Application of perineometer in the assessment of pelvic floor muscle strength and endurance: a reliability study

The Role of Dynamic Neuromuscular Stabilization Exercises in Stress Urinary Incontinence Among Females Aged 18-40 Years

BACKGROUND AND OBJECTIVE

Stress urinary incontinence (SUI) is prevalent among females across various age groups, yet societal taboos and unawareness contribute to under-reporting and hinder effective management strategies. This study aimed to evaluate the efficacy of dynamic neuromuscular stabilization (DNS) compared to traditional Kegel exercises in females with stress urinary incontinence, focusing on assessing the impact of DNS on pelvic floor strength and core musculature activation to provide valuable insights into urinary continence management.

METHODOLOGY

This is a single-blinded, randomized trial with 90 females aged 18-40 years assessed perineometer readings, pelvic floor electromyography (EMG), and transverse abdominis activation via pressure biofeedback.

RESULTS

Significant improvements in pelvic floor strength and core musculature activation were observed in the DNS group compared to the Kegel exercise group. Perineometer values, EMG measurements, and pressure biofeedback unit readings demonstrated substantial enhancements post-intervention in both groups. Effect sizes, including Cohen's D and point biserial correlation coefficient, indicated medium to large effects favoring the DNS intervention.

CONCLUSION

DNS is superior to Kegel exercises for SUI management, emphasizing the importance of targeting core musculature. Future research should explore long-term outcomes and patient-reported measures for a comprehensive understanding.

Can pelvic floor muscle function before surgery determine the outcome of surgical treatment of stress urinary incontinence in women?

AIM

The study aimed to determine whether pelvic floor muscle (PFM) function before surgery may correlate with the success of surgical interventions for treating stress urinary incontinence (SUI). Our hypothesis was that addressing identified variables in preoperative rehabilitation could potentially improve surgical outcomes.

METHODS

This prospective observational study was conducted at a single center and enrolled women qualified to mid-urethral tape insertion for SUI between 2020 and 2022. Digital palpation and manometry (Peritron™ 9300 V) were used to evaluate PFM function. The following parameters were acquired: vaginal resting pressure, vaginal pressure during maximal voluntary contraction (MVC), the area under the curve during a 10-second MVC, moreover the ability to perform correct PFM contraction, reflexive PFM contraction during cough and relaxation were assessed. All measurements were performed before the surgical treatment and during follow-up assessments at 1, 3, and 6 months postoperatively. The primary endpoint of the study was defined as objective cure, characterized by a negative cough stress test (CST), along with a subjective assessment based on the Urogenital Distress Inventory-6 (UDI-6) and Incontinence Impact Questionnaire-7 (IIQ-7).

RESULTS

The study involved 57 eligible female participants, all of whom completed the 6-month follow-up. Objective cure was observed in 75.44% of cases, while subjective cure was reported in 33%. There was no association between PFM parameters and surgical outcomes.

CONCLUSION

The success of surgical treatment of SUI 6 months postsurgery is not related to preoperative pelvic floor muscle function.

Impact of preoperative pelvic floor muscle function on the success of surgical treatment of pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

The objective of this study was to identify the potential characteristics of pelvic floor muscles (PFM) in the preoperative assessment that could be associated with post-surgical prolapse severity. We hypothesized that the same variables, if identified, could be addressed in preoperative rehabilitation to improve surgical results.

METHODS

This was a single-center prospective observational study that included women who underwent surgical pelvic organ prolapse repair between 2020-2022. Genital prolapse was evaluated according to the Pelvic Organ Prolapse Quantification (POP-Q) system. All the participants underwent a PFM assessment, including a vaginal digital assessment and manometry (Peritron™ 9300 V) before surgery and at 1-, 3-, and 6-month follow-ups. Several PFM variables were recorded: vaginal resting pressure, vaginal pressure during maximal voluntary contraction (MVC), area under the curve during a 10-second MVC, ability to correctly contract the PFMs, and reflexive activation during cough and relaxation. The primary endpoint of the analysis was objective surgical success defined as POP-Q 0 or 1 at the 6-month follow-up. Additionally, a change in pelvic floor muscle function was recorded during postoperative visits.

RESULTS

A total of 106 females were included in the study. Fifty-one were lost during the 6-month follow-up, which is a major limitation of the study. None of the examined parameters evaluating PFM were associated with surgical success. No statistically significant difference was found in MVC and PFM endurance before and after surgery. Post-surgery, a significant change was observed in the vaginal resting pressure and the ability to correct PFM activation and relaxation.

CONCLUSIONS

Preoperative PFM function is not associated with surgical success 6 months after surgery.

Comparing the Efficacy of Dynamic Neuromuscular Stabilization Exercises and Kegel Exercises on Stress Urinary Incontinence in Women: A Pilot Study

Background and objective Stress urinary incontinence (SUI) is a prevalent condition affecting women of various age groups, significantly impacting their quality of life. To address this multifaceted issue, a comprehensive approach that goes beyond traditional pelvic floor exercises is needed. Dynamic neuromuscular stabilization (DNS) exercises, targeting the integrated spinal stabilization system, offer a promising alternative. Thus, this study aimed to compare the effectiveness of DNS exercises and Kegel exercises in managing SUI among women. Methods This single-blinded, pilot study involved 24 women aged 18-40 years with mild to moderate SUI. Participants were divided into DNS and Kegel exercise groups. Outcome measures included perineometer readings, electromyography (EMG) data, and the Urogenital Distress Inventory-6 (UDI-6). Statistical analysis compared baseline and 12-week data within and between groups, and rank-biserial correlation coefficient (r) as a measure of effect size in our study was calculated. Results At 12 weeks, the DNS group showed significant improvement in pelvic floor muscle strength compared to Kegel exercises (p = 0.005). Both groups had significantly enhanced pelvic floor muscle strength (p < 0.05). A significant change occurred for EMG average, EMG peak, and EMG maximum voluntary contraction (MVC) at 12 weeks (average p = 0.005; peak p = 0.001; MVC p = 0.009), with significant improvements in both groups (p < 0.05). For UDI-6, a significant difference emerged between the two groups at 12 weeks (p < 0.05), with significant improvements in both groups individually from baseline to 12 weeks (p < 0.05). The effect size "r" for all variables indicated a medium to large effect size, underscoring the substantial and significant impact of DNS exercises in managing SUI among women compared to Kegel exercises. Conclusion This study suggests that DNS exercises, emphasizing the coordinated activation of the diaphragm, abdominals, multifidus, and pelvic floor, may provide a more effective approach for managing SUI in women compared to traditional Kegel exercises.

What are the cut-off points for vaginal manometry to differentiate women with a weak from those with a strong pelvic floor muscle contraction?: Vaginal manometry to classify a pelvic floor muscle contraction

BACKGROUND

Vaginal manometry is regarded as an objective method to assess pelvic floor muscles (PFM) function and can measure several variables during contraction.

OBJECTIVE

To determine which variables could differentiate women with/without a weak/strong PFM contraction and determine their cut-off points.

METHODS

This is a diagnostic accuracy study performed on 156 women with a mean age of 40.4 (SD, 15.9) years. The reference test was vaginal palpation and the index test was vaginal manometry (Peritron™ manometer). Variables were pressure at rest, pressure achieved with maximal voluntary contraction (MVC), MVC average, duration, gradient, and area under the curve (AUCm). The Receiver Operating Curve (AUC/ROC) and logistic regression were used to analyze the data and obtain cut-off points.

RESULTS

Excellent ability to discriminate women with a weak/strong PFM contraction was found for MVC average (cut-off: 28.93 cmH2O), MVC (cut-off: 38.61 cmH2O), and the AUCm (cut-off: 1011.93 cm²*s). The gradient variable had good discrimination ability (AUC/ROC=0.81; cut-off: 28.68 cmH2O/s). The MVC average assessed by manometry, menopausal status, and the presence of stress urinary incontinence (SUI) were associated with a weak/strong PFM contraction in the multivariate analysis; however, the most parsimonious model to discriminate weak/strong PFM contraction included only the MVC average (AUC/ROC = 0.95; sensitivity: 0.87; specificity: 0.91).

CONCLUSION

These results suggest which manometry variables are appropriate to assess and classify PFM function in females. These could be used to help physical therapists to make clinic decisions about the management of female PFM.

A randomised interventional parallel study to evaluate the effect of different frequencies of pelvic floor muscle exercises with core stabilisation using three-dimensional ultrasound: the PELSTAB study

INTRODUCTION AND HYPOTHESIS

The primary objective was to compare high- and low-frequency pelvic floor muscle training (PFMT) with the impact on urinary incontinence episode frequency over 1 week (IEF/week). The secondary objective was to compare the two groups with regard to pelvic floor muscle function, morphometry, incontinence quality of life, and patient global impression.

METHODS

This was a randomised parallel controlled study. The setting was regional gynaecological and urological outpatient clinics. The subjects consisted of a sample of 86 women with stress urinary incontinence (SUI). Group A underwent high-frequency PFMT and group B underwent low-frequency PFMT for 12 weeks. We recorded the IEF/week. The International Consultation on Incontinence Questionnaire Urinary Incontinence Short Form (ICIQ-UI SF) was used. Pelvic floor muscle function was evaluated using a perineometer. Pelvic floor muscle morphometry was evaluated with 3D/4D ultrasound. The Urinary Incontinence Quality of Life Scale (I-QoL) was used.

RESULTS

Significant differences between group A and B after treatment (p<0.001) were noted in favour of group A in IEF/week (group A 10.2±7.0/2.3±3.0 vs group B 9.3±4.7/6.3±4.9), in the ICIQ-UI SF (group A 9.7±3.0/3.7 ± 3.6 vs group B 9.9±3.2/9.4±3.4). Significant differences between groups A and B after treatment were noted in favour of group A for pelvic floor muscle function in terms of maximal voluntary contraction and its duration, and also for pelvic floor muscle morphometry in terms of a reduction of the hiatal area during rest, contraction, and the Valsalva manoeuvre.

CONCLUSIONS

High-frequency PFMT for 12 weeks significantly decreased IEF/week in comparison with low-frequency PFMT. In the high-frequency exercise group, women had significantly better pelvic floor muscle function, morphometry and quality of life than the low-frequency exercise group.

Does a Kegel Exercise Program Prior to Resistance Training Reduce the Risk of Stress Urinary Incontinence?

This comparative pre-post intervention study investigated the feasibility and benefits of Kegel exercises amongst incontinent women, prior to commencing resistance training (RT), to reduce the risk of stress urinary incontinence (SUI) compared to a group of women without prior Kegel exercises (KE). Incontinence severity index (ISI) score, pelvic floor muscle strength (PFMS), and body composition (such as body mass index (BMI), fat, and muscle mass), were obtained pre and post intervention. Results demonstrated that RT reduced SUI to a significantly greater extent only if preceded by KE as was observed in the Kegel exercise plus RT group (KE + RT) over time. The improvements in total ISI in both the KE + RT and RT groups were large (d = 1.50 and d = 1.17 respectively). A two-way ANOVA indicated a statistically significant improvement in average PFMS within the KE + RT group over time and between the two groups. A positive correlation was found between the average strength of pelvic floor muscles and SUI. Participants in KE + RT group demonstrated a significant increase in muscle mass (p ≤ 0.001) and concomitant reduction in fat mass (p = 0.018). This study determined a dedicated program of KE preceding a RT program improved average pelvic floor muscle strength and was effective in reducing SUI among incontinent women.

Efficacy Comparison between Kegel Exercises and Extracorporeal Magnetic Innervation in Treatment of Female Stress Urinary Incontinence: A Randomized Clinical Trial

Background and Objectives: To estimate the effectiveness of Kegel exercises versus extracorporeal magnetic innervation (EMI) in the treatment of stress urinary incontinence (SUI). Materials and Methods: A parallel group, randomized clinical trial was conducted in the Department of Obstetrics and Gynecology, Clinical Hospital Centre Zagreb, Croatia. After assessing the inclusion/exclusion criteria, each eligible participant was randomized to one of the two observed groups by flipping a coin: the first group underwent treatment with Kegel exercises for 8 weeks, while the second group underwent EMI during the same time interval. The primary outcome was the effectiveness of treatment as measured by the ICIQ-UI-SF overall score, eight weeks after the commencement of treatment. Results: During the study period, 117 consecutive patients with SUI symptoms were assessed for eligibility. A total of 94 women constituted the study population, randomized into two groups: Group Kegel (N = 48) and Group EMI (N = 46). After 8 weeks of follow-up, intravaginal pressure values in the EMI group were 30.45 cmH2O vs. the Kegel group, whose values were 23.50 cmH2O (p = 0.001). After 3 months of follow-up, the difference was still observed between the groups (p = 0.001). After the end of treatment and 3 months of follow-up, the values of the ICIQ-UI SF and ICIQ-LUTSqol questionnaires in the EMI group were lower than in the Kegel group (p < 0.001). Treatment satisfaction was overall better in the EMI group than in the Kegel group (p < 0.001). Conclusions: Patients treated with EMI had a lower number of incontinence episodes, a better quality of life, and higher overall satisfaction with treatment than patients who performed Kegel exercises.

Predictive Value of Pelvic Floor Muscle Morphometry Using 3D/4D Ultrasound in Relation to the Success of Pelvic Floor Muscle Training in Women with Stress Urinary Incontinence

The aim of our study was to establish the predictive value of pelvic floor muscle morphometry using 3D/4D ultrasound in relation to the success of pelvic floor muscle training (PFMT) for 12 weeks in women with stress urinary incontinence (SUI). A total of 86 women with SUI from regional gynaecological and urological outpatient clinics were enrolled on this cross-sectional study. SUI symptoms were assessed by the International Consultation on Incontinence Questionnaire (ICIQ-UI SF). Pelvic floor muscle function was evaluated using a perineometer. Pelvic floor muscle morphometry (PFMM) was evaluated by the size of the urogenital hiatus (HA in cm²) at rest (R), at contraction (C) and during the Valsalva manoeuvre, i.e., a strong push (V), by 3D/4D USG. The intervention was PFMT for 12 weeks. After PFMT, we noted significant improvement in SUI symptoms, pelvic floor muscle function and morphometry. Moderately significant (0.001) negative correlations were confirmed between the total ICIQ-UI SF score and strength (-0.236 **) and endurance (-0.326 **) of the maximal voluntary contraction (MvC), the number of MvC lasting 3 s (-0.406 **) and 1 s (-0.338 **). Moderately significant (0.001) positive correlations were confirmed between the total ICIQ-UI SF score and R (r = 0.453 **), C (r = 0.533 **) and V (r = 0.442 **). The predictive value of PFMM reached a positive prediction of a decrease with an ICIQ-UI SF score below 8. HA during V was most strongly associated with SUI reduction, with an area under the curve (AUC) of 0.87 (p ≤ 0.001), a positive predictive value of 83.3%, a negative predictive value of 75.0%, sensitivity of 78.9% and specificity of 80.0%. The predictive values of pelvic floor muscle morphometry using 3D/4D USG confirmed the success of PFMT in women with SUI.

Efficacy of intravaginal electrical stimulation with different treatment frequency in women with refractory idiopathic overactive bladder

Objective

The aim of this study is to evaluate the effect of intravaginal electrical stimulation (IVES) therapies with different treatment frequencies (two or five days in a week) added to bladder training (BT) on incontinence-related quality of life (QoL) and clinical parameters in women with refractory idiopathic overactive bladder (OAB).

Material and Methods

Fifty-two women with refractory idiopathic OAB were randomized into two groups as follows: Group 1 (n:26) received BT and IVES, two times in a week, for 10 weeks and Group 2 (n:26) received BT and IVES five times in a week, for 4 weeks. IVES was performed 20 minutes in a day, a total of 20 sessions for both groups. Women were evaluated for incontinence severity (24h pad test), pelvic floor muscles strength (perineometer), 3-day voiding diary (frequency of voiding, nocturia, incontinence episodes, and the number of pads), symptom severity (OAB-V8), quality of life (IIQ-7), treatment success (positive response rate), cure/improvement rate and treatment satisfaction (Likert scale).

Results

There was no statistically significant differences in all parameters between the two groups at the end of the treatment. It was found that the treatment satisfaction scores, cure/improvement and positive response rates were not significantly different between two groups (p>0.05).

Conclusion

We concluded that the application of IVES twice a week or 5 times a week added to BT were both effective on incontinence-related QoL and clinical parameters in women with refractory idiopathic OAB. These two IVES frequencies had similar clinical efficacy and patient satisfaction with a slight difference between them; 5 times per week IVES has a shorter treatment duration.

The Association between Postpartum Pelvic Girdle Pain and Pelvic Floor Muscle Function, Diastasis Recti and Psychological Factors-A Matched Case-Control Study

There is uncertainty regarding the association between abdominal morphology, pelvic floor function, and psychological factors in women with postpartum pelvic girdle pain (PGP). The aim of this case-control study was to evaluate the differences between women with and without persistent PGP regarding pelvic floor function, diastasis recti, and psychological factors 6−24 weeks postpartum. Pelvic floor manometry, palpation examination of abdominal muscles, the International Consultation on Incontinence Questionnaire Short Form, The Depression, Anxiety and Stress Scale—21, and the Pain Catastrophizing Scale were used. The PGP group presented with lower vaginal resting pressure (p < 0.001), more tenderness (p = 0.018) and impaired voluntary activation of pelvic floor muscles (p ≤ 0.001). Women with pain also had more distortion on the level of the anterior abdominal wall (p = 0.001) and more severe diastasis recti (p = 0.046) when compared to pain-free controls. Lower vaginal resting pressure was the strongest factor explaining PGP (OR 0.702, 95%CI 0.502−0.981). There were no differences in terms of the pelvic floor strength, endurance, severity of urinary incontinence and reported distress between the groups. Women with PGP 6−24 weeks postpartum differ in pelvic floor and abdominal muscle function from the pain-free controls. Vaginal resting pressure may be an important factor in pelvic girdle pain shortly postpartum. Further studies are needed to see a trend in changes over time.

Are Perineal Massage and Instrument-Assisted Perineal Stretching With Short Protocol Effective for Increasing Pelvic Floor Muscle Extensibility? A Randomized Controlled Trial

OBJECTIVE

The purpose of this study was to compare (1) the effects of the instrument-assisted perineal stretching technique with different application protocols in combination with perineal massage and (2) the effects of the isolated techniques on the extensibility and strength of the pelvic floor muscles (PFMs).

METHODS

A randomized controlled clinical trial with parallel randomization, assessor blinding, and concealed allocation was conducted in the Campus Physical Education at the Federal University of Uberlândia in Brazil. Ninety-six pregnant women (18-40 years of age) were allocated into 4 groups: perineal massage (PnM) group (PnM protocol for 10 minutes); instrument-assisted perineal stretching with a long static protocol for 15 minutes [IStrLS group]); PnM + IStrLS group (both techniques applied in the 2 previous groups); and PnM + IStrSR group (the same techniques as used in the PnM + IStrLS group but with a short repeated protocol; 4 sets lasting 30 seconds each). Eight interventions were performed in all 4 groups twice weekly (beginning at the 34th gestational week). The primary outcome was PFM extensibility, assessed using vaginal dilator circumference, and the secondary outcome was PFM strength, assessed using vaginal manometry.

RESULTS

For the PFM extensibility variable, a significant main effect of time (F2,88 = 87.951) and group (F3,88 = 7.193) was found. Tukey post hoc test results showed that the PnM + IStrSR group presented greater extensibility than the PnM and IStrLS groups. The PnM group showed increased PFM strength after 8 sessions compared with the other groups.

CONCLUSIONS

Women who were pregnant and received the combination of perineal massage and instrument-assisted perineal stretching with short repeated application had a greater increase in PFM extensibility than perineal massage and instrument-assisted perineal stretching alone.

IMPACT

The combination of perineal massage and instrument-assisted perineal stretching techniques with a short, repeated protocol led to better PFM extensibility results than the application of the techniques alone in women who were pregnant.

LAY SUMMARY

Pregnant women can benefit from intervention using the combination of perineal massage and instrument-assisted perineal stretching techniques with a short, repeated protocol.

A prospectively collected observational study of pelvic floor muscle strength and erectile function using a novel personalized extracorporeal perineometer

To investigate the association between pelvic floor muscle strength and erectile function in a prospectively collected observational cohort. 270 male volunteers were prospectively collected and grouped by International Index of Erectile Function-5 (IIEF-5) scores. Pelvic floor muscle strength was compared. Patients with obvious neurologic deficits, abnormal pelvic bones, history of pelvic radiation therapy, prostatectomy, or urinary incontinence were excluded. We analyzed 247 patients with mean (± standard deviation, SD) age of 62.8 (± 10.1) years. Mean (± SD) maximal and average strength were 2.0 (± 1.5) and 1.1 (± 0.8) kgf, respectively. Mean (± SD) endurance and IIEF-5 scores were 7.2 (± 2.6) seconds and 13.3 (± 7.9), respectively. Patients with IIEF-5 scores ≤ 12 tended to be older, with a higher occurrence of hypertension and lower body mass index. Age [odds ratio (OR) 1.08, 95% confidence interval (CI) 1.04–1.12, p < 0.001], and maximal strength < 1.9 kgf (OR 2.62, 95% CI 1.38–4.97, p = 0.003) were independent predictors for IIEF-5 scores ≤ 12 in multivariate regression analysis. Patients with erectile dysfunction were older and showed lower pelvic floor muscle maximal strength. Future prospective trials needed for using physiotherapy are required to verify our results.

Efficacy of intravaginal electrical stimulation added to bladder training in women with idiopathic overactive bladder: A prospective randomized controlled trial

PURPOSE

To evaluate the efficacy of intravaginal electrical stimulation (IVES) added to bladder training (BT) on incontinence-related quality of life (QoL) and clinical parameters in women with idiopathic overactive bladder (OAB).

MATERIALS AND METHODS

Sixty-two women with idiopathic OAB were randomized into two groups using the random numbers generator as follows: Group 1 received BT alone (n:31), and Group 2 received BT+IVES (n:31). IVES was performed for twenty minutes three days a week over a course of eight weeks for a total of 24 sessions. Patients were evaluated in terms of incontinence severity (24-hour pad test), pelvic floor muscles strength (perineometer), 3-day voiding diary (frequency of voiding, nocturia, incontinence episodes and number of pads), symptom severity (OAB-V8), incontinence-related QoL (IIQ-7), treatment success (positive response rate), cure/improvement rate and treatment satisfaction (Likert scale).

RESULTS

A statistically significant improvement was found in all parameters for all groups at the end of the treatment compared to the baseline values except pelvic floor muscles strength in Group 1 (p < 0.05). At the end of treatment, incontinence severity, frequency of voiding, nocturia, incontinence episodes, number of pads, symptom severity, and QoL were significantly improved in Group 2 compared to Group 1 (p < 0.05). Treatment satisfaction, cure/improvement, and positive response rates were significantly higher in group 2 compared to Group 1 (p < 0.05).

CONCLUSION

We conclude that BT+IVES were more effective than BT alone on both incontinence-related QoL and clinical parameters in women with idiopathic OAB.

Hip and Pelvic Floor Muscle Strength in Women with and without Urgency and Frequency Predominant Lower Urinary Tract Symptoms

Background

Urgency and frequency are common lower urinary tract symptoms (UF-LUTS) in women. There is limited evidence to guide physical therapist-led treatment.

Objectives

To compare hip and pelvic floor muscle strength between women with and without UF-LUTS. We hypothesized women with UF-LUTS would demonstrate 1) diminished hip external rotator and abductor strength and 2) equivalent pelvic floor strength and diminished endurance compared to controls.

Study Design

A matched case-control study.

Methods

Women with UF-LUTS (cases) and controls were matched on age, body mass index (BMI), vaginal parity. Examiner measured participants' 1) hip external rotator and abductor strength via dynamometry (maximum voluntary effort against fixed resistance) and 2) pelvic floor muscle strength (peak squeeze pressure) and endurance (squeeze pressure over a 10 second hold) via vaginal manometry. Values compared between cases and controls with paired-sample t-tests (hip) or Wilcoxon signed rank tests (pelvic floor).

Results

21 pairs (42 women): Hip external rotation (67.0 ± 19.0 N vs 83.6 ± 21.5 N; P=0.005) and hip abduction strength (163.1 ± 48.1 N vs 190.1 ± 53.1 N; P=0.04) were significantly lower in cases than controls. There was no significant difference in pelvic floor strength (36.8 ± 19.9 cmH₂0 vs 41.8 ± 21.0 cmH₂0; P=0.40) or endurance (234.0 ± 149.6 cmH₂0*seconds vs 273.4 ± 149.1 cmH₂0*seconds; P=0.24).

Conclusion

Women with UF-LUTS had weaker hip external rotator and abductor muscles, but similar pelvic floor strength and endurance compared to controls. Hip strength may be important to assess in patients with UF-LUTS, further research is needed.

Relationship between the types of urinary incontinence, handgrip strength, and pelvic floor muscle strength in adult women

AIM

To investigate the relationship between handgrip strength with types of urinary incontinence (UI) and pelvic floor muscle strength (PFMS) in women.

METHODS

Ninety-two women, who presented to the geriatric and urology outpatient clinics complaining of UI between July 2019 and February 2020 and had indicated to undergo urodynamic assessment after basic neurourological evaluation, were included in this cross-sectional study. The presence and types of UI were identified by clinical examination and urodynamic studies. Demographic parameters, anthropometric data, comorbidities and medications were recorded. The International Consultation on Incontinence Questionnaire-Short Form was applied. Handgrip strength (HGS) was measured by a hand dynamometer. The PFMS was subjectively assessed via vaginal digital palpation and measured quantitatively by the vaginal probe of the perineometer.

RESULTS

Thirty-eight urodynamic stress, 28 detrusor overactivity, 26 urodynamic mixed UI patients were reported. Perineometer measurements were significantly lower in the urodynamic stress UI group compared to the other two groups (p = 0.020). There was no relationship between the types of urinary incontinence and HGS. However, a positive correlation was found between PFMS and HGS (p = 0.045, r = 0.298).

CONCLUSION

The positive correlation between HGS and PFMS indicates that low HGS may be a marker for PFMS weakness. Furthermore, the association between sarcopenia and UI may be explained by this condition.

The Effect of Commonly Performed Exercises on the Levator Hiatus Area and the Length and Strength of Pelvic Floor Muscles in Postpartum Women

OBJECTIVE

The aim oft his study was to compare the effects of 10 common exercises to traditional pelvic floor muscle (PFM) contractions (Kegel) on levator hiatus (LH) area and PFM length and strength.

METHODS

This is a cross-sectional study of 15 healthy postpartum women. Ten exercises were studied. These were common variations of leg, core, and back exercises used in yoga, Pilates, strength training, and physical therapy. Each participant performed all 10 exercises at a single visit in 2 examination settings: transperineal ultrasound and perineometry. Ultrasound measured the LH area and PFM length, and perineometry measured the muscle strength (peak squeeze pressure).

RESULTS

Kegel generates an increase in squeeze pressure (24.3 cm H2O), shortens the muscles (-0.46 cm) and narrows the LH (-0.13 cm). The bird-dog and plank exercises were not different from Kegel in any measurement. While the leg-lift ultrasound dimensions are similar to Kegel, leg lifts generated peak squeeze pressures stronger than any other exercise (including Kegel). Whereas ultrasound dimensions were similar to Kegel, tucked and untucked squats and thigh adductions generated weaker contractions than Kegel. While crunch generated a squeeze pressure similar to Kegel, the ultrasound dimensions showed a significantly wider LH and longer muscle than Kegel. Bridge, clam, and plié exercises affected the PFMs differently than Kegel in all measures.

CONCLUSIONS

Bird-dog, plank, and leg-lift exercises should be evaluated as alternative exercises to Kegel as they affect PFM strength and length and LH area similarly to Kegel, and leg lifts generate a stronger contraction than Kegel.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Investigating Pelvic Floor Muscle Strength in Women of Reproductive Age and Factors Affecting It

This descriptive study was designed to investigate the pelvic floor muscle strength (PFMS) of women aged 18 to 49 years and to examine the factors that may have an effect on PFMS. The study was conducted on 258 women who visited a gynecology outpatient clinic between January 2019 and January 2020, who met the research criteria, and who agreed to participate in the study. The data were collected using the Sociodemographic Characteristics Information Form. The Modified Oxford Scale (MOS) and a perineometer were used to evaluate the PFMS of the women. The mean PFMS value measured using the perineometer was 31.56 ± 12.17 cmH₂O (moderate pressure). The PFMS values were 20.00 to 29.9 cmH₂O (weak pressure) and 30.00 to 39.9 cmH₂O (moderate pressure) in 23.6% of the women, respectively. The PFMS values measured with MOS were of grade 3 strength (moderate pressure) in 23.6% of the women and grade 2 strength (weak pressure) in 23.3%. A statistically significant strong correlation was found between the perineometer measurement and the women's MOS values. Moreover, a statistically significant difference was found between the PFMS values measured with the perineometer, MOS scores, and women's age groups, educational status, marital status, employment status, income status, persistent cough, use of nicotine, alcohol and coffee consumptions, chronic constipation, history of frequent urinary tract infections, regular exercise, body mass index, history of pregnancy, mode of delivery, use of episiotomy at birth, perineal rupture at birth, use of forceps vacuum at birth, multiple pregnancies, delivery of a baby weighing ≥4,000 g, treatment during pregnancy, hysterectomy, menopause, frequency of sexual intercourse, and pain during sexual intercourse (p < .05). We conclude that most of the women in the study had weak to moderate PFMS, that the evaluation of PFMS with the MOS positively overlapped with the perineometric measurements, and that a number of sociodemographic and obstetric variables act as risk factors that affect PFMS. The PFMS of all women should be assessed as part of their routine gynecological examinations.

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.

Reliability and validity of pelvic floor muscle strength assessment using the MizCure perineometer

Background

The purpose of this study was to clarify the reliability and validity of pelvic floor muscle (PFM) strength assessment using the MizCure perineometer in healthy women.

Methods

Twenty healthy women (age 20–45 years) participated in this study. The vaginal pressure measured using the MizCure and validated Peritron perineometers were repeated during PFM contraction in the supine and standing positions. All women were evaluated twice by examiners 1 and 2. Following the measurements in the first session (Test 1), they were repeated after an interval of between 2 and 6 weeks (Test 2). Within- and between-session intra- and inter-rater reliabilities in vaginal pressure were analyzed using intraclass correlation coefficients (ICC) (1, 1) and (2, 1), respectively. Validity was assessed by Pearson’s product-moment correlation coefficient and Spearman’s rank correlation analysis.

Results

Within-session intra-rater reliabilities for both examiners 1 and 2 for all vaginal pressures in Tests 1 and 2 were 0.90–0.96 for both perineometers. Between-session intra-rater reliability for the MizCure was 0.72–0.79 for both positions for examiner 1, and 0.63 in the supine position and 0.80 in the standing position for examiner 2. Inter-rater reliability for Test 1 was 0.91 in the supine position and 0.87 in the standing position for the MizCure. The vaginal pressures using the MizCure and Peritron were significantly associated with the supine position (r = 0.68, P < .001) and the standing position (r_s = 0.82, P < .001).

Conclusion

MizCure perineometer is a validated tool to measure PFM strength in both supine and standing positions in healthy nulliparous women.

Inter- and intrarater reliability of unidigital and bidigital vaginal palpation to evaluation of maximal voluntary contraction of pelvic floor muscles considering risk factors and dysfunctions

AIMS

To evaluate inter- and intrarater reliability of unidigital and bidigital vaginal palpation of pelvic floor muscle (PFM) maximal voluntary contraction (MVC) according to PFM risk factors and dysfunctions.

METHODS

A total of 187 women were recruited and evaluated by two examiners. Both performed the evaluation of MVC with unidigital and bidigital palpation, graded by Modified Oxford Scale. After 7-10 days, one examiner repeated the assessment. To analyze reliability by Cohen's linear Kappa (κw), participants were allocated into different groups according to: body mass index (BMI), menopause, parity, type of delivery and PFM dysfunctions, as pelvic organ prolapse (POP), constipation, urgency, urgency urinary incontinence, pelvic pain, and stress urinary incontinence.

RESULTS

Inter-rater reliability of unidigital palpation was considered fair (κw = 0.21-0.40) to moderate (κw = 0.41-0.60) according to BMI, postmenopausal status, parity, type of delivery, and PFM dysfunctions. Inter-rater reliability of bidigital palpation varied from none (κw = 0.00-0.20) to moderate for all risk factors and PFM dysfunctions. Intra-rater reliability of unidigital palpation was considered fair only for women with POP (κw = 0.37) and moderate to substantial (κw = 0.61-0.80) to all other variables. Intra-rater reliability of bidigital palpation ranged from moderate to almost perfect (κw = 0.81-1.00).

CONCLUSIONS

When performing vaginal palpation, physiotherapists must consider the way that is performing the evaluation, as some PFM risk factors and dysfunctions could influence the inter- and intrarater reliability of unidigital and bidigital palpation.

Which combination is most effective in women with idiopathic overactive bladder, including bladder training, biofeedback, and electrical stimulation? A prospective randomized controlled trial

OBJECTIVE

To evaluate the efficacy of single and combined use of biofeedback (BF) and electrical stimulation (ES) added to bladder training (BT) on incontinence-related quality of life (QoL) and clinical parameters in women with idiopathic overactive bladder (OAB).

MATERIAL AND METHODS

Seventy women were randomized into four groups as follows: Group 1 received BT alone (n = 18), Group 2 received BT + BF (n = 17), Group 3 received BT + ES (n = 18), and Group 4 received BT + BF + ES (n = 17). BF and ES were performed 3 days a week, 20 min a day, a total of 24 sessions for 8 weeks. All women were evaluated in terms of incontinence severity (pad test), pelvic floor muscles strength (perineometer), 3-day voiding diary (frequency of voiding, nocturia, incontinence episodes, and number of pads), QoL (incontinence impact questionnaire), treatment success (positive response rate), cure/improvement rate, treatment satisfaction (Likert scale), and discomfort level (visual analog scale).

RESULTS

At the end of the treatment, severity of incontinence, frequency of voiding, incontinence episodes, and treatment satisfaction significantly improved in Group 3 and Group 4 compared with the other two groups. In Group 3 and Group 4, high statistically significant values were found in cure/improvement and positive response rates as opposed to Group 1 and Group 2. In Group 2 and Group 3, statistically significant improvements were seen in nocturia and QoL compared with Group 1. Moreover, statistically significant improvements in nocturia and QoL were found in Group 4 compared with the other three groups. There was no difference in the discomfort level of application between the groups.

CONCLUSION

We conclude that in the first-line conservative treatment of women with idiopathic OAB: (i) adding BF and/or ES to BT increases treatment effectiveness, (ii) clinical efficiency is greater when the combination includes ES, (iii) BT + BF + ES (triple combination) is the most effective treatment option in reducing nocturia and improving QoL.

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.

A randomized interventional parallel study to evaluate the effect of pelvic floor muscle training with stabilization exercises of high and low intensity in women with stress urinary incontinence: The PELSTAB study

INTRODUCTION

The effect of different intensities of pelvic floor muscle training (PFMT) assessed by 2D/3D ultrasound (USG) have not been sufficiently monitored in the literature. The objective of the study will be to evaluate the effect of this intervention by assessing the change in incontinence episode frequency, hiatal area (HA) and hiatal diameter by 2D/3D USG and quality of life over 12 weeks of treatment.

METHODS

Using a randomized interventional parallel study, patients will be assigned to groups A and B using simple software randomization according to odd and even patient sequence numbers. The following methods will be used for evaluation: change in incontinence episode frequency, power and endurance of pelvic floor muscles assessed by perineometer (in cmH2O), HA (in cm) during contraction, Valsalva manoeuvre assessed by 3D USG, hiatal diameter assessed by 2D USG, the Incontinence Quality of Life scale (I-QoL) and the Patient Global Impression of Improvement score (PGI-I).

INTERVENTIONS

Group A, high-intensity PFMT 5 times a week for 30 minutes per day. Group B, low-intensity PFMT twice a week for 15 minutes per day. The duration of the intervention will be 12 weeks.

DISCUSSION

The study protocol presents the starting points, design, and methods of the PELSTAB Study. We expect that, after 12 weeks of high-intensity PFMT, women with stress urinary incontinence will have significantly less incontinence episode frequency, better reduction of HA during contraction and Valsalva manoeuvre, higher power and endurance of pelvic floor muscles and better quality of life compared to the group with low-intensity PFMT.

REGISTRATION

This study was registered in the ClinicalTrials.govNCT04340323.

Effects of home-based pelvic floor muscle training on decreasing symptoms of stress urinary incontinence and improving the quality of life of urban adult Omani women: A randomized controlled single-blind study

AIM

This study aims to determine the effectiveness of home-based pelvic floor muscle training (PFMT) on decreasing the severity of symptoms and improving the quality of life (QOL) among Omani women with stress urinary incontinence (SUI).

METHODS

A randomized controlled single-blind trial was conducted in three primary health care centers in Muscat. Eligible women who were diagnosed with SUI (from a concurrent phase-I study which was a cross-sectional study to determine the prevalence of urinary incontinence in Oman) were invited to take part. The consenting subjects were randomly allocated to either an intervention group (unsupervised PFMT) or a control group (lecture with no PFMT). Baseline and 12-week assessment of both groups was carried out for the primary outcome using the validated Arabic version of the International Consultation on Incontinence Questionnaire (ICIQ)-short form and the secondary outcome by blinded measures of pelvic floor muscle (PFM) strength using the modified Oxford grading system (MOGS), endurance, and perineometer.

RESULTS

A total of 73 subjects were included in the study. They were randomly divided into two groups. Both groups were similar at the baseline in terms of sociodemographic characteristics, ICIQ score, and PFM strength. At the 12-weeks assessment, there was a significant difference in the ICIQ score (P < .001) between the intervention group and the control one. There was no statistical difference between the two groups in MOGS, endurance, or perineometer values.

CONCLUSIONS

The home-based PFMT is an effective treatment in reducing the severity of symptoms and improving the QOL in women with SUI.

Reliability of manometry for assessing pelvic floor muscle function in healthy men

Objectives

To the best of our knowledge, no study has examined the reliability of assessment methods for male pelvic floor muscle (PFM) function. Therefore, this study aimed to clarify the reliability of manometry with an anal sensor (Peritron cat 9300A) to assess PFM function in healthy men.

Methods

Healthy male subjects (n = 21) without urinary leakage underwent testing to assess PFM function, and intra‐ and interrater reliability tests among examiners were performed. The PFM function included maximal anorectal squeeze pressure, endurance, mean anorectal squeeze pressure, gradient, and area under the curve during PFM voluntary contraction.

Results

Participants had a median age of 38 years (range 26‐51), and a mean BMI of 23.2 ± 2.0 kg/m². Satisfactory intra‐ and interrater reliability scores were found for resting pressure, anorectal squeeze pressure, and endurance. The intra‐rater reliability of resting pressure, anorectal squeeze pressure, and endurance were 0.71, 0.89, and 0.75 for examiner 1 and 0.72, 0.89, and 0.87 for examiner 2. The interrater reliability for resting pressure, anorectal squeeze pressure, and endurance were 0.58, 0.93, and 0.61, respectively.

Conclusions

This is the first prospective study showing the favorable intra‐ and interrater reliability of manometry for PFM function in healthy men. Our findings demonstrated that manometry can provide both reliable and reproducible data regarding PFM function in continent men, suggesting Peritron cat 9300A can be used to evaluate the PFM function in men.

Perioperative pelvic floor muscle training did not improve outcomes in women undergoing pelvic organ prolapse surgery: a randomised trial

QUESTION

In women undergoing surgery for pelvic organ prolapse (POP), what is the average effect of the addition of perioperative pelvic floor muscle training on pelvic organ prolapse symptoms, pelvic floor muscle strength, quality of life, sexual function and perceived improvement after surgery?

DESIGN

Randomised controlled trial with concealed allocation, blinded assessors, and intention-to-treat analysis.

PARTICIPANTS

Ninety-six women with an indication for POP surgery.

INTERVENTION

The experimental group received a 9-week pelvic floor muscle training protocol with four sessions before the surgery and seven sessions after the surgery. The control group received surgery only.

OUTCOME MEASURES

Symptoms were assessed using the Pelvic Floor Distress Inventory (PFDI-20), which is scored from 0 'unaffected' to 300 'worst affected'. Secondary outcomes were assessed using vaginal manometry, validated questionnaires and Patient Global Impression of Improvement, which is scored from 1 'very much better' to 7 'very much worse'. All participants were evaluated 15 days before surgery, and at Days 40 and 90 after surgery.

RESULTS

There was no substantial difference in POP symptoms between the experimental and control groups at Day 40 (31 (SD 24) versus 38 (SD 42), adjusted mean difference -6, 95% CI -25 to 13) or Day 90 (27 (SD 27) versus 33 (SD 33), adjusted mean difference -4, 95% CI -23 to 14). The experimental group perceived marginally greater global improvement than the control group; mean difference -0.4 (95% CI -0.8 to -0.1) at Day 90. However, the estimated effect of additional perioperative pelvic floor muscle training was estimated to be not beneficial enough to be considered worthwhile for any other secondary outcomes.

CONCLUSION

In women undergoing POP surgery, additional perioperative pelvic floor muscle training had negligibly small effects on POP symptoms, pelvic floor muscle strength, quality of life or sexual function.

TRIAL REGISTRATION

ReBEC, RBR-29kgz5.

Pelvic Floor Muscle Parameters Affect Sexual Function After 8 Weeks of Transcutaneous Electrical Stimulation in Women with Stress Urinary Incontinence

INTRODUCTION

Stress urinary incontinence (SUI) is often associated with female sexual dysfunction. We investigated which pelvic floor muscle (PFM) parameters (strength, power, and endurance) are associated with improvement of sexual function after 8 weeks of transcutaneous electrical stimulation (TES) training.

AIM

This study was performed to determine the effects of TES in the seated position on PFM parameters and female sexual function and to identify correlation between improved PFM parameters and sexual function after 8 weeks of TES training in women with SUI.

METHODS

The present study was performed between August 2018 and November 2018 in women with SUI who were randomized into a TES group (n = 17) or a control group (n = 17). One subject in each of the TES and control groups ultimately withdrew during the intervention due to a lack of time. Both groups were measured at baseline and after 8 weeks of intervention.

MAIN OUTCOME MEASURE

As outcome measures, PFM parameters (strength, power, and endurance) and female sexual function were assessed using a perineometer and the Female Sexual Function Index (FSFI), respectively.

RESULTS

The final study population consisted of 32 women with SUI. There were significant differences in PFM strength, power, and endurance and FSFI domain scores (desire, arousal, orgasm, satisfaction, and total score) in both between-group analyses (TES vs control group) and within-group analyses (pre-TES vs post-TSE). Change in PFM endurance had the highest association with change in total FSFI total score (r = 0.437; P = .006), and change in PFM power had the highest association with change in FSFI satisfaction (r = 0.420; P = .008).

CONCLUSION

TES in a seated position showed a beneficial effect on sexual function in females with SUI. Consideration of PFM parameters associated with FSFI domain scores may be important when developing intervention guidelines to improve female sexual function. Hwang UJ, Lee MS, Jung SH, et al. Pelvic Floor Muscle Parameters Affect Sexual Function After 8 Weeks of Transcutaneous Electrical Stimulation in Women with Stress Urinary Incontinence. Sex Med 2019;7:505-513.

Parity: a risk factor for decreased pelvic floor muscle strength and endurance in middle-aged women

INTRODUCTION AND HYPOTHESIS

The incidence of pelvic floor muscle (PFM) dysfunction increases rapidly with menopause and aging. Despite the raised magnitude and prevalence of pelvic floor disorders in middle-aged women, the risk factors underlying PFM dysfunction still remain to be identified. PFM function can be clinically measured as the maximum strength and endurance using manometry. The aim of this study was to evaluate PFM function in terms of strength and endurance by perineometer and to assess the risk factors that decrease PFM strength and endurance in middle-aged women.

METHODS

This was a cross-sectional study. Overall, 125 parous women (age 40-60 years) completed the study. A questionnaire was used to collect information on several demographic and obstetric variables. The Peritron perineometer measured PFM strength and endurance. Multiple linear regression analysis was used to evaluate the effects of sociodemographic variables on PFM function.

RESULTS

Both average strength of PFMs and maximum muscle strength significantly reduced as the number of parity increased. Average and maximum strength of PFMs showed a significant difference between women with parities of two and one (β = -0.435, p < .001; β = -0.441, p < 0.001, respectively). Both were even more influenced in women with parity of three (β = -0.503, p < .001; β = -0.500, p < .001). However, PFM endurance did not decrease with increasing parity number until the parity of two; however, it decreased in women with parity of three (β = -0.302, p < 0.05).

CONCLUSION

Parity appeared to have a dominant influence on weakness of PFM, and strength was more significantly associated with parity than endurance in middle-aged women.

Hip exercises improve intravaginal squeeze pressure in older women

Objective: Pelvic Floor Muscle Training (PFMT), an accepted treatment for incontinence and pelvic floor dysfunction, has good evidence, though it is unknown if adjunct therapies can be useful. Strengthening the obturator internus (OI), along with other hip external rotator muscles, may help strengthen the pelvic floor muscles (PFM) through fascial attachment. We hypothesized that strengthening the hip external rotators will improve intravaginal squeeze pressure in older women.Methods: A total of 25 women (with or without pelvic floor dysfunction) greater than 55 years of age participated in monitored and home exercise sessions three times a week for 12 weeks. The exercises included concentric, isometric, and eccentric training of hip external rotators, without instruction to include PFM contraction. A physical therapist performed the assessments of each participant: Pelvic Floor Distress Inventory-20 (PFDI-20), a manual pelvic assessment, hip strength testing using a hand-held dynamometer and maximum intravaginal squeeze pressure using the Peritron^TM PFM manometer (correct PFM contraction was confirmed visually and with palpation). Comparison was made to data obtained in a previous study in young women. Data were analyzed using paired t-tests and mixed model ANOVA.Results: Average intravaginal squeeze pressure increased from 21.47 ± 2.55 to 29.1 ± 3.15 cm H2O p < 0.0001. Hip external rotation strength increased in the right hip from 12.75 ± 0.46 to 15.42 ± 0.63 lbs p = 0.0009 and the left hip from 11.43 ± 0.43 to 15.61 ± 0.69 lbs p < 0.0001. The PFDI-20 scores decreased from 56.88 ± 10.76 to 40.62 ± 10.63, p > 0.05. Compared to a previous study in young women, both hip external rotation strength and intravaginal squeeze pressure increased with no significant difference between groups.Conclusion: Hip external rotation exercises may be effective as an indirect form of PFM exercise.

Review of pelvic and perineal neuromuscular fatigue: Evaluation and impact on therapeutic strategies

BACKGROUND

Pelvic floor fatigue is known by its clinical consequences (fecal incontinence, stress urinary incontinence, pelvic organ prolapse), but there are still few studies on the subject.

OBJECTIVE

This article presents an overview of the current knowledge of pelvic and perineal fatigue, focusing on its assessment and consequences in terms of evaluation and therapeutic strategies, to propose an evaluation that could be routinely performed.

METHODS

We performed a systematic review of the literature in MEDLINE via PubMed and Cochrane Library databases by using the keywords pelvic floor, muscular fatigue, physiopathology, stress urinary incontinence, pelvic organ prolapse, fecal incontinence, physical activity, and pelvic rehabilitation. We included reports of systematic reviews and retrospective and prospective studies on adult humans and animals in English or French published up to April 2018 with no restriction on start date.

RESULTS

We selected 59 articles by keyword search, 18 by hand-search and 3 specific guidelines (including the 2009 International Continence Society recommendations); finally 45 articles were included; 14 are described in the Results section (2 reviews of 6 and 20 studies, and 12 prospective observational or cross-over studies of 5 to 317 patients including 1 of animals). Perineal fatigue can be assessed by direct assessment, electromyography and spectral analysis and during urodynamics. Because pelvic floor fatigue assessments are not evaluated routinely, this fatigability is not always identified and is often falsely considered an exclusive pelvic floor weakness, as suggested by some rehabilitation methods that also weaken the pelvic floor instead of enhancing it.

CONCLUSION

Pelvic floor fatigue is not evaluated enough on a routine basis and the assessment is heterogeneous. A better knowledge of pelvic floor fatigue by standardized routine evaluation could lead to targeted therapeutic strategies.

Clinical functional evaluation of female's pelvic floor: integrative review

Abstract Introduction: The effectiveness of pelvic floor muscle training (PFMT) depends on the correct prescription of intensity, repetition and endurance of muscle contractions, which are provided by an adequate assessment of pelvic floor muscle. Objective: Verify the techniques, resources and strategies used for clinical functional evaluation of female pelvic floor (PF) described in literature. Methods: It’s an integrative review of published studies and books from 2010 until December 2015. Relevant articles with complete description of PF evaluation were found through the use of Scielo, LILACS, PubMed and Medline databases. Results: 34 articles that fulfilled all the criteria were selected. Conclusion: The most used techniques, resources and strategies were: anamnesis, physical examination, measurement of pelvic floor muscle activity using Modified Oxford Scale or perineometry, and use of questionnaires to analyze patient's perspective of their own symptoms. Thus, we could use the parameters obtained in the evaluation to plan an ideal PFMT for each patient, so the physiotherapist would have a good database to analyze the evolution and define the end of therapy.

An education program about pelvic floor muscles improved women's knowledge but not pelvic floor muscle function, urinary incontinence or sexual function: a randomised trial

QUESTION

Does an educational program with instructions for performing 'the Knack' improve voluntary contraction of the pelvic floor muscles, reduce reports of urinary incontinence, improve sexual function, and promote women's knowledge of the pelvic floor muscles?

DESIGN

Randomised, controlled trial with concealed allocation, intention-to-treat analysis and blinded assessors.

PARTICIPANTS

Ninety-nine women from the local community.

INTERVENTION

The experimental group (n=50) received one lecture per week for 4 weeks, and instructions for performing 'the Knack'. The control group (n=49) received no intervention.

OUTCOME MEASURES

The primary outcome was maximum voluntary contraction of the pelvic floor muscles measured using manometry. Secondary outcomes were: ability to contract the pelvic floor muscles measured using vaginal palpation; severity of urinary incontinence measured by the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) scored from 0 to 21; self-reported sexual function; and knowledge related to the pelvic floor. Outcomes were measured at baseline and after 4 weeks.

RESULTS

The intervention did not significantly improve: maximum voluntary contraction (MD 2.7 cmH₂O higher in the experimental group, 95% CI -0.5 to 5.9); ability to contract the pelvic floor muscles (RR 2.18, 95% CI 0.49 to 9.65); or self-reported severity of urinary incontinence (MD 1 point greater reduction in the experimental group, 95% CI -3 to 1). Sexual function did not significantly differ between groups, but very few of the women engaged in sexual activity during the study period. The educational program did, however, significantly increase women's knowledge related to the location, functions and dysfunctions of the pelvic floor muscles, and treatment options.

CONCLUSION

Education and teaching women to perform 'the Knack' had no significant effect on voluntary contraction of the pelvic floor muscles, urinary incontinence or sexual function, but it promoted women's knowledge about the pelvic floor.

TRIAL REGISTRATION

Brazilian Registry of Clinical Trials, RBR-95sxqv. [de Andrade RL, Bø K, Antonio FI, Driusso P, Mateus-Vasconcelos ECL, Ramos S, Julio MP, Ferreira CHJ (2018) An education program about pelvic floor muscles improved women's knowledge but not pelvic floor muscle function, urinary incontinence or sexual function: a randomised trial. Journal of Physiotherapy 64: 91-96].

Correlation between electromyography and perineometry in evaluating pelvic floor muscle function in nulligravidas: A cross-sectional study

OBJECTIVE

To correlate the results of electromyography and perineometry in the assessment of PFM function in nulligravidas.

METHODS

The cross-sectional observational study was approved by the internal review board of the Instituto de Medicina Integral Prof. Fernando Figueira (IMIP) and was conducted in the Instituto Paraibano de Pesquisa Professor Joaquim Amorim Neto (IPESQ). Thirty-eight nulligravidas aged 18-39 years of age, who had already initiated their sexual life, participated in the study. Exclusion criteria consisted of the presence of genital prolapse, a history of pelvic or urogenital surgery and the presence of neurological disease producing muscle disorders. For the evaluation procedure, the women were submitted to a clinical evaluation of the pelvic floor muscles followed by electromyography. Perineometry was performed 72 h later. Prior to electromyography and perineometry, the women were given standardized training with electromyographic biofeedback to teach them to contract only their pelvic floor muscles.

RESULTS

A highly positive, statistically significant correlation (r = 0.968; P < 0.001) was found between the electromyographic and perineometric findings.

CONCLUSIONS

A strong correlation was found between perineometric and electromyographic findings of pelvic floor muscle function.

A manometry classification to assess pelvic floor muscle function in women

OBJECTIVE

To develop a classification scale for manometry of pelvic floor muscles (PFM) in Brazilian women, according to the modified Oxford scale.

METHODS

A cross sectional study, with 288 women enrolled in the Maternity, Natal, Brazil. Manometry and PFM strength data were collected and classified according to the modified Oxford scale. A simple linear regression was performed to determine the classification scale of manometry using the modified Oxford scale as the explanatory variable and the arithmetic mean of the manometry measurements as the response variable.

RESULTS

The average age was 52.80 (±8.78; CI: 51.67-53.93) years. Manometry showed an average of 35.1 (±22.7; CI: 32.1-38.0) cmH2O and most women (29.7%) scored grade 3 on the modified Oxford scale. According to the proposed scale, values between 7.5 to 14.5 cmH2O correspond to very weak pressure; 14.6 to 26.5 cmH2O represent weak pressure; 26.6 to 41.5 cmH2O represent moderate pressure; 41.6 to 60.5 cmH2O represent good pressure, and values above 60.6 cmH2O correspond to strong pressure.

CONCLUSION

Manometry values were rated on a five-point scale. It is possible to rank the pressure levels performed by voluntary contraction of PFM with this new scale.

Comparing a novel hand held device (Peritron+) to standard urodynamics in measuring intravesical pressure

AIMS

Peritron+ is a new handheld device, which can be attached to a urethral catheter to measure intravesical pressures (Pves). The goal of this study was to assess if Pves recorded by standard urodynamics (UDs) are comparable to those recorded by the Peritron+.

METHODS

Patients with voiding dysfunction and an indication for UD underwent measurement of Pves with nonvideo UD and Peritron+. Pves were recorded at volumes of 50, 100, and 200 mL for the supine and sitting positions. A failure of the Peritron+ was considered to be a discrepancy of Pves values >3 cmH₂ O between Peritron+ and UD recordings. Two-way ANOVA was used to assess for statistical significance. P-values < 0.05 were considered significant.

RESULTS

Ten female patients, mean age 51 years old, were enrolled in the study. The difference in Pves measurements between Peritron+ and UD were ≤3 cmH₂ O at all bladder volumes measured in a supine and sitting positions. There were no adverse events and there were no malfunctions of the Peritron+ device during the study.

CONCLUSIONS

Peritron+ handheld device accurately assessed Pves at different intravesical volumes when compared to UD measurements. The Peritron+ is a simple and safe device, which can be used in the office by a clinician and at home by a patient to monitor Pves and help to select patients who may require standard UD re-evaluation. This will be a valuable tool in managing patients with neurogenic and nonneurogenic bladders who are at a risk of upper urinary tract deterioration.

Correlation between maximum voluntary contraction and endurance measured by digital palpation and manometry: An observational study

Introduction:

Digital palpation and manometry are methods that can provide information regarding maximum voluntary contraction (MVC) and endurance of the pelvic floor muscles (PFM), and a strong correlation between these variables can be expected.

Objective:

To investigate the correlation between MVC and endurance, measured by digital palpation and manometry.

Method:

Forty-two women, with mean age of 58.1 years (±10.2), and predominant symptoms of stress urinary incontinence (SUI), were included. Examination was firstly conducted by digital palpation and subsequently using a Peritron manometer. MVC was measured using a 0-5 score, based on the Oxford Grading Scale. Endurance was assessed based on the PERFECT scheme.

Results:

We found a significant positive correlation between the MVC measured by digital palpation and the peak manometric pressure (r=0.579, p<0.001), and between the measurements of the endurance by Peritron manometer and the PERFECT assessment scheme (r=0.559, P<0.001).

Conclusion:

Our results revealed a positive and significant correlation between the capacity and maintenance of PFM contraction using digital and manometer evaluations in women with predominant symptoms of SUI.

Comparison of the efficacy of perineal and intravaginal biofeedback assisted pelvic floor muscle exercises in women with urodynamic stress urinary incontinence

OBJECTIVE

To assess the effectiveness of intravaginal pressure biofeedback (P-BF) and perineal electromyographic biofeedback (EMG-BF) assisted pelvic floor muscle (PFM) exercises in women with stress urinary incontinence (SUI).

MATERIAL AND METHODS

Fifty-three women with SUI were randomized into three groups as follows: the Group 1 received PFM home exercise program alone (n:18); the Group 2 received PFM home exercise program plus intravaginal P-BF assisted PFM exercise program (n:17); and the Group 3 received PFM home exercise program plus perineal EMG-BF assisted PFM exercise program (n:18). Subjects were also assessed with the 1-h pad test (severity of incontinence), perineometer (PFM strength), social activity index (SAI), IIQ7 (quality of life associated with incontinence), treatment success (cure and improvement rate) and treatment satisfaction.

RESULTS

A statistically significant improvement was found in all parameters for all groups at 4th week and 8th week compared to the baseline values. It was found that severity of incontinence, PFM strength, and SAI scores were significantly improved in both BF groups compared to the Group 1 at 8th week. Also, statistically higher cure and improvement rate and treatment satisfaction values were detected in both BF groups compared to the Group 1. There was no statistically significant difference between Group 2 and Group 3 in all parameters evaluated at the follow-up period.

CONCLUSIONS

We conclude that both the home exercises plus intravaginal P-BF and home exercises plus perineal EMG-BF are superior to home exercises in women with SUI. Intravaginal P-BF and perineal EMG-BF were similarly effective and they can be used as their alternatives.

Pelvic floor muscle strength in primiparous women according to the delivery type: cross-sectional study

OBJECTIVES

to compare the pelvic floor muscle strength in primiparous women after normal birth and cesarean section, related to the socio-demographic characteristics, nutritional status, dyspareunia, urinary incontinence, perineal exercise in pregnancy, perineal condition and weight of the newborn.

METHODS

this was a cross-sectional study conducted after 50 - 70 postpartum days, with 24 primiparous women who underwent cesarean delivery and 72 who had a normal birth. The 9301 PeritronTM was used for analysis of muscle strength. The mean muscle strength was compared between the groups by two-way analysis of variance.

RESULTS

the pelvic floor muscle strength was 24.0 cmH2O (±16.2) and 25.4 cmH2O (±14.7) in postpartum primiparous women after normal birth and cesarean section, respectively, with no significant difference. The muscular strength was greater in postpartum women with ≥ 12 years of study (42.0 ±26.3 versus 14.6 ±7.7 cmH2O; p= 0.036) and in those who performed perineal exercises (42.6±25.4 11.8±4.9 vs. cmH2O; p = 0.010), compared to caesarean. There was no difference in muscle strength according to delivery type regarding nutritional status, dyspareunia, urinary incontinence, perineal condition or newborn weight.

CONCLUSION

pelvic floor muscle strength does not differ between primiparous women based on the type of delivery. Postpartum women with normal births, with higher education who performed perineal exercise during pregnancy showed greater muscle strength.

OBJETIVOS

comparar a força muscular do assoalho pélvico em primíparas no pós-parto normal e cesariana, relacionando-a às características sociodemográficas, estado nutricional, incontinência urinária, dispareunia, exercício perineal na gestação, condição perineal e peso do recém-nascido.

MÉTODO

estudo transversal realizado entre 50 e 70 dias de pós-parto, com 24 primíparas submetidas à cesariana e 72 ao parto normal. Utilizou-se PeritronTM 9301 para análise da força muscular. Comparou-se as médias da força muscular entre os grupos pela Análise de Variância a dois fatores.

RESULTADOS

a força muscular do assoalho pélvico foi de 24,0 cmH2O(±16,2) e 25,4 cmH2O(±14,7) em primíparas pós-parto normal e cesariana, respectivamente, sem diferença significativa. A força muscular foi maior nas mulheres de pós-parto normal com ≥12 anos de estudo (42,0±26,3 versus 14,6±7,7 cmH2O; p=0,036) e que realizaram exercício perineal (42,6±25,4 versus 11,8±4,9 cmH2O; p=0,010), comparadas às de cesariana. Não houve diferença na força muscular segundo o tipo de parto quanto ao estado nutricional, incontinência urinária, dispareunia, condição perineal e peso do recém-nascido.

CONCLUSÃO

a força muscular do assoalho pélvico não difere entre primíparas quanto ao tipo de parto. Mulheres pós-parto normal com maior escolaridade e que realizaram exercício perineal na gestação, tem maior força muscular.

OBJETIVOS

comparar la fuerza muscular del suelo pélvico en primíparas en el posparto normal y cesárea, relacionándola a las características sociodemográficas, estado nutricional, incontinencia urinaria, coito doloroso, ejercicio perineal en la gestación, condición perineal y peso del recién nacido.

MÉTODO

estudio transversal realizado entre 50 y 70 días de posparto, con 24 primíparas sometidas a cesárea y 72 a parto normal. Se utilizó PeritronTM 9301 para analizar la fuerza muscular. Se compararon los promedios de la fuerza muscular entre los grupos por medio del Análisis de Variancia de dos factores.

RESULTADOS

la fuerza muscular del suelo pélvico fue de 24,0 cmH2O(±16,2) y 25,4 cmH2O(±14,7) en primíparas posparto normal y cesárea, respectivamente, sin diferencia significativa. La fuerza muscular fue mayor en las mujeres de posparto normal con ≥12 años de estudio (42,0±26,3 versus 14,6±7,7 cmH2O; p=0,036) y que realizaron ejercicio perineal (42,6±25,4 versus 11,8±4,9 cmH2O; p=0,010), comparadas con las de cesárea. No hubo diferencia en la fuerza muscular según el tipo de parto en lo que se refiere al estado nutricional, incontinencia urinaria, coito doloroso, condición perineal y peso del recién nacido.

CONCLUSIÓN

la fuerza muscular del suelo pélvico no difiere entre las primíparas en lo que se refiere al tipo de parto. Las mujeres posparto normal con mayor escolaridad y que realizaron ejercicio perineal en la gestación, tienen mayor fuerza muscular.

Supplementary home biofeedback improves quality of life in younger patients with fecal incontinence

BACKGROUND

Biofeedback is a scarce, resource-intensive clinical therapy. It is used to treat patients with bowel problems, including fecal incontinence (FI), who fail to respond to simple dietary advice, medication, or pelvic floor exercises. Populations are aging and younger cohorts use technology in managing their health, affording FI self-management opportunities.

AIM

Does supplementary home-based biofeedback improve FI and quality of life (QOL)?

METHODS

Seventy-five incontinent participants (12 male), mean age 61.1 years, consented to participate. Thirty-nine patients (5 male) were randomized to the standard biofeedback protocol plus daily home use of a Peritron perineometer (intervention) and 36 patients (7 male) to the standard biofeedback protocol (control). On completion of the study each perineometer exercise session was rated for technique by 2 raters, blinded to the patient and order of sessions.

RESULTS

With the exception of Fecal Incontinence Quality of Life Scale lifestyle improvement (intervention--9.1% vs. controls--0.3%, P=0.026) and embarrassment improvement (intervention--50.0% vs. controls--18.3%, P=0.026), supplementary home biofeedback did not result in greater clinical improvement for the intervention group as a whole. However, on stratification around the mean age, continence and QOL of younger people in the intervention group were significantly better than those of their control counterparts. Graphed perineometer sessions demonstrated high compliance and improvement in exercise technique. Perineometers provided reassurance, motivation, and an exercise reminder ensuring that confidence was achieved quickly.

CONCLUSIONS

Home biofeedback was acceptable and well tolerated by all users. Younger participants significantly benefited from using this technology.

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

OBJECTIVE:

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

METHOD:

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

RESULTS:

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

CONCLUSIONS:

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

Efeitos da cirurgia bariátrica na função do assoalho pélvico

RACIONAL: A incontinência urinária é bem documentada como comorbidade da obesidade. Estudos demonstram resolução ou atenuação da incontinência após a perda de peso. Porém, os mecanismos pelos quais isso ocorre ainda não estão claros. OBJETIVO: Avaliar os efeitos da cirurgia bariátrica na função do assoalho pélvico em mulheres. MÉTODOS: Foram avaliadas 30 mulheres que estavam em lista de espera para realizar a operação. Foi verificada a prevalência de incontinência urinária no pré e no pós-operatório e seu impacto na qualidade de vida através do King's Health Questionnaire. A qualidade da contração muscular do assoalho pélvico foi avaliada através da Escala de Oxford Modificada e da perineometria. RESULTADOS: Vinte e quatro mulheres finalizaram o estudo. O índice de massa corporal passou de 46,96±5,77 kg/m2 no pré-operatório para 29,97±3,48 kg/m2 no pós-operatório, e a perda percentual do excesso de peso média foi de 70,77±13,26%. A prevalência de incontinência urinária passou de 70,8% no pré-operatório para 20,8% no pós-operatório. Após um ano da cirurgia bariátrica, houve redução do impacto da incontinência urinária na qualidade de vida em sete dos nove domínios avaliados no questionário. A mediana da Escala de Oxford Modificada aumentou de três no pré-operatório para quatro no pós-operatório. A perineometria apresentou aumento significativo na média das três contrações solicitadas, passou de 21,32±12,80 sauers para 28,83±16,17 sauers na comparação pré e pós-operatória. O pico de contração também aumentou significativamente no pós-operatório em relação ao pré-operatório, passou de 25,29±14,49 sauers para 30,92±16,20 sauers. CONCLUSÃO: A perda massiva de peso através da cirurgia bariátrica repercute positivamente na função do assoalho pélvico e na qualidade de vida das mulheres com obesidade mórbida.