Recognition and management of nonrelaxing pelvic floor dysfunction

Younger Age Is Associated With Pelvic Floor Muscle Dysfunction in Women With Urinary Symptoms

IMPORTANCE

Recent articles have highlighted the existence of pelvic floor myofascial dysfunction in women presenting with pelvic floor disorders.

OBJECTIVE

The aim of the study was to evaluate whether younger age is associated with pelvic floor muscle dysfunction in women with lower urinary tract symptoms, including urinary urgency, frequency, nocturia, and urinary incontinence.

STUDY DESIGN

This retrospective cohort study included women seeking an initial outpatient urogynecology evaluation for urinary symptoms from 8/2018 to 2/2022. The primary outcome was the presence of pelvic floor muscle dysfunction, defined as a diagnosis of levator myalgia/spasm. Multivariable logistic regression was used to evaluate the association.

RESULTS

Four hundred twenty-one women with lower urinary tract symptoms were included, and 115 (27.3%) were diagnosed with pelvic floor muscle dysfunction. Women with pelvic floor dysfunction were 13 years younger, less likely to report any incontinence (60% vs 71.9%, P = 0.026) and urgency incontinence (8.7% vs 17.3%, P = 0.04). There was no difference in reported urgency, frequency, or nocturia. Women with pelvic floor dysfunction were more likely to report dysuria (19.1% vs 9.5%, P = 0.012), dyspareunia (39% vs 7.5%, P < 0.001), vulvodynia (11.3% vs 2.3%, P < 0.001), and pelvic pain (25.2% vs 7.2%, P < 0.001). The odds of pelvic floor muscle dysfunction in women <40 years old was 2.34 times greater than women ≥40 years old, after adjusting for other factors (adjusted odds ratio 2.341, 95% confidence interval [1.102, 4.972]).

CONCLUSIONS

Younger women with lower urinary tract symptoms were significantly more likely to have pelvic floor muscle dysfunction compared to older women with similar symptoms, even after controlling for other associated characteristics.

Videourodynamics - role, benefits and optimal practice

Videourodynamics (VUDS) is an advanced diagnostic procedure that simultaneously combines functional and anatomical evaluation of the lower urinary tract. The goal of this synchronous assessment is to promote accurate diagnosis of the aetiology responsible for patient symptoms, improving therapeutic decision-making. Overall, high-quality VUDS is advocated when other tests such as traditional urodynamics might not provide sufficient data to guide therapy, particularly in patients with complex, persistent or recurrent dysfunctions of the lower urinary tract. Additionally, VUDS is often crucial in the follow-up monitoring of many patients with these dysfunctions. A VUDS study is frequently considered a gold standard in patients with neurogenic lower urinary tract dysfunction, female bladder outlet obstruction or congenital anomalies of the lower urinary tract. Nevertheless, this specialized test should be limited to patients in whom VUDS data add value. Particularly, reliable studies comparing the effect of diagnosis with and without imaging on management outcomes are lacking, and no standardized procedures for undertaking VUDS are available. Additionally, patients should be carefully selected for VUDS evaluation, considering the increased cost and risks associated with radiological imaging. In routine practice, clinicians should balance the additional value of synchronous imaging and the enhanced diagnostic precision of VUDS against the limitations of this approach, which mainly include an uncertain effect of VUDS on final treatment outcomes.

Comparison of Pelvic Floor Dysfunction in Women with Ulcerative Colitis and Healthy Population

Background

The possibility of pelvic floor dysfunction (PFD) occurrence seems to be higher in patients with inflammatory bowel disease (IBD) due to the presence of functional gastrointestinal disorders in these patients. Hence, this study aimed to evaluate the association of ulcerative colitis (UC) in women with PFD and its comparison with the healthy (without IBD) population.

Methods

The present study was conducted on 150 women with UC and 150 without-IBD individuals. Pelvic Floor Distress Inventory (PFDI-20) was used to evaluate the pelvic floor function.

Results

The results of this study revealed that UC had a significant role in increasing not only the PFD score (Beta=3.04; P<0.001) but also the score of each sub-scale of Pelvic Organ Prolapse Distress Inventory (POPDI) (Beta=6.61; P<0.001), Colo-Rectal-Anal Distress Inventory (CRADI) (Beta=9.37; P<0.001), and Urinary Distress Inventory (UDI) (Beta=5.56; P=0.015). In addition, aging, increased body mass index (BMI) and menopause had significant role in increasing POPDI, UDI, and PFDI scores, respectively (P<0.05).

Conclusion

The percentage of PFD in women with UC was significantly higher than its percentage in women without IBD. This dysfunction was more visible in the two sub-scales of POPDI and CRADI. In addition to having UC, aging, BMI, and menopause played a significant role in increasing PFD.

A Comparison of the Effect of Kegel Exercises and Conventional Therapy versus Conventional Therapy Alone in the Treatment of Functional Constipation in Children: A Randomized Clinical Trial

Background

There have been few studies on the effect of Kegel exercises on the treatment of functional constipation in children. Hence, the present study investigated the add-on role of Kegel exercises in children with functional constipation.

Methods

This clinical trial was conducted on children with functional constipation, according to Rome IV, who were referred to the pediatric department of Imam Reza Clinic (Shiraz, Iran) in 2022. The sample consisted of 64 children who were randomly assigned to either the intervention or the control groups. In the control group, a pediatrician administered conventional therapy, including diet training, defecation training, and polyethylene glycol (PEG) syrup (0.7 g/Kg daily). In the treatment group, in addition to conventional therapy, a pediatrician taught Kegel exercises to the child both verbally and in writing in the presence of their parents. To investigate the effectiveness of the intervention, frequency of defecation, defecation time, assistance used for defecation, incomplete emptying, unsuccessful defecation, abdominal pain, and painful defecation were selected as the outcomes. Independent sample t test was used for continuous variables. Categorical variables were reported as frequency and percentages. To examine the difference in categorical outcome variables, Wilcoxon (pre and post), Chi square, and Fisher exact tests were used. Data were analyzed using SPSS software version 21. P<0.05 were considered statistically significant.

Results

Twenty-seven (88.4%) patients in the Kegel exercise group reported a defecation time of less than 5 min, while only 12 (37.5%) patients in the control group reached this time, and this difference was statistically significant (P=0.001). Moreover, patients in the treatment group showed significant improvements in terms of incomplete emptying of stool, unsuccessful defecation, abdominal pain, and painless defecation (P=0.001, P=0.001, P=0.001, P=0.037, respectively). After intervention, the use of laxatives, digits, or enemas to assist defecation was not significantly different between the groups (P=0.659).

Conclusion

Kegel exercise was an effective adjunctive treatment for pediatric functional constipation.Trial Registration Number: IRCT20230424057984N1.

A Treatment Algorithm for High-Tone Pelvic Floor Dysfunction

OBJECTIVE

To develop evidence- and consensus-based clinical practice guidelines for management of high-tone pelvic floor dysfunction (HTPFD). High-tone pelvic floor dysfunction is a neuromuscular disorder of the pelvic floor characterized by non-relaxing pelvic floor muscles, resulting in lower urinary tract and defecatory symptoms, sexual dysfunction, and pelvic pain. Despite affecting 80% of women with chronic pelvic pain, there are no uniformly accepted guidelines to direct the management of these patients.

METHODS

A Delphi method of consensus development was used, comprising three survey rounds administered anonymously via web-based platform (Qualtrics XM) to national experts in the field of HTPFD recruited through targeted invitation between September and December 2021. Eleven experts participated with backgrounds in urology, urogynecology, minimally invasive gynecology, and pelvic floor physical therapy (PFPT) participated. Panelists were asked to rate their agreement with rated evidence-based statements regarding HTPFD treatment. Statements reaching consensus were used to generate a consensus treatment algorithm.

RESULTS

A total of 31 statements were reviewed by group members at the first Delphi round with 10 statements reaching consensus. 28 statements were reposed in the second round with 17 reaching consensus. The putative algorithm met clinical consensus in the third round. There was universal agreement for PFPT as first-line treatment for HTPFD. If satisfactory symptom improvement is reached with PFPT, the patient can be discharged with a home exercise program. If no improvement after PFPT, second-line options include trigger or tender point injections, vaginal muscle relaxants, and cognitive behavioral therapy, all of which can also be used in conjunction with PFPT. Onabotulinumtoxin A injections should be used as third line with symptom assessment after 2-4 weeks. There was universal agreement that sacral neuromodulation is fourth-line intervention. The largest identified barrier to care for these patients is access to PFPT. For patients who cannot access PFPT, experts recommend at-home, guided pelvic floor relaxation, self-massage with vaginal wands, and virtual PFPT visits.

CONCLUSION

A stepwise approach to the treatment of HTPFD is recommended, with patients often necessitating multiple lines of treatment either sequentially or in conjunction. However, PFPT should be offered first line.

Effects of Pelvic Floor Muscle Physiotherapy on Urinary, Bowel, and Sexual Functions in Women with Deep Infiltrating Endometriosis: A Randomized Controlled Trial

Background and Objectives: Endometriosis is a chronic and recurrent disease defined as the presence and proliferation of endometrial glands and stroma outside the uterine cavity. It affects up to 6-10% of women of reproductive age and can be classified into superficial, ovarian, and deep infiltrating endometriosis (DIE). Deep infiltrating endometriosis can be associated with pain symptoms and pelvic floor muscle hypertone. Moreover, it may be responsible of bowel, urinary, and sexual dysfunctions with impairment of women's quality of life. Few studies have investigated the role of physiotherapy in women with DIE. Here, we aimed first to evaluate the effects of pelvic floor physiotherapy (PFP) on urinary, bowel, and sexual functions. Secondly, we aimed to evaluate the effects of ultrasound visual feedback during PFP on pelvic floor and subjective modifications in the frequency of sexual intercourse. Materials and Methods: This randomized controlled trial was conducted between June 2018 and December 2019 at our tertiary center. Nulliparous women with DIE and superficial dyspareunia were enrolled. At first examination, levator hiatal area (LHA) assessed with 3D/4D transperineal ultrasound, pain symptoms, urinary, bowel, and sexual functions were evaluated. Then, women were randomly assigned to no intervention (control group) or treatment with five individual sessions of PFP (experimental group), and after four months women underwent a second examination. Urinary, bowel, and sexual functions were assessed with validated questionnaires at first and second examinations. In particular, the Bristol Female Lower Urinary Tract Symptoms questionnaire was used to evaluate urinary symptoms, the Knowles-Eccersley-Scott-Symptom questionnaire to assess the presence of constipation, and the Female Sexual Function Index to investigate sexual function. Study outcomes were the comparisons among groups in terms of differences in actual changes in median of questionnaire scores between first and second examinations. Results: Thirty women (17 in the experimental group and 13 in the control group) completed the study. No significant differences were found between the two groups regarding urinary, bowel, and sexual functions, although women in the experimental group showed a tendency towards an improvement in constipation symptoms. Conclusion: In women with DIE, PFP does not appear to affect urinary, bowel, and sexual functions. Therefore, despite the improvement in superficial dyspareunia, chronic pelvic pain, and PFM relaxation with high treatment satisfaction, women should be informed about the unclear impact of PFP on urinary, bowel, and sexual functions. Larger studies are necessary to further investigate the impact of PFP on these functions.

A preoperative predictive model for stage IV endometriosis

This was a retrospective study that evaluated a total of 280 patients who underwent surgery for complete removal of endometriosis to develop and validate the predictive model for stage IV endometriosis. The differences between stage I-III and stage IV endometriosis were performed by logistic regression. A model for the prediction of stage IV endometriosis was constructed, which was subsequently validated. The independent variables were visual analogue scale (VAS)≥4 [3.855, 95% confidence interval (CI): 1.675-8.871, p = 0.002], painful nodularity on uterosacral ligaments (13.954, 95% CI: 1.658-117.423, p = 0.015), and bilateral endometriosis (5.933, 95% CI: 1.931-18.225, p = 0.002). The AUC of the model was 0.777, with a sensitivity of 71.9% and specificity of 76.3% for stage IV endometriosis. Therefore, a complete collection of patient information prior to surgery, asking about pain and VAS scores, careful completion of pelvic examinations, and application of imaging techniques are conducive to better diagnosis and prediction of advanced endometriosis.IMPACT STATEMENTWhat is already known on this subject? Endometriosis, a chronic disease causing pain and infertility, is characterised by endometrial-like tissue outside the uterine cavity, which is often treated via surgery at present. Considering the risks of surgery, it is necessary to identify patients with stage IV endometriosis through non-invasive predictive models for adequate preparation for surgery. However, there is no reliable non-invasive predictive model now, despite utilisation of patient medical history, symptoms especially pain-related ones, pelvic examinations, laboratory examinations, and images in the preoperative diagnosis of endometriosis in the clinic.What do the results of this study add? A model developed based on three simple, accessible and non-invasive indicators displays good performance in predicting stage IV endometriosis.What are the implications of these findings for clinical practice and/or further research? It is conducive to diagnosing and predicting advanced endometriosis before surgery, so as to reduce the difficulty and improve the safety of surgery.

The Persistency Index: a novel screening tool for identifying myofascial pelvic floor dysfunction in patients seeking care for lower urinary tract symptoms

BACKGROUND

Patients with myofascial pelvic floor dysfunction often present with lower urinary tract symptoms, such as urinary frequency, urgency, and bladder pressure. Often confused with other lower urinary tract disorders, this constellation of symptoms, recently termed myofascial urinary frequency syndrome, is distinct from other lower urinary tract symptoms and optimally responds to pelvic floor physical therapy. A detailed pelvic floor myofascial examination performed by a skilled provider is currently the only method to identify myofascial urinary frequency syndrome. Despite a high influence on quality of life, low awareness of this condition combined with no objective diagnostic testing leads to the frequent misdiagnosis or underdiagnosis of myofascial urinary frequency syndrome.

OBJECTIVE

This study aimed to develop a screening measure to identify patients with myofascial urinary frequency syndrome (bothersome lower urinary tract symptoms secondary to myofascial pelvic floor dysfunction) from patient-reported symptoms.

STUDY DESIGN

A population of patients with isolated myofascial urinary frequency syndrome was identified by provider diagnosis from a tertiary urology practice and verified by standardized pelvic floor myofascial examination and perineal surface pelvic floor electromyography. Least Angle Shrinkage and Selection Operator was used to identify candidate features from the Overactive Bladder Questionnaire, Female Genitourinary Pain Index, and Pelvic Floor Distress Index predictive of myofascial urinary frequency syndrome in a pooled population also containing subjects with overactive bladder (n=42), interstitial cystitis/bladder pain syndrome (n=51), and asymptomatic controls (n=54) (derivation cohort). A simple, summated score of the most discriminatory questions using the original scaling of the Pelvic Floor Distress Index 5 (0-4) and Genitourinary Pain Index 5 (0-5) and modified scaling of Female Genitourinary Pain Index 2b (0-3) had an area under the curve of 0.75. As myofascial urinary frequency syndrome was more prevalent in younger subjects, the inclusion of an age penalty (3 points added if under the age of 50 years) improved the area under the curve to 0.8. This score was defined as the Persistency Index (possible score of 0-15). The Youden Index was used to identify the optimal cut point Persistency Index score for maximizing sensitivity and specificity.

RESULTS

Using a development cohort of 215 subjects, the severity (Pelvic Floor Distress Index 5) and persistent nature (Female Genitourinary Pain Index 5) of the sensation of incomplete bladder emptying and dyspareunia (Female Genitourinary Pain Index 2b) were the most discriminatory characteristics of the myofascial urinary frequency syndrome group, which were combined with age to create the Persistency Index. The Persistency Index performed well in a validation cohort of 719 patients with various lower urinary tract symptoms, including overactive bladder (n=285), interstitial cystitis/bladder pain syndrome (n=53), myofascial urinary frequency syndrome (n=111), controls (n=209), and unknown diagnoses (n=61), exhibiting an area under the curve of 0.74. A Persistency Index score ≥7 accurately identified patients with myofascial urinary frequency syndrome from an unselected population of individuals with lower urinary tract symptoms with 80% sensitivity and 61% specificity. A combination of the Persistency Index with the previously defined Bladder Pain Composite Index and Urge Incontinence Composite Index separated a population of women seeking care for lower urinary tract symptoms into groups consistent with overactive bladder, interstitial cystitis/bladder pain syndrome, and myofascial urinary frequency syndrome phenotypes with an overall diagnostic accuracy of 82%.

CONCLUSION

Our study recommends a novel screening method for patients presenting with lower urinary tract symptoms to identify patients with myofascial urinary frequency syndrome. As telemedicine becomes more common, this index provides a way of screening for myofascial urinary frequency syndrome and initiating pelvic floor physical therapy even before a confirmatory pelvic examination.

Triangulation of a Needs Assessment on High-Tone Pelvic Floor Dysfunction

IMPORTANCE

High-tone pelvic floor dysfunction is a complex condition that is challenging to manage effectively. Pelvic floor physical therapy (PFPT) is often used in the treatment and relies on a coordinated effort between the physician, patient, and physical therapist. Collaboration is crucial for therapy success, but there is limited research that includes personal perspectives from these individuals.

OBJECTIVE

The objective of this qualitative study was to gain further insight from these groups to identify areas for improvement in patient counseling and understanding of the diagnosis of high-tone pelvic floor dysfunction and the role of physical therapy.

STUDY DESIGN

The following participants were recruited: urogynecologists, pelvic floor physical therapists, and patients. Semistructured interviews were conducted exploring participant experiences with therapy and management of the condition and surrounding phenomena.

RESULTS

Participants interviewed included 5 urogynecologists, 5 pelvic floor physical therapists, and 15 patients. Similarities in key themes were identified: (1) the usefulness of pelvic models and illustrations in counseling, (2) appropriate descriptions of therapy, (3) motivating factors for patients, and (4) patient barriers to completing therapy. Several emergent themes revealed a misalignment in perspectives, including (1) patients reporting an unclear understanding of PFPT, (2) patient unawareness of the intimacy of therapy, and (3) reports of unsupportive and unempathetic physician providers.

CONCLUSIONS

There are both similarities and discrepancies in the perspectives among physicians, pelvic floor physical therapists, and patients regarding high-tone pelvic floor dysfunction and PFPT. Acknowledging these comparisons and adapting practices could facilitate patient-centered care and improve patient understanding of their diagnosis.

Approach of Chronic Pelvic Pain with Top Flat Magnetic Stimulation

Materials and Methods

Vulvar Functional Status Questionnaire (VQ) was used for the evaluation of patient's chronic pelvic pain and muscle hypertone improvements. The interstitial cystitis was assessed by the Leary-Sant symptom and problem indexes (ICSI and ICPI). In this study, the scores resulting from the sum of the two indexes were evaluated as OSS (ICSI + ICPI).

Results

Women with chronic pelvic pain and muscle hypertone showed VQ mean values significantly lower than the controls (p  <  0.005) from the second treatment up to the sixth one. In 6 patients affected by interstitial cystitis, the mean score of OSS was significantly lower than the controls (p  <  0.005) from the second treatment up to 2 months follow-up after the last treatment session. No side effects were observed.

Conclusion

Based on these results, this technology may successfully manage muscle hypertonicity condition, the chronic pelvic pain, and interstitial cystitis.

Trigger point injections followed by immediate myofascial release in the treatment of pelvic floor tension myalgia

PURPOSE

Pelvic floor physical therapy (PFPT) is first-line therapy for treatment of pelvic floor tension myalgia (PFTM). Pelvic floor trigger point injections (PFTPI) are added if symptoms are refractive to conservative therapy or if patients experience a flare. The primary objective was to determine if a session of physical therapy with myofascial release immediately following PFTPI provides improved pain relief compared to trigger point injection alone.

METHODS

This was a retrospective cohort analysis of 87 female patients with PFTM who underwent PFTPI alone or PFTPI immediately followed by PFPT. Visual analog scale (VAS) pain scores were recorded pre-treatment and 2 weeks post-treatment. The primary outcome was the change in VAS between patients who received PFTPI alone and those who received PFTPI followed by myofascial release.

RESULTS

Of the 87 patients in this study, 22 received PFTPI alone and 65 patients received PFTPI followed by PFPT. The median pre-treatment VAS score was 8 for both groups. The median post-treatment score was 6 for the PFTPI only group and 4 for the PFTPI followed by PFPT group, showing a median change in VAS score of 2 and 4, respectively (p = 0.042). Seventy-seven percent of patients in the PFTPI followed by PFPT group had a VAS score improvement of 3 or more, while 45% of patients in the PFTPI only group had a VAS score improvement greater than 3 (p = 0.008).

CONCLUSION

PFTPI immediately followed by PFPT offered more improvement in pain for patients with PFTM. This may be due to greater tolerance of myofascial release immediately following injections.

Long-term pelvic floor symptoms and urogenital prolapse after hysterectomy

BACKGROUND

The aim of this study was to describe the natural course of pelvic floor symptoms and pelvic floor anatomy for women long-term after hysterectomy.

METHODS

Women who underwent hysterectomy between 1996-2004 carried out the PFDI-20 questionnaire and POP-Q examination. We collected data on the presence and type of pelvic floor symptoms and its relation to the degree of pelvic organ prolapse (POP) per compartment (≥ stage 2).

RESULTS

We obtained data from 247 women on average sixteen years after hysterectomy, with no prolapse (n = 94), anterior prolapse (n = 76), posterior prolapse (n = 38), both anterior- and posterior prolapse (n = 20), and a prolapse involving the vaginal vault (n = 19). Of all 153 women with ≥ stage 2 prolapse, 80 (52%) experienced moderate and/or severe symptoms of the PFDI-20. Most frequently reported symptoms by women with POP were uncontrollable flatus, urinary frequency and urge incontinence. Bulging was associated with a prolapse beyond the hymen. 39% Of women without prolapse experienced bothersome pelvic floor symptoms as well. Most often these were stress incontinence, straining to pass stool and incomplete bowel emptying. Women with a history of hysterectomy for prolapse have more pelvic floor symptoms than women who underwent hysterectomy for other indications, regardless of the current presence of POP (57% versus 40%, p = 0.009).

CONCLUSION

In a group of post-hysterectomy women who did not actively seek help, 47% experienced problematic pelvic floor symptoms, independent of the presence or absence of an anatomic POP. Creating more knowledge and awareness of the impact of hysterectomy on the pelvic floor can help women in the future.

TRIAL REGISTRATION

The study was registered in the Dutch Trial Registry; Trial NL5967 (NTR6333, 2017-02-01) and approved by the Medical Research Ethics Committee of the Máxima Medical Center (NL60096.015.16, 2017-02-24).

Prevalence of pelvic floor dysfunction among women with polycystic ovarian syndrome: a case-control study

Background

Pelvic floor dysfunction (PFD) is a wide term, involving a large array of conditions that negatively impact many women around the world. Polycystic ovarian syndrome (PCOS) is another disorder with long-term serious consequences. Being a disease of hormonal imbalances, PCOS may possibly affect the function of the pelvic floor muscles leading to PFD. Thus, the current study aimed to explore the prevalence of PFD among women with PCOS.

Methods

This is an observational, case-control study. A total of 368 women, aged from 20 to 35 years, with a body mass index (BMI) range of 20 to 30 kg/m2 recruited from Kasr El-Ainy teaching hospital shared in the study. They were classified into case group (PCOS patients; n=184) and control group (non-PCOS participants; n=184), with matched age and BMI for comparison. All case-group women were diagnosed with PCOS, based on Rotterdam diagnostic criteria, while the control group women had regular menstrual cycles. Pelvic Floor Distress Inventory-20 (PFDI-20) was used to identify PFD in the tested groups. The demographic features of the two groups were compared using the unpaired t test, while the chi-squared test was used to determine the prevalence of PFD among women with PCOS. Also, multiple linear regression was done to asses other PFD risk factors in both groups.

Results

Out of 380 women, 368 were involved in the study with mean ± standard deviation (SD) for the age and BMI of 28.48±4.87 years and 25.9±5.8 kg/m2, respectively, for the control group, and 28.76±5.33 years and 27±6.1 kg/m2, respectively, for the PCOS group, without a significant difference in either of the age and BMI between groups (P > 0.05). The frequency distribution of women with and without PFD in both groups revealed that the PCOS group included 68 (37%) women with PFD. While the control group included 12 (6%) women with PFD, with a significant difference (P=0. 03) in the prevalence between both groups. Also, multiple regression revealed that PCOS condition significantly affected PFD.

Conclusion

PFD was prevalent among women with PCOS, compared to the control group, suggesting a possible link between both conditions.

Transurethral Incision of the Bladder Neck with or without Additional Procedure Resumes Spontaneous Voiding in Female Voiding Dysfunction-A Long-Term Retrospective Follow-Up

AIM

This study evaluated the long-term effectiveness of transurethral incision of the bladder neck (TUI-BN) with or without an additional procedure for female voiding dysfunction.

METHODS

Women with voiding difficulty who underwent TUI-BN in the last 12 years were included. All patients underwent a videourodynamics study (VUDS) at baseline and after TUI-BN. A successful outcome was defined as having a voiding efficiency (VE) increase by ≥50% after treatment. Patients with insufficient improvement were chosen for repeated TUI-BN, urethral onabotulinumtoxinA injection, or transurethral external sphincter incision (TUI-ES). The current voiding status, surgical complications, and additional surgeries were evaluated.

RESULTS

A total of 102 women with VUDS evidence of a narrow bladder neck during voiding were enrolled. The long-term success rate of the first TUI-BN was 29.4% (30/102) and increased to 66.7% (34/51) after combining TUI-BN and an additional procedure. The overall long-term success rates were 74.6% in women with detrusor underactivity (DU), 52.0% in detrusor overactivity and low contractility, 50.0% in bladder neck obstruction, 20.0% in hypersensitive bladder, and 75% in stable bladder (p = 0.022). Patients with a lower maximum flow rate (Qmax), (p = 0.002), lower voided volume (p < 0.001), lower corrected Qmax (p < 0.001), lower ladder contractility index (p = 0.003), lower voiding efficiency (p < 0.001), but larger post-void residual volume (p < 0.001) had a satisfactory surgical outcome. Spontaneous voiding was achieved in 66 (64.7%) patients, de novo urinary incontinence in 21 (20.6%), and vesicovaginal fistula in 4 (3.9%), all were repaired.

CONCLUSIONS

TUI-BN alone or in combination with an additional procedure was safe, effective, and durable in patients with DU to resume spontaneous voiding.

Pelvic Pain in Transgender People Using Testosterone Therapy

Purpose: This descriptive study aimed to assess the characteristics of pelvic pain and explore predictive factors for pelvic pain in transgender (trans) individuals using testosterone therapy. Methods: An online cross-sectional survey was open between August 28, 2020, and December 31, 2020, to trans people presumed female at birth, using testosterone for gender affirmation, living in Australia, and >16 years of age. The survey explored characteristics of pelvic pain following initiation of testosterone therapy, type and length of testosterone therapy, menstruation history, and relevant sexual, gynecological, and mental health experiences. Logistic regression was applied to estimate the effect size of possible factors contributing to pain after starting testosterone. Results: Among 486 participants (median age = 27 years), 351 (72.42%) reported experiencing pelvic pain following initiation of testosterone therapy, described most commonly as in the suprapubic region and as "cramping." Median duration of testosterone therapy was 32 months. Persistent menstruation, current or previous history of post-traumatic stress disorder, and experiences of pain with orgasm were associated with higher odds of pelvic pain after testosterone therapy. No association was observed with genital dryness, intrauterine device use, previous pregnancy, penetrative sexual activities, touching external genitalia, or known diagnoses of endometriosis, vulvodynia, vaginismus, depression, anxiety, or obesity. Conclusions: Pelvic pain is frequently reported in trans people following initiation of testosterone therapy. Given the association with persistent menstruation and orgasm, as well as the known androgen sensitivity of the pelvic floor musculature, further research into pelvic floor muscle dysfunction as a contributor is warranted.

The influence of the menstrual cup on female pelvic floor muscles variables: a prospective case series

The aim was to assess and report the effects of menstrual cup on pelvic floor muscles (PFM) function and tone, as well as check the acceptability after a period of three menstrual cycles in healthy young women. The data collected in assessments and reassessments included the International Consultation on Incontinence Questionnaire - Vaginal Symptoms (ICIQ-VS) questionnaire, evaluation of PFM function through PERFECT Scheme, PFM muscle tone, and PFM manometry (Peritron 9300®). A diary regarding the overall colletor acceptability and satisfaction was collected. Ten healthy young women completed the study. There was an improvement in the mean values of maximal voluntary contraction (MVC) (p = 0.032), a decrease in the vaginal resting pressure (VRP) (p = 0.05), and an increase in the number of repetitions of sustained muscle contractions (p = 0.042). Seven women reported some discomfort while using the vaginal cup only in the first cycle while three revealed discomfort during the whole experiment. This study provides preliminary case-based evidence that the use of the vaginal cup for a period of three menstrual cycles changes the VRP, MVC, and PFM tone, as well as improves the repetitions of PFM assessed by digital palpation. Moreover, the women reported the use of vaginal cup as a positive experience.

Overactive Bladder Patients With and Without Urgency Incontinence: A Spectrum of One Condition or Different Phenotypes?

IMPORTANCE

The importance of this study is to explore potential differences in pathophysiologies of OAB-wet and OAB-dry.

OBJECTIVES

The aim of this study was to define fundamental and unique presenting features of patients exhibiting storage lower urinary tract symptoms (LUTS) with urgency incontinence (OAB-wet) and patients without urgency incontinence (OAB-dry).

STUDY DESIGN

This was a secondary analysis of cross-sectional data from the National Institutes of Health/National Institute of Diabetes and Digestive and Kidney Diseases-sponsored Symptoms of Lower Urinary Tract Dysfunction Research Network. Demographic, physical examination, and questionnaire responses were analyzed for women seeking care for LUTS at 6 U.S. centers. Differences between OAB-wet and OAB-dry patients were compared using the Fisher exact test and Mann-Whitney U test. Differences in questionnaire data were assessed using a Benjamini-Hochberg false discovery rate correction.

RESULTS

Fifty-six, 84, and 67 women were included in the OAB-dry, wet, and control cohorts, respectively. There was no difference in demographic and physical examination characteristics of the 2 groups. OAB-wet patients reported more urgency incontinence symptoms (LUTS 16a, P < 0.001). OAB-dry reported more bladder pain, feeling of incomplete bladder emptying (LUTS 4, P < 0.001), and a need to strain to urinate (AUA-SI 7, P = 0.003). Sensation of incomplete emptying and straining with urination did not correlate with elevated postvoid residual volumes. Although degrees of symptomatic bother were similar, bother in OAB-dry patients was most closely related to pelvic floor tenderness severity, whereas bother in OAB-wet patients was most related to urgency severity.

CONCLUSIONS

Women with OAB-dry have distinct presenting features of straining with urination, bladder pain, and a feeling of incomplete emptying. These suggest a unique pathophysiology driving OAB-dry symptoms, which we hypothesize is pelvic floor myofascial dysfunction.

Three-Dimensional Ultrasound Evaluation of Pelvic Floor Muscle Contraction in Women Affected by Deep Infiltrating Endometriosis: Application of a Quick Contraction Scale

OBJECTIVES

Using transperineal 3D/4D ultrasound, we evaluated the prevalence of the various categories of a 4-point pelvic contraction scale among women affected by ovarian endometriosis (OE), deep infiltrating endometriosis (DIE), and healthy controls.

METHODS

This prospective study was conducted on nulliparous women scheduled for surgery to remove endometriosis, and nulliparous healthy volunteers who did not show any clinical or sonographic signs of endometriosis, who served as controls. Patients were subjected to 3D/4D transperineal ultrasound obtaining measurements of the antero-posterior diameter (APD), both at rest and during maximal pelvic floor muscle (PFM) contraction (PFMC). The difference of APD from rest to maximal PFMC was then calculated as percent change from baseline (ΔAPD) and patients were thus categorized using the 4-point pelvic contraction scale.

RESULTS

One hundred sixty-four patients were considered for the study. Mean difference in APD between relaxed state and maximal PFMC was 23.3 ± 7.9% (range 2.4-40.0) in controls, 20.5 ± 9.0% (range 0.0-37.3) in patients with OE, and 14.6 ± 10.4% (range 0.0-37.1) in patients with DIE (F-test = 19.5, P-value < .001). A significant negative correlation was found between the contraction scale and dyspareunia (rs = -0.17, P = .032), and it appeared to be stronger among patients with DIE (rs = -0.20, P = .076).

CONCLUSIONS

PFM function in endometriotic patients could be assessed reliably through this 4-point scale. The rapid identification of women suffering from PFM dysfunction, along with deep dyspareunia, could enable gynecologists to offer them additional therapies, such as PFM rehabilitation.

Maximizing Recovery in the Postpartum Period: A Timeline for Rehabilitation from Pregnancy through Return to Sport

Increased participation and duration in sport has become commonplace for women with their involvement often including the transition to motherhood in the peak of their athletic careers. No rehabilitation models that assess the full spectrum of pregnancy to postpartum have been developed for women to assist in safe exercise progressions that reduce postpartum symptoms and optimize performance during the return to full activity. Referral to physical therapy both in the prenatal and postnatal period is currently not considered standard of care to reduce prevalence of symptoms such as musculoskeletal pain, diastasis recti, and pelvic floor dysfunction which may ultimately interfere with physical activity and performance. This commentary presents a timeline and suggested progression for exercise participation to improve awareness of the musculoskeletal changes that occur after labor and delivery. The concepts covered may increase the understanding of how to manage pregnant and postpartum athletes from a musculoskeletal perspective and serve as a starting point for establishing appropriate and guided rehabilitation for safe return to sport after childbirth.

Defining normal pouch function in patients with ileal pouch-anal anastomosis: a pilot study

BACKGROUND

Most patients experience good functional outcomes following ileal pouch-anal anastomosis (IPAA) for ulcerative colitis.

AIM

We aimed to determine if asymptomatic patients with an IPAA had findings consistent with normal defecation on standard objective anorectal tests.

METHODS

Patients 18-65 years old with IPAA and self-reported healthy pouch function were recruited. Patients with chronic pouchitis, Crohn's disease, anastomotic stricture, or indication for IPAA other than ulcerative or indeterminate colitis were excluded. Patients underwent an interview with an abbreviated Rome Questionnaire followed by high-resolution ano-pouch manometry, balloon expulsion test, pouch barostat, and magnetic resonance (MR) defecography.

RESULTS

Twenty patients completed all testing. Six patients were excluded from the final analysis due to symptoms suggestive of pouch evacuation disorder on the abbreviated Rome Questionnaire (n = 2), structural abnormality on MR imaging (n = 3), or both (n = 1). Of the remaining 14 patients, mean anal resting pressure during high-resolution manometry was 72 ± 16 mmHg, mean anal squeeze pressure was 247 ± 69 mmHg, and mean pouch-anal gradient during the simulated evacuation was -27 ± 37 mmHg. The meantime to balloon expulsion was 54 seconds. During dynamic MR defecography, the mean descent of ano-pouch junction was 2.6 cm, and mean pouch evacuation was 44.5% and 74.2% pre- and posttoilet phase, respectively.

CONCLUSIONS

A substantial proportion of patients with IPAA and self-reported healthy pouch function have anatomic and/or functional abnormalities of the pouch. In asymptomatic IPAA patients with an anatomically normal pouch, we have proposed normal parameters for high-resolution ano-pouch manometry, time to balloon expulsion, pouch barostat, and MR defecography.

Pelvic Floor Mobility measured by Transperineal Ultrasound Imaging in Women with and without Urgency and Frequency Predominant Lower Urinary Tract Symptoms

BACKGROUND

Women with urgency/frequency predominant lower urinary tract symptoms (UF-LUTS) may have elevated pelvic floor muscle (PFM) position at rest and limited mobility with PFM contraction and bearing down, but this has not been quantified.

OBJECTIVES

To compare PFM position and mobility using transperineal ultrasound (TPUS) at rest, maximal PFM contraction (perineal elevation), and bearing down (perineal descent) in women with and without UF-LUTS. We hypothesized that women with UF-LUTS would demonstrate elevated resting position and decreased excursion of pelvic landmarks during contraction and bearing down as compared to women without UF-LUTS.

STUDY DESIGN

Case-control study.

METHODS

Women with UF-LUTS were matched 1:1 on age, body mass index and vaginal parity to women without UF-LUTS. TPUS videos were obtained during 3 conditions: rest, PFM contraction, and bearing down. Levator plate angle (LPA) and puborectalis length (PR length), were measured for each condition. Paired t-tests or Wilcoxon signed rank tests compared LPA and PR length between cases and controls.

RESULTS

21 case-control pairs (42 women): Women with UF-LUTS demonstrated greater LPA at rest (66.8 ± 13.2 degrees vs 54.9 ± 9.8 degrees; P=0.006), and less PR lengthening from rest to bearing down (0.2 ± 3.1 mm vs 2.1 ± 2.9 mm; P=.03).

CONCLUSION

Women with UF-LUTS demonstrated more elevated (cranioventral) position of the PFM at rest and less PR muscle lengthening with bearing down. These findings highlight the importance of a comprehensive PFM examination and possible treatment for women with UF-LUTS to include PFM position and mobility.

"Having Pain is Normal": How Talk about Chronic Pelvic and Genital Pain Reflects Messages from Menarche

Chronic pelvic and genital pain conditions (CPGPCs) often go undiagnosed and untreated in women for years after symptom onset. This is due, in part, to communication challenges experienced by patients such as difficulties describing pain and the stigmatized nature of CPGPCs. However, studies have yet to explore how early messages about menstruation, a context similar in its stigmatized and painful nature, may contribute to undertreatment and diagnostic delays for adult women experiencing CPGPCs by normalizing pelvic and genital pain when they are young girls. Guided by critical feminist theorizing (CFT) and sensitized by an existing typology of negative messages communicated by mothers to daughters about menstruation, this study analyzes interviews with 17 women with CPGPCs to explore how features of negative messages about menstruation (i.e., information restriction and omission) appear and recur in women's descriptions of their later CPGP experiences. Findings suggest that early life talk about menstruation forms a communicative precedent for young girls which later constrains how they talk about CPGP in adulthood. Findings also problematize early-life communication about menstruation, which normalizes women's pain, and suggest connections to outcomes (e.g., diagnostic delays) for women with CPGPCs. Theoretical and practical implications are offered. Limitations and future directions are described.

A Pain in the Butt: Hemorrhoids, Fissures, Fistulas, and Other Anorectal Syndromes

Painful and bothersome anorectal syndromes can be a diagnostic and therapeutic challenge for clinicians because structural and functional abnormalities may often coexist and require a multidisciplinary approach to management. Although it is often difficult to attribute all of a patient's anorectal symptoms to a singular disorder with definitive intervention and cure, improving quality of life, treating coexistent conditions such as functional constipation and/or defecation disorders, addressing psychological comorbidities if present, and confirming there is no evidence of inflammatory or malignant conditions are top priorities.

Management of genitourinary syndrome of menopause in breast cancer survivors: An update

There is increasing attention about managing the adverse effects of adjuvant therapy (Chemotherapy and anti-estrogen treatment) for breast cancer survivors (BCSs). Vulvovaginal atrophy (VVA), caused by decreased levels of circulating estrogen to urogenital receptors, is commonly experienced by this patients. Women receiving antiestrogen therapy, specifically aromatase inhibitors, often suffer from vaginal dryness, itching, irritation, dyspareunia, and dysuria, collectively known as genitourinary syndrome of menopause (GSM), that it can in turn lead to pain, discomfort, impairment of sexual function and negatively impact on multiple domains of quality of life (QoL). The worsening of QoL in these patients due to GSM symptoms can lead to discontinuation of hormone adjuvant therapies and therefore must be addressed properly. The diagnosis of VVA is confirmed through patient-reported symptoms and gynecological examination of external structures, introitus, and vaginal mucosa. Systemic estrogen treatment is contraindicated in BCSs. In these patients, GSM may be prevented, reduced and managed in most cases but this requires early recognition and appropriate treatment, but it is normally undertreated by oncologists because of fear of cancer recurrence, specifically when considering treatment with vaginal estrogen therapy (VET) because of unknown levels of systemic absorption of estradiol. Lifestyle modifications and nonhormonal treatments (vaginal moisturizers, lubricants, and gels) are the first-line treatment for GSM both in healthy women as BCSs, but when these are not effective for symptom relief, other options can be considered, such as VET, ospemifene, local androgens, intravaginal dehydroepiandrosterone (prasterone), or laser therapy (erbium or CO2 Laser). The present data suggest that these therapies are effective for VVA in BCSs; however, safety remains controversial and a there is a major concern with all of these treatments. We review current evidence for various nonpharmacologic and pharmacologic therapeutic modalities for GSM in BCSs and highlight the substantial gaps in the evidence for safe and effective therapies and the need for future research. We include recommendations for an approach to the management of GSM in women at high risk for breast cancer, women with estrogen-receptor positive breast cancers, women with triple-negative breast cancers, and women with metastatic disease.

A Novel Technique Combining Human Acellular Dermal Matrix (HADM) and Enriched Platelet Therapy (EPT) for the Treatment of Vaginal Laxity: A Single-Arm, Observational Study

BACKGROUND

There is a paucity of knowledge about cosmetic vaginal tightening procedures; therefore, the present study aimed to describe the clinical effects of a novel combination technique of human acellular dermal matrix (HADM) and enriched platelet therapy (EPT) for the treatment of vaginal laxity.

METHODS

This single-arm, observational study was conducted on 52 patients with grade II to III vaginal relaxation. HADM biological band (U-shaped) was implanted in these patients by submucosal puncture in vagina under anesthesia. This was followed by thrice administration of EPT injection, once at the time surgery followed by each dose at a time interval of one month. Patients were followed up for a period of 6 months based on Female Sexual Function Index (FSFI) and Vaginal Health Index (VHI) scores. Patient satisfaction was measured using Visual Analogue Score (VAS).

RESULTS

About 52 women with median age of 39 years were included in the study. The average time reported to complete HADM surgery was reported as 27 minutes. Following implantation, it was found that labia minora was significantly closed and perineal length was increased from 1.5 to 2.2 cm. Moreover, there was improvement in elasticity, contractility and lubricity of vaginal mucosa. The sexual function scores from pre- to post-surgery were significantly increased (7.95 vs. 30.09; p value: <0.001). The mean VHI score also increased significantly after 6 months of treatment (mean ± S.D. before vs after treatment: 11.2 ± 3.3 vs. 19.6 ± 4.1, P < 0.0001). The mean VAS after surgery was 1.61 ± 0.31. About 96% of the patients did not feel any pain after treatment at 6-month follow-up. No adverse effects were reported in this study.

CONCLUSIONS

These findings supported that combination treatment with HADM and EPT was safe and associated with both improved vaginal laxity and sexual function. These results may provide a novel surgical technique for this prevalent and undertreated condition.

LEVEL OF EVIDENCE IV

Therapeutic Study This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Pelvic floor dysfunction at transperineal ultrasound and chronic constipation in women with endometriosis

OBJECTIVE

To assess the association between sonographic findings at transperineal ultrasound (TPU) and chronic constipation (CC) in women with endometriosis.

METHODS

An observational prospective cohort study was performed by enrolling all endometriosis women scheduled for surgery between September 2019 and October 2020. Women underwent TPU at rest and during Valsalva maneuver evaluating levator-hiatal-area (LHA), antero-posterior diameter (APD), levator-ani muscle (LAM)-coactivation. Ultrasound findings were compared between women with and without CC in the whole study population, and subsequently in two subgroups [only ovarian and deep infiltrating endometriosis (DIE)].

RESULTS

87 women were enrolled: 29 (33%) with CC and 58 (67%) without CC. Women with endometriosis and CC showed a smaller LHA during Valsalva, less LHA and APD enlargement from rest to maximum Valsalva, a higher prevalence of LAM-coactivation compared to women without CC. In ovarian-subgroup, women with CC had smaller LHA at Valsalva, less enlargement of LHA and APD from rest to maximum Valsalva and higher prevalence of LAM-coactivation compared to non-CC patients. In DIE-subgroup, TPU did not significantly differ between CC and non-CC patients.

CONCLUSION

TPU signs of pelvic floor muscle hypertone are more frequent in endometriosis patients with CC compared to those without constipation, particularly in women affected by isolated ovarian endometriosis.

Family Physician's Educational Interview with Patients Helps in Early Recognition of Lower Urinary Tract Symptoms

Purpose

Lower urinary tract symptoms (LUTS) can have an etiology outside the lower urinary tract (LUT) and are therefore an important diagnostic indicator for assessing the overall health of a person. However, LUTS is still mainly neglected by primary health care providers as well as by patients. In this study, we assessed the importance of an educational interview (EI) conducted by a GP on the patients’ ability to recognize LUTS. We also investigated other factors that affect the recognition of LUTS: subjects’ personal educational level, number of LUT symptoms and their bothersome level on a scale 0–10.

Patients and Methods

This cross-sectional study was conducted in Croatia (2018–2020) by interviewing 499 subjects. We compared recognized LUT symptoms before and after the EI and determined whether their number, their bothersome level, or the subjects’ personal educational level were associated with LUTS recognition.

Results

EI significantly improved the ability to recognize LUTS (p=0.001). The number of LUT symptoms and bothersome level in subjects before EI was much greater than the number in subjects after EI (p<0.0001, mean>4 and p<0.0001, median>8, respectively). Subjects with higher educational level recognized LUTS with fewer symptoms after the EI (p<0.01), but no difference was observed among subjects who recognized LUTS before the EI.

Conclusion

For subjects to recognize LUTS, their condition had to be severe – more than 4 symptoms and bothersome level >8/10. Personal educational level had little impact on LUTS recognition. However, an EI proved to be an excellent tool for raising awareness about LUTS and its early recognition.

Endometriosis: Epidemiology, Classification, Pathogenesis, Treatment and Genetics (Review of Literature)

Endometriosis is a “mysterious” disease and its exact cause has not yet been established. Among the etiological factors, congenital, environmental, epigenetic, autoimmune and allergic factors are listed. It is believed that the primary mechanism of the formation of endometriosis foci is retrograde menstruation, i.e., the passage of menstrual blood through the fallopian tubes into the peritoneal cavity and implantation of exfoliated endometrial cells. However, since this mechanism is also observed in healthy women, other factors must also be involved in the formation of endometriosis foci. Endometriosis is in many women the cause of infertility, chronic pain and the deterioration of the quality of life. It also represents a significant financial burden on health systems. The article presents a review of the literature on endometriosis—a disease affecting women throughout the world.

Assessment of the effect of Mulabandha yoga therapy in healthy women, stigmatized for pelvic floor dysfunctions: A randomized controlled trial

Background

In developing countries, women do not reveal their perineum related health issues because most of the time they are stigmatized by the society. Multiparity, mostly found in women of rural areas is one of the major causes of pelvic floor dysfunctions (PFDs) like pelvic organ prolapse, urinary incontinence, rectal incontinence, etc. Usually, they visit health centres in the advanced stage of diseases, and then medical treatment is not the only choice left. Many research studies show that yoga practices promote health conditions, contribute to enhancing endurance, flexibility, and muscular strength, and improving quality of life.

Objective(s)

The study was conducted to assess the impact of Mulabandha yoga therapy (MYT) in healthy woman participants as a preventive measure.

Material and methods

The study was a prospective and randomized controlled trial. Fifty healthy woman participants were allocated in two groups viz., MYT group and No MYT group. Mulabandha yoga was conducted for the MYT group for 12 weeks. No MYT group was advised not to do yoga. Pelvic floor muscle strength was internally evaluated by employing the PERFECT scheme score (P = power, E = endurance, R = repetitions, F = fast contractions, ECT = every contraction timed). For eligible samples, MYT sessions were held for 12 weeks. Data interpretation was done with SPSS software 20.0 (IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY, USA).

Results

Fifty healthy woman participants were allocated for analysis. There was no statistically significant difference in between the groups comparison in terms of age, socio-economic status, occupation, education, parity and mode of delivery. PERFECT scheme score significantly improved in participants after 12 weeks of regular MYT. No statistically significant differences were observed between the groups comparison in terms of PERFECT scheme score.

Conclusion

The current study shows that regular practice of MYT for 12 weeks is a better means to reinforce the strength of pelvic floor muscles in women. This MYT procedure will establish evidence for women who are reluctant towards their pelvic organ-related issues. Women must incorporate the MYT practice in their routine life as a preventive measure to refrain from pelvic floor dysfunctions.

Pelvic floor muscle dysfunctions in women with deep infiltrative endometriosis: An underestimated association

AIMS

Deep infiltrative endometriosis (DIE) may cause pelvic pain and thus negatively affect the function of different structures. We hypothesised that women with DIE may have dysfunctions of the pelvic floor muscles (PFMs) and lower limb muscles (LLMs).

METHODS

This cross-sectional study included 160 women (80 with DIE under hormonal treatment and 80 women without DIE), who were assessed to determine the presence of pelvic symptoms (dysmenorrhea, chronic pelvic pain [CPP], deep/penetration dyspareunia, dysuria, dyschezia and vulvodynia), PFM function (PERFECT scheme, presence of hypertonia and trigger points, and muscle contraction and relaxation), abdominal muscle pain (Carnett's test) and muscle shortening in LLM (Thomas, Pace and Ober tests).

RESULTS

Women with DIE presented more CPP (30% vs 5%; P < .001), dysuria (12.5% vs 3.75%; P = .043) and dyschezia (47.5% vs 2.5%; P < .001) than the control group. Moreover, they had higher PFM hypertonia (28.75% vs 13.75%; P = .02), weaker PFM contraction (36.35% vs 2.5%; P < .001), and incomplete PFM relaxation (45% vs 13.75%; P < .001). Women with DIE had a higher rate of positive results in the Carnett's test (21.25% vs 2.5%; P < .001) than the control group. Moreover, they had a higher frequency of shortening of the anterior thigh (30% vs 10% in both LLM; P < .001), piriformis (16.25% vs 6.25%; P < .001) and iliotibial band muscles (bilateral; P < .001). Multivariate analysis revealed that the presence of pain increased the risk of PFM hypertonia (OR = 3.73 [1.26-11.07]; P = .018) and caused difficulty in PFM relaxation (OR = 2.98 [1.01-9.37]; P = .049).

CONCLUSION

Women with DIE exhibited a greater number of pelvic symptoms and greater PFM/LLM dysfunction than those in the control group. Pain was associated with PFM hypertonia and difficulty in PFM relaxation.

Managing female sexual dysfunction

OBJECTIVE

Provide an overview of sexual dysfunction in female urologic cancer patients, approaches for assessing sexual problems, and interventions to treat sexual dysfunction in this patient population.

METHODS

A review of the literature in urologic oncology was conducted. Research on other female pelvic cancers with similar treatments was also reviewed.

RESULTS

Sexual health is an important element of women's quality of life that is often not discussed and problems remain unaddressed. Urologic cancer treatments commonly result in sexual dysfunction (e.g., dyspareunia, vaginal dryness, problems with orgasm) in female patients, although more research is necessary to understand the impact of non-surgical treatments (e.g., radiation, chemotherapy, immunotherapy). As such, provider teams should complete necessary screening for sexual dysfunction during and after treatment. The 5 A's model (i.e., Ask, Advise, Assess, Assist, Arrange Follow-Up) provides a helpful guide for communicating about and addressing sexual health concerns with patients during the screening process. If it is determined that referral for further assessment and treatment of sexual dysfunction is needed, a number of non-pharmacologic (e.g., pelvic floor physical therapy; psychosexual counseling) and pharmacologic treatment approaches are available.

CONCLUSION

Sexual dysfunction is common in female urologic cancer survivors. Routine assessment and appropriate referral are essential for high quality patient care.

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.

Pelvic Floor Physical Therapy for Pelvic Floor Hypertonicity: A Systematic Review of Treatment Efficacy

INTRODUCTION

Hypertonicity of the pelvic floor (PFH) is a disabling condition with urological, gynecological and gastrointestinal symptoms, sexual problems and chronic pelvic pain, impacting quality of life. Pelvic floor physical therapy (PFPT) is a first-line intervention, yet no systematic review on the efficacy of PFPT for the treatment of PFH has been conducted.

OBJECTIVES

To systematically appraise the current literature on efficacy of PFPT modalities related to PFH.

METHODS

PubMed, Embase, Emcare, Web of Science, and Cochrane databases were searched from inception until February 2020. A manual search from reference lists of included articles was performed. Ongoing trials were reviewed using clinicaltrial.gov. Randomized controlled trials (RCTs), prospective - and retrospective cohorts and case-study analyses were included. Outcome measures were pelvic floor muscle tone and function, pain reports, sexual function, pelvic floor symptom scores, quality of life and patients' perceived effect.

RESULTS

The literature search resulted in 10 eligible studies including 4 RCTs, 5 prospective studies, and 1 case study published between 2000 and 2019. Most studies had a high risk of bias associated with the lack of a comparison group, insufficient sample sizes and non-standardized interventions. Six studies were of low and 4 of medium quality. All studies were narratively reviewed. Three of 4 RCTs found positive effects of PFPT compared to controls on five out of 6 outcome measures. The prospective studies found significant improvements in all outcome measures that were assessed. PFPT seems to be efficacious in patients with chronic prostatitis, chronic pelvic pain syndrome, vulvodynia, and dyspareunia. Smallest effects were seen in patients with interstitial cystitis and painful bladder syndrome.

CONCLUSION

The findings of this systematic review suggest that PFPT can be beneficial in patients with PFH. Further high-quality RCTs should be performed to confirm the effectiveness of PFPT in the treatment of PFH. van Reijn-Baggen DA, Han-Geurts IJM, Voorham-van der Zalm PJ, et al. Pelvic Floor Physical Therapy for Pelvic Floor Hypertonicity: A Systematic Review of Treatment Efficacy. Sex Med Rev 2021;XX:1-22.

Narrative review of pelvic floor muscle training for childbearing women-why, when, what, and how

INTRODUCTION AND HYPOTHESIS

Urinary incontinence (UI) is prevalent during pregnancy and postpartum. UI in pregnancy strongly predicts UI postpartum and later in life. UI reduces women's wellbeing and quality of life and presents a significant burden to healthcare resource.

METHODS

A narrative review summarizing quantitative and qualitative evidence about pelvic floor muscle training (PFMT) for prevention and treatment of UI for childbearing women.

RESULTS

There are clinically important reductions in the risk of developing UI in pregnancy and after delivery for pregnant women who start PFMT during pregnancy, and PFMT offers additional benefits preventing prolapse and improving sexual function. If women develop UI during pregnancy or postpartum then PFMT is an appropriate first-line treatment. For novice exercisers, a programme comprising eight contractions, with 8-s holds, three times a day, 3 days a week, for at least 3 months is a reasonable minimum and 'generic' prescription. All women need clear accurate verbal instruction in how to do PFMT. Incontinent women, and women who cannot do a correct contraction, require referral for pelvic floor rehabilitation. Behavioural support from maternity care providers (MCPs)-increasing women's opportunity, capability, and motivation for PFMT-is as important as the exercise prescription.

CONCLUSION

PFMT is effective to prevent and treat UI in childbearing women. All pregnant and postpartum women, at every contact with a MCP, should be asked if they are continent. Continent women need exercise prescription and behavioural support to do PFMT to prevent UI. Incontinent women require appropriate referral for diagnosis or treatment.

It Takes a Village: The First 100 Patients Seen in a Multidisciplinary Pelvic Floor Clinic

OBJECTIVE

This study aimed to assess the characteristics of patients assessed and treated at a multidisciplinary pelvic floor program that includes representatives from multiple specialties. Our goal is to describe the process from triaging patients to the actual collaborative delivery of care. This study examines the factors contributing to the success of our multidisciplinary clinic as evidenced by its ongoing viability.

METHODS

This is a descriptive study retrospectively analyzing a prospectively maintained database that included the first 100 patients seen in the Program for Abdominal and Pelvic Health clinic between December 2017 and October 2018. We examined patient demographics, their concerns, and care plan including diagnostic tests, findings, treatments, referrals, and return visits.

RESULTS

The clinic met twice monthly, and the first 100 patients were seen over the course of 10 months. The most common primary symptoms were pelvic pain (45), constipation (30), bladder incontinence (27), bowel incontinence (23), high tone pelvic floor dysfunction (23), and abdominal pain (23); most patients had more than one presenting symptom (76). The most common specialties seen at the first visit to the clinic included gastroenterology (56%), followed by physical medicine and rehabilitation (45%), physical therapy (31%), female pelvic medicine and reconstructive surgery (25%), behavioral health (19%), urology (18%), and colorectal surgery (13%). Eleven patients were entirely new to our hospital system. Most patients had diagnostic tests ordered and performed.

CONCLUSIONS

A multidisciplinary clinic for abdominal and pelvic health proves a sustainable model for comprehensive treatment for patients with pelvic floor dysfunction, including difficulties with defecation, urination, sexual dysfunction, and pain.

Female Urethral Stricture Management: The Initial Experience of an Female Pelvic Medicine and Reconstructive Surgery-Trained Urologist

OBJECTIVE

Given the rarity of female urethral strictures (the cause of <1% of female lower urinary tract symptoms), most trainees have little experience diagnosing and managing the problem as they begin practice. Presented are the female urethral stricture outcomes of an attending surgeon after the completion of a female pelvic medicine and reconstructive surgery fellowship.

METHODS

With institutional review board approval, a retrospective review of all cases of suspected female urethral stricture through the first 7 years of practice was completed.

RESULTS

Over the study period, 13 women were treated for urethral stricture. One underwent simple meatotomy, 9 underwent vaginal wall flap (Blandy) urethroplasty, and 3 underwent urethral dilation only because they were not reconstructive candidates (1 due to severe radiation damage and 2 with panurethral strictures that included the bladder neck). Women undergoing urethral dilations (n = 3) have all required subsequent dilations, whereas those undergoing reconstructive procedures have not required further intervention (all with max flow rates greater than 17 mL/s at last follow-up [median = 35 months, range = 10-70]).

CONCLUSION

Over the course of 7 years, our limited experience suggests that (a) urethral dilation is not usually successful but surgical reconstruction is, (b) preoperative urethral rest before reconstruction may reduce failure rates, (c) staging a stricture in the operating room is the best route to confirm the diagnosis, (d) de novo stress urinary incontinence seems to rarely if ever occur after female urethroplasty, and (e) postoperative follow-up with simple uroflow and postvoid residual testing suffices.

International Society for the Study of Women's Sexual Health (ISSWSH) Review of Epidemiology and Pathophysiology, and a Consensus Nomenclature and Process of Care for the Management of Persistent Genital Arousal Disorder/Genito-Pelvic Dysesthesia (PGAD/GPD)

BACKGROUND

Persistent genital arousal disorder (PGAD), a condition of unwanted, unremitting sensations of genital arousal, is associated with a significant, negative psychosocial impact that may include emotional lability, catastrophization, and suicidal ideation. Despite being first reported in 2001, PGAD remains poorly understood.

AIM

To characterize this complex condition more accurately, review the epidemiology and pathophysiology, and provide new nomenclature and guidance for evidence-based management.

METHODS

A panel of experts reviewed pertinent literature, discussed research and clinical experience, and used a modified Delphi method to reach consensus concerning nomenclature, etiology, and associated factors. Levels of evidence and grades of recommendation were assigned for diagnosis and treatment.

OUTCOMES

The nomenclature of PGAD was broadened to include genito-pelvic dysesthesia (GPD), and a new biopsychosocial diagnostic and treatment algorithm for PGAD/GPD was developed.

RESULTS

The panel recognized that the term PGAD does not fully characterize the constellation of GPD symptoms experienced by patients. Therefore, the more inclusive term PGAD/GPD was adopted, which maintains the primacy of the distressing arousal symptoms and acknowledges associated bothersome GPD. While there are diverse biopsychosocial contributors, there is a common underlying neurologic basis attributable to spontaneous intense activity of the genito-pelvic region represented in the somatosensory cortex and its projections. A process of care diagnostic and treatment strategy was developed to guide the clinician, whenever possible, by localizing the symptoms as originating in any of five regions: (i) end organ, (ii) pelvis/perineum, (iii) cauda equina, (iv) spinal cord, and (v) brain. Psychological treatment strategies were considered critical and should be performed in conjunction with medical strategies. Pharmaceutical interventions may be used based on their site and mechanism of action to reduce patients' symptoms and the associated bother and distress.

CLINICAL IMPLICATIONS

The process of care for PGAD/GPD uses a personalized, biopsychosocial approach for diagnosis and treatment.

STRENGTHS AND LIMITATIONS

Strengths and Limitations: Strengths include characterization of the condition by consensus, analysis, and recommendation of a new nomenclature and a rational basis for diagnosis and treatment. Future investigations into etiology and treatment outcomes are recommended. The main limitations are the dearth of knowledge concerning this condition and that the current literature consists primarily of case reports and expert opinion.

CONCLUSION

We provide, for the first time, an expert consensus review of the epidemiology and pathophysiology and the development of a new nomenclature and rational algorithm for management of this extremely distressing sexual health condition that may be more prevalent than previously recognized. Goldstein I, Komisaruk BR, Pukall CF, et al. International Society for the Study of Women's Sexual Health (ISSWSH) Review of Epidemiology and Pathophysiology, and a Consensus Nomenclature and Process of Care for the Management of Persistent Genital Arousal Disorder/Genito-Pelvic Dysesthesia (PGAD/GPD). J Sex Med 2021;18:665-697.

Premature ovarian insufficiency: a toolkit for the primary care physician

Premature ovarian insufficiency (POI) refers to the loss of ovarian activity before the age of 40 years, which leads to hypoestrogenism and amenorrhea. The diagnosis of POI in a young woman has potentially life-changing physical and emotional consequences for both the patient and her family. Therefore, it is very important that the diagnosis is correct and that it is made in a timely manner. Unfortunately, the diagnosis and therefore the effective treatment of POI are often delayed, which underlines the need for education of the broad medical community on the issue. A panel of menopause experts reviewed and critically appraised the literature, and present: (1) the diagnostic approach to POI, (2) the investigation of the etiology of this condition, (3) the therapeutic strategy regarding both hormone replacement therapy and fertility, and (4) the long-term follow-up and management for ensuring quality of life, as well as urogenital, cardiovascular, bone and mental health. The ultimate goal of this article is to provide a complete toolkit for the primary care physician to have easy access to all the information needed for the optimal management of women with POI, in the context of evidence-based and personalized medicine.HIGHLIGHTSPremature ovarian insufficiency occurs in 1% of the female population of reproductive age, yet the diagnosis is often delayed, with severe physical and emotional consequences for the patient.Primary care physicians should be aware of the possibility of premature ovarian insufficiency in young women presenting with menstrual irregularity.Prompt initiation of hormone replacement therapy ensures quality of life and prevents osteoporosis and cardiovascular disease.Women seeking fertility should be referred to specialists to discuss assisted reproduction options.

Premature ovarian insufficiency: A toolkit for the primary care physician

Premature ovarian insufficiency (POI) refers to the loss of ovarian activity before the age of 40 years, which leads to hypoestrogenism and amenorrhoea. The diagnosis of POI in a young woman has potentially life-changing physical and emotional consequences for both the patient and her family. Therefore, it is very important that the diagnosis is correct and that it is made in a timely manner. Unfortunately, the diagnosis and therefore the effective treatment of POI are often delayed, which underlines the need for education of the broad medical community on the issue. A panel of menopause experts reviewed and critically appraised the literature, and present: 1) the diagnostic approach to POI, 2) the investigation of the etiology of this condition, 3) the therapeutic strategy regarding both hormone replacement therapy (HRT) and fertility and 4) the long-term follow-up and management for ensuring quality of life, as well as urogenital, cardiovascular, bone and mental health. The ultimate goal is to provide a complete toolkit for the primary care physician to have easy access to all the information needed for the optimal management of women with POI, in the context of evidence-based and personalized medicine.

Impact of pelvic floor muscle training in pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

This review article was aimed at evaluating the effectiveness of pelvic floor muscle training (PFMT) during conservative management and as an adjunct to prolapse surgery based on recently published articles.

METHODS

The PubMed and PEdro databases were searched from 2005 to 2020 for all types of studies reporting on PFMT as the primary treatment for conservative management of prolapse as well as an adjunct for prolapse surgery.

RESULT

The result of this review demonstrated that PFMT is effective in conservative management, especially in women with mild to moderate prolapse(stages I-III), for those who wish to have more children, who are not willing to undergo surgery, who are frail because of co-morbidities, and for those who need to delay surgery. However, results evaluating the effectiveness of PFMT as an adjunct to surgery demonstrated insufficient evidence to support the benefit of PFMT in addition to prolapse surgery over the use of surgery alone.

CONCLUSION

Through this review, we have concluded that PFMT shows a more prominent effect when applied as conservative management. Currently available evidence demonstrated no additional clinically significant augmentation of PFMT as an adjunct to surgery compared with prolapse surgery alone.

Updates on Therapeutic Alternatives for Genitourinary Syndrome of Menopause: Hormonal and Non-Hormonal Managements

Postmenopausal atrophic vaginitis, along with vasomotor symptoms and sleep disorders, is one of the most troublesome symptoms of menopause. However, many women do not manage this symptom properly due to insufficient knowledge of the symptoms or sexual embarrassment. With appropriate treatment, many postmenopausal women can experience relief from discomforts, including burning sensation or dryness of the vagina and dyspareunia. Topical lubricants and moisturizers, systemic and local estrogens, testosterones, intravaginal dehydroepiandrosterones (DHEAs), selective estrogen receptor modulators, and energy-based therapies are possible treatment modalities. Systemic and local estrogen therapies effectively treat genitourinary syndrome of menopause (GSM), but they are contraindicated in patients with breast cancer, for whom lubricants and moisturizers must be considered as the primary treatment. Intravaginal DHEA and ospemifene can be recommended for moderate to severe GSM; however, there is insufficient data on the use of intravaginal DHEA or ospemifene in patients with breast cancer, and further studies are needed. Energy-based devices such as vaginal laser therapy reportedly alleviate GSM symptoms; however, the U.S. Food and Drug Administration warning has recently been issued because of complications such as chronic pain and burning sensations of the vagina. To summarize, clinicians should provide appropriate individualized treatment options depending on women's past history, symptom severity, and chief complaints.

MicroRNA-124-3p affects myogenic differentiation of adipose-derived stem cells by targeting Caveolin-1 during pelvic floor dysfunction in Sprague Dawley rats

Background

The aim of this study was to investigate using myogenic differentiation of adipose stem cells for the treatment of female pelvic floor dysfunction (PFD) and aimed to further study the influences of microRNA-124-3p (miR-124-3p) in the process of myogenic differentiation of adipose-derived stem cells (ADSCs) through targeting Caveolin-1 (Cav1) during PFD in Sprague Dawley (SD) rats.

Methods

The ADSCs were separated from 6–8-week-old female SD rats (n=25) and were cultivated. Then, we observed the cell status and conducted fat and osteogenic experiments. We then constructed an ADSC-green fluorescent protein (GFP) stable transfer strain. Flow cytometry was used to identify the positive rates of CD44, CD90, and CD45 in ADSCs and ADSC-GFP. Real-time quantitative polymerase chain reaction (qRT-PCR) and western blotting were used to mRNA and protein expression levels. Myogenic differentiation of ADSCs was measured with immunofluorescence methods. A dual-luciferase reporter assay was executed to affirm whether Cav1 was a target of miR-124-3p.

Results

The isolated ADSCs cells were in good condition under the microscope. The results of flow cytometry showed that the positive rate of CD44 and CD90 was high, and the positive rate of CD45 was low in ADSCs and ADSC-GFP. Under normal culture conditions, ADSCs-GFP cells can be massively adipated and osteogenic. After 5-Aza induced ADSC-GFP myogenic differentiation, the level of miR-124-3p was significantly increased. We found that MiR-124-3p mimics promoted the myogenic differentiation of ADSCs. Moreover, we discovered that Cav1 was a target gene of miR-124-3p and was negatively regulated by miR-124-3p. The results of leak point pressure (LPP), hematoxylin and eosin (HE), and Masson showed that the collagen fiber content of the PFD group was lower than that of the control group; the collagen fiber content of ADSC-GFP, 5-Aza, or miR-124-3p mimics were increased after intervention. Furthermore, the outcomes qRT-PCR, western blotting, and immunofluorescence suggested that miR-124-3p facilitated the survival ADSC-GFP fat transplantation by regulating many key factors in vivo.

Conclusions

These results proofed that miR-124-3p could accelerate myogenic differentiation of ADSCs by down-regulating Cav1 to improve PFD in SD rats, which will pave the way for therapeutic delivery of miRNA targeting PFD disease.

The Rolf Method of Structural Integration and Pelvic Floor Muscle Facilitation: Preliminary Results of a Randomized, Interventional Study

The management of pelvic floor dysfunctions might need to be based on a comprehensive neuro-musculoskeletal therapy such as The Rolf Method of Structural Integration (SI). The aim of the study was to evaluate the pelvic floor muscle (PFM) after the tenth session of SI by using surface electromyography (sEMG). This was a randomized, interventional study. Thirty-three healthy women were randomly assigned to the experimental (SI) or control group. The outcome measures included PFM bioelectrical activity, assessed using sEMG and endovaginal probes. An intervention in the SI group included 60 min of SI once a week, and teaching on how to contract and relax PFMs; in the control group, only the teaching was carried out. In the SI group, a significant difference was found between the PFM sEMG activity during “pre-baseline rest” (p < 0.014) and that during “rest after tonic contraction” (p = 0.021) in the supine position, as were significant increases in “phasic contraction” in the standing position (p = 0.014). In the intergroup comparison, higher PFM sEMG activity after the intervention “phasic contraction” (p = 0.037) and “pre-baseline rest” (p = 0.028) was observed in the SI group. The SI intervention significantly changes some functional bioelectrical activity of PFMs, providing a basis for further research on a new approach to PFM facilitation, particularly in clinical populations.

A Systematic Review of Intravaginal Diazepam for the Treatment of Pelvic Floor Hypertonic Disorder

This systematic review evaluates the efficacy of intravaginal diazepam in treating chronic pelvic pain and sexual dysfunction associated with high-tone pelvic floor dysfunction. A literature search was conducted in Medline and Web of Science, including articles from the database's inception to July 2019. The search identified 126 articles, and 5 articles met study inclusion criteria: 2 observational reviews and 3 small randomized, controlled trials (RCTs) evaluating intravaginal diazepam for high-tone pelvic floor dysfunction. The 2 observational studies identified subjective reports of improvement in sexual function for a majority of women, 96% and 71%, in each study. However, there were no statistical differences between Female Sexual Function Index (FSFI) and Visual Analog Scale (VAS) scores for pain identified. One RCT found no significant changes between groups in median FSFI or VAS scores, and a second RCT found no significant changes between groups in 100-mm VAS scores. The third RCT demonstrated that compared with placebo, treatment with transcutaneous electrical nerve stimulation and intravaginal diazepam for women with vestibulodynia and high-tone pelvic floor dysfunction yielded significant differences in reduction of dyspareunia (P ≤ .05), ability to relax pelvic floor muscles after contraction (P ≤.05), and current perception threshold values at a 5-Hz stimulation related to C fibers (P < .05), but no significant changes in 10-cm VAS scores. Intravaginal diazepam may be helpful in women with a specific diagnosis of high-tone pelvic floor dysfunction, but more and larger studies are needed to confirm these potential effects.

Management of Vaginal Mesh Exposures Following Female Pelvic Reconstructive Surgery

PURPOSE OF REVIEW

To discuss considerations and current evidence for the diagnosis and management of vaginal mesh exposures following female mesh-augmented anti-incontinence and pelvic organ prolapse surgery.

RECENT FINDINGS

Since the introduction of mesh into female pelvic surgery, various applications have been reported, each with their own unique risk profile. The most commonly encountered mesh-related complication is vaginal mesh exposure. Current evidence on the management of vaginal mesh exposure is largely limited to observational studies and case series, though this is continuing to expand. We present a synthesis of the available data, as well as clinical and surgical approaches to managing this complication. It is important for surgeons to be familiar with the management of vaginal mesh exposures. Depending on the patient's presentation and goals, there is a role for conservative measures, mesh revision, or mesh excision. Further study is warranted to standardize mesh resection techniques and explore non-surgical treatments.

Pelvic Floor Biometric Changes Assessed by 4D Translabial Ultrassound in Women With Vulvodynia Submitted to Physical Therapy: A Pilot Study of a Randomized Controlled Trial

BACKGROUND

Vulvodynia is a disabling condition in which pelvic floor muscles' (PFM) hypertonicity plays an important role.

AIM

To evaluate biometric changes in PFM in women with vulvodynia undergoing kinesiotherapy treatment protocol (KTP).

METHODS

A single-blinded randomized controlled trial of 57 women with vulvodynia randomly assigned to either KTP + amitriptyline or amitriptyline alone (controls) for treatment. Four-dimensional translabial ultrasound assessed PFM regarding symphysis-levator distance at rest, anorectal angle at rest, excursion of the levator plate angle, and levator hiatal narrowing. Volunteers underwent a vaginal examination for a cotton swab test (CST), fulfillment of Friedrich criteria score and PFM power of contraction, and completed a diary of sexual pain and frequency of vaginal intercourse. Outcomes were assessed at baseline and after 8 weeks of treatment.

OUTCOMES

Primary outcomes were differences in biometric parameters assessed by four-dimensional translabial ultrasound after treatment, between groups. Secondary outcomes were changes in clinical variables (CST, Friedrich criteria, PFM power of contraction, frequency of intercourse, and intensity of sexual pain) between groups and correlation analysis between biometric parameters and clinical variables.

RESULTS

Only the KTP group had statistically significant changes in biometric parameters after treatment (symphysis-levator distance: 0.22 ± 0.2, 95% CI = 0.1-0.4, P = .008; levator hiatal narrowing: -0.33 ± 0.2, 95% CI = -1 to -0.2, P = .04). Comparisons between groups showed that symphysis-levator distance (0.3, 95% CI = 0.2-0.6, P = .005) and excursion of levator plate angle (4.9, 95% CI = -0.4 to 10.1, P = .02) improved significantly after KTP treatment. Clinical variables showed greater improvement in the group treated with KTP for CST (difference of -3.7, 95% CI = -7 to -0.4, P = .01), Friedrich criteria (difference of -1.9, 95% CI = -3.2 to -0.6, P = .003), PFM power of contraction (0.3, 95% CI = 0.1-0.6, P = .05) and intensity of sexual pain (reduction of 1.7, 95% CI = -3.1 to -0.2, P = .01). Some clinical and biometric variables correlated positively, for example, frequency of vaginal intercourse and anorectal angle (P = .04; r = 0.25), or inversely, for example, pain intensity at CST and anorectal angle (P = .004, r = -0.31).

CLINICAL IMPLICATIONS

This study provides evidence on efficiency of a physical therapy protocol for improvement of symptoms of vulvodynia and hypertonicity changes.

CONCLUSION

This pilot study suggests that KTP for women with vulvodynia promoted significant changes in PFM biometric measures, consistent with alterations in hypertonicity and clinical improvement. Bardin MG, Giraldo PC, Martinho N. Pelvic Floor Biometric Changes Assessed by 4D Translabial Ultrassound in Women With Vulvodynia Submitted to Physical Therapy: A Pilot Study of a Randomized Controlled Trial. J Sex Med 2020;17:2236-2246.

Imaging of chronic male pelvic pain: what the abdominal imager should know

Chronic pelvic pain is an important but underrecognized cause of morbidity in men. While there is abundant literature discussing female pelvic pain and the diagnostic role of imaging, much less attention has been given to imaging of non-gynecologic causes of chronic pelvic pain. Chronic pelvic pain in men can be a challenge to diagnose as pain may arise from visceral, musculoskeletal, or neurovascular pathology. Imaging of the pelvic viscera has been covered in detail elsewhere in this edition and therefore will not be reviewed here. We will focus upon topics less familiar to the abdominal radiologist, including imaging of pelvic floor, musculoskeletal, and neurovascular pathology.