, University of Michigan College of Engineering, Ann Arbor, Michigan
| | - Janis M Miller
- University of Michigan School of Nursing, Ann Arbor, Michigan.,Department of Obstetrics and Gynecology, School of Medicine, University of Michigan, Ann Arbor, Michigan
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Da Silva AS, Asfour V, Digesu GA, Cartwright R, Fernando R, Khullar V. Levator Ani avulsion: The histological composition of this site. A cadaveric study. Neurourol Urodyn 2018; 38:123-129. [PMID: 30375038 DOI: 10.1002/nau.23847] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 07/25/2018] [Indexed: 12/28/2022]
Abstract
INTRODUCTION The sonographic appearance of a levator muscle "avulsion" representing the literal detachment of the pubovisceral muscle (PVM) enthesis has been contested. The nature of the levator ani "avulsion" is still not fully understood. It is known, that the tensile strength of a tendon is dependent on collagen with increased synthesis of collagen occurring in tissue with increased mechanical load levels. This study aims to perform a quantitative histological evaluation of the PVM enthesis with or without the imaging finding of levator ani "avulsion" to determine if there is a difference in the proportion of muscle and collagen. METHOD Three-dimensional translabial ultrasound for PVM "avulsion" was performed on cadavers using a GE Voluson I with a 5-9 MHz electronic probe. Cadavers were meticulously dissected to identify the presence or absence of an anatomical avulsion. The PVM enthesis was excised for further histopathological processing and treated with three different colorations. Quantitative analysis using ImageJ software was conducted to compare tissue composition in samples with or without sonographic "avulsion." All stages were performed by two separate investigators blinded to each other's results. The results were analyzed using SPSS v24, IBM. RESULTS Twenty-three PVM enthesis with histological staining were procured. Ultrasonographic "avulsions" were seen in 5/23 PVM enthesis. No anatomical avulsions were seen. There was no difference in the overall muscle or collagen content (Kruskal-Wallis, P = 0.864). The mean organized skeletal muscle content was 23% in the sonographic "avulsion" group versus 62% in the no "avulsion" group (Kruskall-Walis, P = 0.02). "Avulsions" were associated with a disorganized appearance at histology. CONCLUSION The tissue composition relating to the proportion of muscle and collagen was not significantly different in specimens with or without sonographic "avulsions." However, morphological differences were observed in the organization of the muscle fibres, which requires further evaluation.
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Affiliation(s)
- Ana Sofia Da Silva
- Department of Urogynaecology, St. Mary's Hospital, London, United Kingdom.,Institute of Women's Health, University College London, London, United Kingdom
| | - Victoria Asfour
- Department of Urogynaecology, St. Mary's Hospital, London, United Kingdom
| | | | - Rufus Cartwright
- Department of Urogynaecology, St. Mary's Hospital, London, United Kingdom
| | - Ruwan Fernando
- Department of Urogynaecology, St. Mary's Hospital, London, United Kingdom
| | - Vik Khullar
- Department of Urogynaecology, St. Mary's Hospital, London, United Kingdom
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Saltiel F, Miranda-Gazzola APG, Vitória RO, Figueiredo EM. Terminology of Pelvic Floor Muscle Function in Women With and Without Urinary Incontinence: A Systematic Review. Phys Ther 2018; 98:876-890. [PMID: 30010919 DOI: 10.1093/ptj/pzy084] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Accepted: 04/08/2018] [Indexed: 02/09/2023]
Abstract
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.
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Affiliation(s)
- Fernanda Saltiel
- Rehabilitation Sciences Program, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil; Women's Health Specialist, Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, Brazil
| | | | | | - Elyonara M Figueiredo
- Physical Therapy Department, Rehabilitation Sciences Program, Universidade Federal de Minas Gerais, Av. Antonio Carolos, 6627, Pampulha, Belo Horizonte, Minas Gerais, 31270-901 Brazil
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Panicker JN, Anding R, Arlandis S, Blok B, Dorrepaal C, Harding C, Marcelissen T, Rademakers K, Abrams P, Apostolidis A. Do we understand voiding dysfunction in women? Current understanding and future perspectives: ICI-RS 2017. Neurourol Urodyn 2018; 37:S75-S85. [DOI: 10.1002/nau.23709] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 03/05/2018] [Indexed: 12/12/2022]
Affiliation(s)
- Jalesh N. Panicker
- Department of Uro-Neurology; The National Hospital for Neurology and Neurosurgery and UCL Institute of Neurology; Queen Square London United Kingdom
| | - Ralf Anding
- Neurourology; Department of Urology and Pediatric Urology; University Hospital Bonn; Bonn Germany
| | - Salvador Arlandis
- Department of Urology; Hospital Universitario y Politécnico La Fe; Valencia Spain
| | - Bertil Blok
- Department of Urology; Erasmus Medical Center; Rotterdam The Netherlands
| | | | - Chris Harding
- Department of Urology; Freeman Hospital; Newcastle Upon-Tyne United Kingdom
| | - Tom Marcelissen
- Department of Urology; Maastricht University Medical Centre; Maastricht The Netherlands
| | - Kevin Rademakers
- Department of Urology; Maastricht University Medical Centre; Maastricht The Netherlands
| | - Paul Abrams
- Department of Urology; University of Bristol; Bristol United Kingdom
- Department of Teaching and Research, Bristol Urological Institute; International Consultation on Urological Diseases; Bristol United Kingdom
| | - Apostolos Apostolidis
- 2nd Department of Urology; Aristotle University of Thessaloniki; Thessaloniki Greece
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Catanzarite T, Bremner S, Barlow CL, Bou-Malham L, O'Connor S, Alperin M. Pelvic muscles' mechanical response to strains in the absence and presence of pregnancy-induced adaptations in a rat model. Am J Obstet Gynecol 2018; 218:512.e1-512.e9. [PMID: 29432755 DOI: 10.1016/j.ajog.2018.02.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 01/09/2018] [Accepted: 02/05/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND Maternal birth trauma to the pelvic floor muscles is thought to be consequent to mechanical demands placed on these muscles during fetal delivery that exceed muscle physiological limits. The above is consistent with studies of striated limb muscles that identify hyperelongation of sarcomeres, the functional muscle units, as the primary cause of mechanical muscle injury and resultant muscle dysfunction. However, pelvic floor muscles' mechanical response to strains have not been examined at a tissue level. Furthermore, we have previously demonstrated that during pregnancy, rat pelvic floor muscles acquire structural and functional adaptations in preparation for delivery, which likely protect against mechanical muscle injury by attenuating the strain effect. OBJECTIVE We sought to determine the mechanical impact of parturition-related strains on pelvic floor muscles' microstructure, and test the hypothesis that pregnancy-induced adaptations modulate muscle response to strains associated with vaginal delivery. STUDY DESIGN Three-month-old Sprague-Dawley late-pregnant (N = 20) and nonpregnant (N = 22) rats underwent vaginal distention, replicating fetal crowning, with variable distention volumes. Age-matched uninjured pregnant and nonpregnant rats served as respective controls. After sacrifice, pelvic floor muscles, which include coccygeus, iliocaudalis, and pubocaudalis, were fixed in situ and harvested for fiber and sarcomere length measurements. To ascertain the extent of physiological strains during spontaneous vaginal delivery, analogous measurements were obtained in intrapartum rats (N = 4) sacrificed during fetal delivery. Data were compared with repeated measures and 2-way analysis of variance, followed by pairwise comparisons, with significance set at P < .05. RESULTS Gross anatomic changes were observed in the pelvic floor muscles following vaginal distention, particularly in the entheseal region of pubocaudalis, which appeared translucent. The above appearance resulted from dramatic stretch of the myofibers, as indicated by significantly longer fiber length compared to controls. Stretch ratios, calculated as fiber length after vaginal distention divided by baseline fiber length, increased gradually with increasing distention volume. Paralleling these macroscopic changes, vaginal distention resulted in acute and progressive increase in sarcomere length with rising distention volume. The magnitude of strain effect varied by muscle, with the greatest sarcomere elongation observed in coccygeus, followed by pubocaudalis, and a smaller increase in iliocaudalis, observed only at higher distention volumes. The average fetal rat volume approximated 3 mL. Pelvic floor muscle sarcomere lengths in pregnant animals undergoing vaginal distention with 3 mL were similar to intrapartum sarcomere lengths in all muscles (P > .4), supporting the validity of our experimental approach. Vaginal distention resulted in dramatically longer sarcomere lengths in nonpregnant compared to pregnant animals, especially in coccygeus and pubocaudalis (P < .0001), indicating significant attenuation of sarcomere elongation in the presence of pregnancy-induced adaptations in pelvic floor muscles. CONCLUSION Delivery-related strains lead to acute sarcomere elongation, a well-established cause of mechanical injury in skeletal muscles. Sarcomere hyperelongation resultant from mechanical strains is attenuated by pregnancy-induced adaptations acquired by the pelvic floor muscles prior to parturition.
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Affiliation(s)
- Tatiana Catanzarite
- Division of Urogynecology and Pelvic Reconstructive Surgery, University of California-San Diego, San Diego, CA; Department of Reproductive Medicine, University of California-San Diego, San Diego, CA
| | - Shannon Bremner
- Department of Orthopedic Surgery, University of California-San Diego, San Diego, CA
| | - Caitlin L Barlow
- Department of Reproductive Medicine, University of California-San Diego, San Diego, CA
| | - Laura Bou-Malham
- Department of Reproductive Medicine, University of California-San Diego, San Diego, CA
| | - Shawn O'Connor
- School of Exercise and Nutritional Sciences, San Diego State University, San Diego, CA
| | - Marianna Alperin
- Division of Urogynecology and Pelvic Reconstructive Surgery, University of California-San Diego, San Diego, CA; Department of Reproductive Medicine, University of California-San Diego, San Diego, CA.
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Yu CH, Chan SSC, Cheung RYK, Chung TKH. Prevalence of levator ani muscle avulsion and effect on quality of life in women with pelvic organ prolapse. Int Urogynecol J 2017; 29:729-733. [DOI: 10.1007/s00192-017-3454-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 08/10/2017] [Indexed: 12/31/2022]
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15
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Dietz HP, Pattillo Garnham A, Guzmán Rojas R. Is it necessary to diagnose levator avulsion on pelvic floor muscle contraction? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 49:252-256. [PMID: 26616261 DOI: 10.1002/uog.15832] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2015] [Revised: 11/14/2015] [Accepted: 11/20/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE Avulsion of the levator ani muscle commonly occurs at vaginal birth. This condition is usually diagnosed by translabial ultrasound (TLUS) during pelvic floor muscle contraction (PFMC). Some patients are unable to achieve a satisfactory PFMC and in these cases avulsion is assessed at rest. The aim of this study was to validate the diagnosis of levator avulsion by means of TLUS at rest. METHODS This was a retrospective study of 233 women seen at a tertiary urogynecological center. All women underwent four-dimensional TLUS in the supine position and after voiding. Volumes were obtained on maximal PFMC and at rest. Analysis of the volumes was performed with the observer blinded against all clinical data. Avulsion was defined as an abnormal levator ani muscle insertion that was visible in at least three consecutive axial plane slices, at and above the level of minimal hiatal dimensions, at 2.5-mm intervals. We examined the correlation between both assessment methods using Cohen's kappa coefficient and tested the association of each method with female pelvic organ prolapse on clinical examination, organ descent on ultrasound and hiatal ballooning. RESULTS In total, datasets from 202 women were available for analysis. The correlation between a diagnosis of avulsion in volumes obtained at rest and those on PFMC was moderate, with a kappa value of 0.583 (95% CI, 0.484-0.683). Agreement for defects visualized on single slices was moderate, with a kappa value of 0.556 (95% CI, 0.520-0.591). When avulsion diagnoses at rest and on PFMC were tested against symptoms of prolapse, and prolapse on clinical examination and on ultrasound, neither of the two methods was superior. CONCLUSION Although tomographic ultrasound imaging during PFMC enhances tissue discrimination, this may not translate to superior diagnostic performance. Hence, volumes obtained at rest may be used in women unable to contract their pelvic floor. The diagnosis of levator avulsion by tomographic pelvic floor ultrasound is equally valid when performed at rest or on PFMC. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- H P Dietz
- Sydney Medical School Nepean, Nepean Hospital, Penrith, NSW, Australia
| | | | - R Guzmán Rojas
- Sydney Medical School Nepean, Nepean Hospital, Penrith, NSW, Australia
- Departamento de Ginecología y Obstetricia, Clínica Alemana de Santiago-Universidad del Desarrollo, Concepción, Chile
- Departamento de Ginecología y Obstetricia, Hospital Clínico de la Universidad de Chile, Santiago, Chile
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García Mejido JA, Valdivieso Mejias P, Fernández Palacín A, Bonomi Barby MJ, De la Fuente Vaquero P, Sainz Bueno JA. Evaluation of isolated urinary stress incontinence according to the type of levator ani muscle lesion using 3/4D transperineal ultrasound 36 months post-partum. Int Urogynecol J 2016; 28:1019-1026. [PMID: 27872979 DOI: 10.1007/s00192-016-3208-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 11/06/2016] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Vaginal delivery can lead to pelvic floor disorders. Many authors have described pelvic floor injuries that can predict future defects such as urinary incontinence and pelvic organ prolapse. We propose the assessment of urinary stress incontinence and its association with levator ani muscle (LAM) microtrauma (>20% in the levator hiatus area during Valsalva) and macrotraumas (avulsion) identified by 3/4D transperineal ultrasound (3D-TpUS) 36 months post-partum. MATERIALS AND METHODS This was a prospective observational study including 168 nulliparous women. All patients included were nulliparous with singleton gestation in cephalic presentation, at ≥37 weeks and were recruited on the first day after delivery. Thirty-six months after delivery, 3D-TpUS was carried out to identify LAM lesions (macro or micro). Clinical assessment of urinary stress incontinence (USI) was based on the ICIQ-UI-SF test; a simple stress test and urodynamic test were carried out in the same visit. RESULTS A total of 105 nulliparous women were studied (51 spontaneous deliveries [SpD] and 54 vacuum-assisted deliveries [VD]). Microtraumas were identified in 35.3% of SpD and 20.4% of VD. Macrotraumas (avulsion) were identified in 9.8% of SpD and 35.2% of VD (p = 0.006). No differences were found in USI between study groups or in relation to the identification of LAM defects (19.2% in the no lesion group, 25% in the macrotrauma and 13.8% in the microtrauma groups; p = not significant). Nor were significant differences found in the results from the different study groups in the International Consultation on Incontinence Modular Questionnaire Urinary Incontinence Short Form (ICIQ-UI SF) test (12.7±2.2 in the no lesion group, 12.5±4.2 in the macrotrauma and 13.25±4.8 in the microtrauma groups; p = NS). CONCLUSION No difference was observed in USI between patients with and without LAM lesions (microtrauma or macrotrauma) 36 months post-delivery.
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Affiliation(s)
| | | | | | | | | | - José Antonio Sainz Bueno
- Obstetrica y Ginecología, Hospital Universitario de Valme, Sevilla, CP: 41014, Spain. .,Universidad de Sevilla, Sevilla, Andalucía, Spain.
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Abstract
This article discusses the background and appraisal of endoluminal ultrasound of the pelvic floor. It provides a detailed anatomic assessment of the muscles and surrounding organs of the pelvic floor. Different anatomic variability and pathology, such as prolapse, fecal incontinence, urinary incontinence, vaginal wall cysts, synthetic implanted material, and pelvic pain, are easily assessed with endoluminal vaginal ultrasound. With pelvic organ prolapse in particular, not only is the prolapse itself seen but the underlying cause related to the anatomic and functional abnormalities of the pelvic floor muscle structures are also visualized.
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Affiliation(s)
- Daniel E Stone
- Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, 920 Stanton L. Young, WP2430, Oklahoma City, OK 73104, USA
| | - Lieschen H Quiroz
- Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, 920 Stanton L. Young, WP2430, Oklahoma City, OK 73104, USA.
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Rostaminia G, Peck J, Quiroz L, Shobeiri SA. Levator Plate Upward Lift on Dynamic Sonography and Levator Muscle Strength. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2015; 34:1787-1792. [PMID: 26333568 PMCID: PMC4881840 DOI: 10.7863/ultra.15.14.11075] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 01/08/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVES To compare digital palpation with levator plate lift measured by endovaginal and transperineal dynamic sonography. METHODS Dynamic transperineal and endovaginal sonographic examinations were performed as part of multicompartmental pelvic floor functional assessment. Patients were instructed to perform Kegel contractions while a probe captured a video clip of levator plate movement at rest and during contraction in a 2-dimensional midsagittal posterior view. We measured the distance between the levator plate and the probe on endovaginal sonography as well as the distance between the levator plate and the gothic arch of the pubis on transperineal sonography. The change in diameter (lift) and levator plate lift ratio (lift/rest × 100) were calculated. Pelvic floor muscle strength was assessed by digital palpation and divided into functional and nonfunctional groups according to the Modified Oxford Scale. Mean differences in levator plate upward lift were compared by Modified Oxford Scale scores using Student t tests and analysis of variance. RESULTS Seventy-four women were available for analysis. The mean age was 55 (SD, 11.9) years. When measured by vaginal dynamic sonography, mean lift and lift/rest ratio values increased with increasing Modified Oxford Scale score (analysis of variance, P= .09 and .04, respectively). When scores were categorized to represent nonfunctional (0-1) and functional (2-5) muscle strength groups, the mean lift (3.2 versus 4.6 mm; P = .03) and lift/rest ratio (13% versus 20%; P = .01) values were significantly higher in women with functional muscle strength. All patients with lift of 30% or greater detected by vaginal sonography had functional muscle strength. CONCLUSIONS A greater levator plate lift ratio detected by dynamic endovaginal sonography was associated with higher muscle strength as determined by the Modified Oxford Scale. This novel measurement can be incorporated into sonographic evaluation of levator ani function.
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Affiliation(s)
- Ghazaleh Rostaminia
- Department of Obstetrics and Gynecology, Inova Fairfax Hospital, Falls Church, Virginia USA (G.R.); and Departments of Obstetrics and Gynecology and Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma USA (J.P., L.Q., S.A.S.)
| | - Jennifer Peck
- Department of Obstetrics and Gynecology, Inova Fairfax Hospital, Falls Church, Virginia USA (G.R.); and Departments of Obstetrics and Gynecology and Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma USA (J.P., L.Q., S.A.S.)
| | - Lieschen Quiroz
- Department of Obstetrics and Gynecology, Inova Fairfax Hospital, Falls Church, Virginia USA (G.R.); and Departments of Obstetrics and Gynecology and Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma USA (J.P., L.Q., S.A.S.)
| | - S Abbas Shobeiri
- Department of Obstetrics and Gynecology, Inova Fairfax Hospital, Falls Church, Virginia USA (G.R.); and Departments of Obstetrics and Gynecology and Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma USA (J.P., L.Q., S.A.S.).
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Jundt K, Peschers U, Kentenich H. The investigation and treatment of female pelvic floor dysfunction. DEUTSCHES ARZTEBLATT INTERNATIONAL 2015; 112:564-74. [PMID: 26356560 PMCID: PMC4570968 DOI: 10.3238/arztebl.2015.0564] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Revised: 07/09/2015] [Accepted: 07/09/2015] [Indexed: 01/12/2023]
Abstract
BACKGROUND 25% of all women report involuntary loss of urine, and 7% may require treatment. METHODS This review is based on a selection of pertinent literature, including guidelines and Cochrane reviews. RESULTS The assessment of pelvic floor dysfunction in women begins with a basic evaluation that is followed by special diagnostic tests if indicated. The physician taking the clinical history should inquire about the patient's behavior, personality, social and other stressors, and eating and drinking habits, as well as any mental disorders that may be present, including anxiety disorders, depression, somatization disorders, and disorders of adaptation. Conservative treatment consists mainly of lifestyle changes, physiotherapy, and medication. Stress incontinence is most commonly treated with pelvic floor exercises, with a documented success rate of 56.1% vs. 6% without such treatment (relative risk 8.38, 95% confidence interval 3.67-19.07). If incontinence persists, surgery may be indicated ( implantation of suburethral tension-free slings, or colposuspension). Feedback and biofeedback training can be used to treat an overactive bladder. If these techniques and drug therapy are unsuccessful, botulinum toxin injections can be considered. CONCLUSION Well-validated treatments for pelvic floor dysfunction are available. Psychosomatic factors must be taken into account and can have a major effect on treatment outcomes.
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Affiliation(s)
- Katharina Jundt
- Private practice for gynecology at Pasinger Bahnhof, München
- PD Dr. Jundt and Prof. Dr. Kentenich have equally contributed to the article
| | - Ursula Peschers
- Pelvic Floor Center München, Surgical Hospital München-Bogenhausen
- PD Dr. Jundt and Prof. Dr. Kentenich have equally contributed to the article
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20
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Da Silva AS, Digesu GA, Dell'Utri C, Fritsch H, Piffarotti P, Khullar V. Do ultrasound findings of levator ani "avulsion" correlate with anatomical findings: A multicenter cadaveric study. Neurourol Urodyn 2015; 35:683-8. [PMID: 25982354 DOI: 10.1002/nau.22781] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 03/16/2015] [Indexed: 11/08/2022]
Abstract
AIMS This study aimed to validate the levator "avulsion" injury as seen on ultrasound against anatomical dissection in the same cadaver. METHODS Puboviseral muscle (PVM) anatomy of female cadavers was studied using 3D-translabial ultrasonography and an "avulsion" confirmed per standard recommendations [Dietz HP. Aust N Z J Obstet Gynaecol 53:220-230, 2013]. Cadavers were then dissected to determine the macroscopic attachment or detachment of the PVM and the dimensions including the PVM symphysis gap and PVM attachment depth. Intra and inter-observer reliability of USS findings and anatomical measurements were assessed using the Cohen's κ and Bland & Altman plots respectively. McNemar's and Mann-Whitney U tests were used to compare imaging and cadaveric dissection findings. RESULTS "Avulsions" were seen on imaging in 11/30 (36.7%) cadavers; the defect was bilateral in 1/30 (3.3%) and unilateral in 10/30 (33.3%). No "avulsion" was found at dissection (McNemar's χ(2) = 60.0, P < 0.001). An additional thirty-nine cadavers were dissected with no "avulsion" identified. A narrower PVM insertion depth was strongly associated with "avulsion" on ultrasound (mean: 4.79 mm vs. 6.32 mm, Z = -3.191, P = 0.001). Intra- and inter-observer agreement was perfect (K = 1.0 ± 0.0) and good (K = 0.85 ± 0.142) for anatomical "avulsions" and USS, respectively. CONCLUSIONS There is a clear difference between anatomical and USS findings. The imaged appearance of an "avulsion" does not represent a true anatomical "avulsion" as confirmed on dissection. The term "avulsion" is misrepresentative and should not be used to describe this imaging finding. Moreover, further attempts at surgically repairing this defect should be avoided, at least until there is a better understanding of its pathophysiology. Neurourol. Urodynam 35:683-688, 2016. © 2015 Wiley Periodicals, Inc.
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Affiliation(s)
| | - G Alessandro Digesu
- St. Mary's Hospital London Imperial College Healthcare NHS Trust, London, United Kingdom
| | | | - Helga Fritsch
- Department of Anatomy, Histology and Embriology, Medical University of Innsbruck, Austria
| | | | - Vik Khullar
- St. Mary's Hospital London Imperial College Healthcare NHS Trust, London, United Kingdom.,Mangiagalli Hospital, University of Milan, Italy
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Alteration of anal sphincter function in patients with levator avulsion: observational study. Int Urogynecol J 2015; 26:985-90. [DOI: 10.1007/s00192-014-2623-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 12/30/2014] [Indexed: 10/24/2022]
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22
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Rostaminia G, Peck JD, Quiroz LH, Shobeiri SA. How well can levator ani muscle morphology on 3D pelvic floor ultrasound predict the levator ani muscle function? Int Urogynecol J 2015; 26:257-62. [PMID: 25246297 PMCID: PMC4874572 DOI: 10.1007/s00192-014-2503-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Accepted: 08/30/2014] [Indexed: 11/26/2022]
Abstract
INTRODUCTION AND HYPOTHESIS The aim of our study was to assess the performance of levator ani muscle deficiency (LAD) evaluated by 3D endovaginal ultrasound (EVUS) to detect pelvic floor muscle function as assessed by digital examination. METHODS This cross-sectional study was conducted among 77 patients referred to our urogynecology clinic for pelvic floor dysfunction symptoms. Patients underwent physical examinations including digital pelvic muscle strength assessment using the Modified Oxford scale (MOS). EVUS volumes were evaluated and levator ani muscles were scored according to a validated LAD scoring system. MOS scores were categorized as nonfunctional (scores 0-1) and functional (scores 2-5). RESULTS Mean age of participants was 56 (SD ± 12.5) and 71% were menopausal. Overall, 32.5% had nonfunctional muscle strength and 44.2% were classified as having significant LAD. LAD identified by ultrasound had a sensitivity of 60% (95% CI 41 -79%) for detecting nonfunctional muscle and a specificity of 63% (95% CI 50 -77%) for detecting functional muscle. Overall, LAD demonstrated fair ability to discriminate between patients with and those without poor muscle function (area under the ROC curve = 0.70 [95% CI 0.58-0.83]). Among patients with an LAD score of 16-18, representing almost total muscle avulsion, 70% had nonfunctional MOS scores, whereas in patients with normal/minimal LAD (scores of 0-4), 89.5% had functional MOS scores. CONCLUSIONS Levator ani deficiency and MOS scales were moderately negatively correlated. Among patients with normal morphology or the most severe muscle deficiency, LAD scores can identify the majority of patients with functional or nonfunctional MOS scores respectively.
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Affiliation(s)
- G Rostaminia
- Section of Female Pelvic Medicine & Reconstructive Surgery, Department of Obstetrics and Gynecology, The University of Oklahoma Health Sciences Center, 920 Stanton L. Young Boulevard, WP2410, P.O. Box 26901, Oklahoma City, OK, 73190, USA
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van Delft KWM, Thakar R, Sultan AH, IntHout J, Kluivers KB. The natural history of levator avulsion one year following childbirth: a prospective study. BJOG 2014; 122:1266-73. [DOI: 10.1111/1471-0528.13223] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2014] [Indexed: 02/05/2023]
Affiliation(s)
- KWM van Delft
- Department of Obstetrics and Gynaecology, Urogynaecology; Croydon University Hospital; Croydon UK
| | - R Thakar
- Department of Obstetrics and Gynaecology, Urogynaecology; Croydon University Hospital; Croydon UK
| | - AH Sultan
- Department of Obstetrics and Gynaecology, Urogynaecology; Croydon University Hospital; Croydon UK
| | - J IntHout
- Radboud University Medical Centre; Department for Health Evidence; Section Biostatistics; Nijmegen the Netherlands
| | - KB Kluivers
- Radboud University Medical Centre; Department of Obstetrics and Gynaecology; Nijmegen the Netherlands
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van Delft K, Sultan AH, Thakar R, Schwertner-Tiepelmann N, Kluivers K. The relationship between postpartum levator ani muscle avulsion and signs and symptoms of pelvic floor dysfunction. BJOG 2014; 121:1164-71; discussion 1172. [DOI: 10.1111/1471-0528.12666] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2013] [Indexed: 01/05/2023]
Affiliation(s)
- K van Delft
- Department of Obstetrics and Gynaecology, Urogynaecology; Croydon University Hospital; Croydon UK
| | - AH Sultan
- Department of Obstetrics and Gynaecology, Urogynaecology; Croydon University Hospital; Croydon UK
| | - R Thakar
- Department of Obstetrics and Gynaecology, Urogynaecology; Croydon University Hospital; Croydon UK
| | - N Schwertner-Tiepelmann
- Department of Obstetrics and Gynaecology, Urogynaecology; Croydon University Hospital; Croydon UK
| | - K Kluivers
- Department of Obstetrics and Gynaecology (791); Radboud University Medical Centre; Nijmegen The Netherlands
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Dietz HP. Translabial ultrasound in the assessment of pelvic floor and anorectal function in women with defecatory disorders. Tech Coloproctol 2014; 18:481-94. [DOI: 10.1007/s10151-013-1117-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Accepted: 12/30/2013] [Indexed: 02/06/2023]
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Calculation of membrane tension in selected sections of the pelvic floor. Int Urogynecol J 2013; 25:499-506. [PMID: 24146072 DOI: 10.1007/s00192-013-2253-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Accepted: 09/30/2013] [Indexed: 01/02/2023]
Abstract
INTRODUCTION AND HYPOTHESIS A mathematical model to estimate membrane tensions (Mt) at the urogenital hiatus and midpelvis in patients with and without prolapse is proposed. For that purpose the complex structures of the pelvic floor were simplified and, based on assumptions concerning geometry and loading conditions, Laplace's law was used to calculate Mt. The pelvic cavity is represented by an ellipsoid in which the midpelvic and hiatal sections are described by an ellipse. The downwards forces within the pelvis (F(in)) are in equilibrium with the support forces within its walls (F(w)). F(in) is the abdominal pressure (PABD) multiplied by the area A of the ellipse. The force inside the tissues (F(w)) is distributed along the circumference of the ellipse C. The Mt can be approximated as Mt = (PABD.A)/C (N/m). Mt-α accounts for the angle α which describes tissue orientation with respect to the anatomical section and is calculated as Mt-α = Mt/sin(α). METHODS We conducted a retrospective study on archived magnetic resonance imaging scans (n = 20) and ultrasound images in patients with (n = 50) or without prolapse (n = 50) and measured actual geometrical variables. PABD was measured in patients with and without prolapse (n = 20). RESULTS Mt at the urogenital hiatus at rest is 0.35 N/cm. They significantly increase with the Valsalva manoeuvre, by a factor of 2.3 (without prolapse) to 3.6 (with prolapse). CONCLUSIONS Calculated Mt are much lower than what is reported for the abdominal cavity. Prolapse patients have significantly larger Mt, which during the Valsalva manoeuvre increase more than in healthy subjects.
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Kim S, Wong V, Moore KH. Why are some women with pelvic floor dysfunction unable to contract their pelvic floor muscles? Aust N Z J Obstet Gynaecol 2013; 53:574-9. [DOI: 10.1111/ajo.12133] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Accepted: 08/09/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Sia Kim
- Pelvic Floor Unit; St George Hospital; Sydney New South Wales Australia
| | - Vivien Wong
- Pelvic Floor Unit; St George Hospital; Sydney New South Wales Australia
| | - Kate H. Moore
- Department of Urogynaecology; University of New South Wales (UNSW); Sydney New South Wales Australia
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Hilde G, Staer-Jensen J, Siafarikas F, Gjestland K, Ellström Engh M, Bø K. How well can pelvic floor muscles with major defects contract? A cross-sectional comparative study 6 weeks after delivery using transperineal 3D/4D ultrasound and manometer. BJOG 2013; 120:1423-9. [DOI: 10.1111/1471-0528.12321] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2013] [Indexed: 11/29/2022]
Affiliation(s)
- G Hilde
- Department of Sports Medicine; Norwegian School of Sport Sciences; Oslo Norway
- Department of Obstetrics and Gynaecology; Akershus University Hospital; Lørenskog Norway
| | - J Staer-Jensen
- Department of Obstetrics and Gynaecology; Akershus University Hospital; Lørenskog Norway
| | - F Siafarikas
- Department of Obstetrics and Gynaecology; Akershus University Hospital; Lørenskog Norway
- Institute of Clinical Medicine; University of Oslo; Oslo Norway
| | - K Gjestland
- Department of Obstetrics and Gynaecology; Akershus University Hospital; Lørenskog Norway
| | - M Ellström Engh
- Department of Obstetrics and Gynaecology; Akershus University Hospital; Lørenskog Norway
- Institute of Clinical Medicine; University of Oslo; Oslo Norway
| | - K Bø
- Department of Sports Medicine; Norwegian School of Sport Sciences; Oslo Norway
- Department of Obstetrics and Gynaecology; Akershus University Hospital; Lørenskog Norway
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Billecocq S, Morel MP, Fritel X. Traumatismes du levator ani après l’accouchement, de l’étirement à l’avulsion : revue de la littérature. Prog Urol 2013; 23:511-8. [DOI: 10.1016/j.purol.2013.04.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2013] [Revised: 04/04/2013] [Accepted: 04/04/2013] [Indexed: 11/26/2022]
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Staer-Jensen J, Siafarikas F, Hilde G, Braekken IH, Bø K, Engh ME. Pelvic floor muscle injuries 6 weeks post partum-an intra- and inter-rater study. Neurourol Urodyn 2012; 32:993-7. [PMID: 23280961 DOI: 10.1002/nau.22337] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Accepted: 09/24/2012] [Indexed: 11/08/2022]
Affiliation(s)
- Jette Staer-Jensen
- Department of Obstetrics and Gynaecology, Akershus University Hospital, Lørenskog, Norway.
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Dietz HP, Beer-Gabel M. Ultrasound in the investigation of posterior compartment vaginal prolapse and obstructed defecation. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2012; 40:14-27. [PMID: 22045564 DOI: 10.1002/uog.10131] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/21/2011] [Indexed: 05/31/2023]
Abstract
Recent developments in diagnostic imaging have made gynecologists, colorectal surgeons and gastroenterologists realize as never before that they share a common interest in anorectal and pelvic floor dysfunction. While we often may be using different words to describe the same phenomenon (e.g. anismus/vaginismus) or attributing different meanings to the same words (e.g. rectocele), we look after patients with problems that transcend the borders of our respective specialties. Like no other diagnostic modality, imaging helps us understand each other and provides new insights into conditions we all need to learn to investigate better in order to improve clinical management. In this review we attempt to show what modern ultrasound imaging can contribute to the diagnostic work-up of patients with posterior vaginal wall prolapse, obstructed defecation and rectal intussusception/prolapse. In summary, it is evident that translabial/perineal ultrasound can serve as a first-line diagnostic tool in women with such complaints, replacing defecation proctography and MR proctography in a large proportion of female patients. This is advantageous for the women themselves because ultrasound is much better tolerated, as well as for healthcare systems since sonographic imaging is much less expensive. However, there is a substantial need for education, which currently remains unmet.
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Affiliation(s)
- H P Dietz
- Department of Obstetrics and Gynecology, Sydney Medical School Nepean, University of Sydney, Penrith, Australia.
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Detection of anal sphincter defects in female patients with fecal incontinence: a comparison of 3-dimensional transperineal ultrasound and 2-dimensional endoanal ultrasound. Dis Colon Rectum 2012; 55:646-52. [PMID: 22595843 DOI: 10.1097/dcr.0b013e318251dca1] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Endoanal ultrasound is widely used for the detection of external and internal anal sphincter defects in patients with fecal incontinence. Recently, 3-dimensional transperineal ultrasound has been introduced as a noninvasive imaging method for the detection of these sphincter defects. OBJECTIVE This study was designed to assess agreement between 3-dimensional transperineal ultrasound and 2-dimensional endoanal ultrasound regarding the detection of anal sphincter defects in women with fecal incontinence. DESIGN This study was designed as a prospective observational study. SETTINGS The study took place in a university hospital. PATIENTS Between October 2008 and June 2009, all women with concerns of fecal incontinence underwent 2-dimensional endoanal ultrasound as well as 3-dimensional transperineal ultrasound. MAIN OUTCOME MEASURES The main outcome measures are the presence of external and internal anal sphincter defects. RESULTS Fifty-five patients were included. External and internal anal sphincter defects were observed with 2-dimensional endoanal ultrasound in 27 (49%) and 15 (27%) patients. Three-dimensional transperineal ultrasound detected an external and internal sphincter defect in 19 (35%) and 16 (29%) patients. The Cohen κ coefficient for the detection of external (κ = 0.63) and internal (κ = 0.78) anal sphincter defects was good. LIMITATIONS This study's limitations include the absence of a surgical examination as the reference standard in the determination of sphincter defects. CONCLUSION This study shows good agreement between 3-dimensional transperineal ultrasound and 2-dimensional endoanal ultrasound regarding the detection of anal sphincter defects. Based on these data, 3-dimensional transperineal ultrasound might be considered as a valuable alternative noninvasive investigation method.
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Schwertner-Tiepelmann N, Thakar R, Sultan AH, Tunn R. Obstetric levator ani muscle injuries: current status. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2012; 39:372-383. [PMID: 22190408 DOI: 10.1002/uog.11080] [Citation(s) in RCA: 89] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Levator ani muscle (LAM) injuries occur in 13-36% of women who have a vaginal delivery. Although these injuries were first described using magnetic resonance imaging, three-dimensional transperineal and endovaginal ultrasound has emerged as a more readily available and economic alternative to identify LAM morphology. Injury to the LAM is attributed to vaginal delivery resulting in reduced pelvic floor muscle strength, enlargement of the vaginal hiatus and pelvic organ prolapse. There is inconclusive evidence to support an association between LAM injuries and stress urinary incontinence and there seems to be a trend towards the development of fecal incontinence. Longitudinal studies with long-term follow-up assessing the LAM before and after childbirth are lacking. Furthermore, the consequence of LAM injuries on quality of life due to prolapse and/or urinary and fecal incontinence have not been evaluated using validated questionnaires. Direct comparative studies using the above-mentioned imaging modalities are needed to determine the true gold standard for the diagnosis of LAM injuries. This would enable consistency in definition and classification of LAM injuries. Only then could high-risk groups be identified and preventive strategies implemented in obstetric practice.
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Cuthbert SC, Rosner AL. Conservative chiropractic management of urinary incontinence using applied kinesiology: a retrospective case-series report. J Chiropr Med 2012; 11:49-57. [PMID: 22942842 PMCID: PMC3315873 DOI: 10.1016/j.jcm.2011.10.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2011] [Revised: 09/04/2011] [Accepted: 10/28/2011] [Indexed: 10/28/2022] Open
Abstract
OBJECTIVE The purpose of this case series is to describe the chiropractic management of 21 patients with daily stress and occasional total urinary incontinence (UI). CLINICAL FEATURES Twenty-one case files of patients 13 to 90 years of age with UI from a chiropractic clinic were reviewed. The patients had a 4-month to 49-year history of UI and associated muscle dysfunction and low back and/or pelvic pain. Eighteen wore an incontinence pad throughout the day and night at the time of their appointments because of unpredictable UI. INTERVENTION AND OUTCOME Patients were evaluated for muscle impairments in the lumbar spine, pelvis, and pelvic floor and low back and/or hip pain. Positive manual muscle test results of the pelvis, lumbar spine muscles, and pelvic floor muscles were the most common findings. Lumbosacral dysfunction was found in 13 of the cases with pain provocation tests (applied kinesiology sensorimotor challenge); in 8 cases, this sensorimotor challenge was absent. Chiropractic manipulative therapy and soft tissue treatment addressed the soft tissue and articular dysfunctions. Chiropractic manipulative therapy involved high-velocity, low-amplitude manipulation; Cox flexion distraction manipulation; and/or use of a percussion instrument for the treatment of myofascial trigger points. Urinary incontinence symptoms resolved in 10 patients, considerably improved in 7 cases, and slightly improved in 4 cases. Periodic follow-up examinations for the past 6 years, and no less than 2 years, indicate that for each participant in this case-series report, the improvements of UI remained stable. CONCLUSION The patients reported in this retrospective case series showed improvement in UI symptoms that persisted over time.
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Affiliation(s)
| | - Anthony L. Rosner
- Research Director, International College of Applied Kinesiology, Brookline, MA
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Levator hiatus dimensions and pelvic floor function in women with and without major defects of the pubovisceral muscle. Int Urogynecol J 2012; 23:707-14. [DOI: 10.1007/s00192-011-1652-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2011] [Accepted: 12/24/2011] [Indexed: 10/14/2022]
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Dietz HP. Pelvic floor ultrasound in prolapse: what’s in it for the surgeon? Int Urogynecol J 2011; 22:1221-32. [DOI: 10.1007/s00192-011-1459-3] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Accepted: 05/10/2011] [Indexed: 02/03/2023]
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Tubaro A, Koelbl H, Laterza R, Khullar V, de Nunzio C. Ultrasound imaging of the pelvic floor: where are we going? Neurourol Urodyn 2011; 30:729-34. [PMID: 21661021 DOI: 10.1002/nau.21136] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
We produced a non systematic review of ultrasound imaging of the pelvic floor in women with urinary incontinence (UI) and/or pelvic organ prolapse (POP). We have searched the PubMed and Embase databases for the following PICO question: women; imaging; urinary incontinence, pelvic organ prolapse, pelvic floor, pelvic floor muscle, pelvic floor muscle training; physical examination, no imaging; diagnosis, prognosis, outcome. The production of a systematic review was deemed impossible based on the type and quality of the published evidence. Clinical research focused on the pathophysiology of the UI and POP looking relation between anatomic abnormalities, childbirth, the risk of UI or POP, the outcome of conservative treatment and reconstructive surgery. Published papers fall into the remits of diagnostic studies but often fail to comply with the recommendations of the STARD initiative. Most published evidence remains the product of a single institution effort and confirmatory studies are rarely found. Imaging studies in patients with UI did not provide evidence of any clinical benefit in the management of patients. In patients with POP, interesting correlations have been identified such as between childbirth, dimension of levator hiatus, avulsion of levator ani and risk of prolapse, but the non clinical benefit of pelvic floor imaging could still not be identified. Research on pelvic floor imaging requires a coordinated, international, multicentre effort to improve internal and external validity of imaging techniques, confirm observations published by single institutions and provide health technology assessment of imaging in the management of UI or POP patients.
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Affiliation(s)
- Andrea Tubaro
- Department of Urology, Sant'Andrea Hospital, 2nd School of Medicine, La Sapienza University of Rome, Italy.
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CHANTARASORN V, SHEK KL, DIETZ HP. Sonographic detection of puborectalis muscle avulsion is not associated with anal incontinence. Aust N Z J Obstet Gynaecol 2011; 51:130-5. [DOI: 10.1111/j.1479-828x.2010.01273.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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