Sacral reflexes and urinary incontinence in women: New concepts

Pelvic floor muscle displacement during jumps in continent and incontinent women: An exploratory study

INTRODUCTION

The prevalence of stress urinary incontinence during high-impact activities is high. Enhanced comprehension of pelvic floor muscle (PFM) displacement and activity is clinically relevant for the development of specific approaches in rehabilitation. The aim of the study is to investigate and to compare PFM displacement between the continent and incontinent women during jumps.

METHODS

A cross-sectional, exploratory design was applied to investigate PFM displacement during drop jumps (DJ) and countermovement jumps (CMJ). PFM displacement was assessed in craniocaudal translation and forward-backward rotation with an electromagnetic tracking system.

RESULTS

Twenty-eight continent and 22 incontinent women were included. During the first landing of DJ, a primary caudal, during the second landing of DJ/CMJ a primary cranial translation and during all jump a primary backward rotation was observed. No significant difference between the groups was found.

DISCUSSION

PFM displacement during running demonstrated caudal translation/forward rotation before and cranial translation/backward rotation after heel strike. During the second landing of DJ/CMJ a cranial translation/backward rotation and during the first landing of DJ a caudal translation/backward rotation has been observed after ground contact. This may be due to the longer lasting bodyweight force in the first landing of DJ. No eccentric-concentric stretch-shortening cycle could be seen.

CONCLUSION

This study indicates that during jumps two opposite reactions of involuntary PFM displacement happen, but no stretch-shortening cycle with an eccentric-concentric contraction could be found. Jumping stimuli inducing involuntary PFM displacement should be used for future investigations to consider a beneficial effect concerning continence.

Pelvic floor muscle reflex activity during coughing - an exploratory and reliability study

OBJECTIVES

Activities that provoke stress urinary incontinence (SUI) rapidly increase the intra-abdominal pressure and the impact loading on the pelvic floor muscles (PFMs). Coughing can cause urinary leakage and is often used to test SUI. However, PFM characteristics during coughing, including their reliability, have not been investigated. Here, we used electromyography (EMG) to describe PFM pre-activity and reflexivity during coughing and examined the reliability of the measurements.

METHODS

This was an exploratory and reliability study including 11 young healthy women to characterize EMG reflex activity in PFMs during coughing. We describe 6 variables, averaged over 3 coughs per subject, and tested their reliability (intraclass correlation coefficient 3,1 [ICC(3,1)] and ICC(3,k), related standard error of measurement (SEM) and minimal difference [MD]). The variables represented the mean EMG activity for PFMs during 30-ms time intervals of pre-activity (initial time point of coughing [T0] and minus 30ms) and reflex activity (T0-30, 30-60, 60-90, 90-120 and 120-150ms after T0) of stretch-reflex latency responses.

RESULTS

The mean %EMG (normalized to maximal voluntary PFM contraction) for EMG variables was 35.1 to 52.2 and was significantly higher during coughing than for PFM activity at rest (mean 24.9±3.7%EMG; P<0.05). ICC(3,k) ranged from 0.67 to 0.91 (SEM 6.1-13.3%EMG and MD 16.7-36.8%EMG) and was higher than ICC(3,1) (range 0.40-0.77; SEM 9.0-18.0%EMG, MD 24.9-50.0%EMG).

CONCLUSIONS

PFM activity during reflex latency response time intervals during coughing was significantly higher than at rest, which suggests PFM pre-activity and reflex activity during coughing. Although we standardized coughing, EMG variables for PFM activity showed poor reliability [good to excellent ICC(3,k) and fair to excellent ICC(3,1) but high SEM and MD]. Therefore, coughing is expected to be heterogeneous, with low reliability, in clinical test situations. Potential crosstalk from other muscles involved in coughing could limit the interpretation of our results.

[Drug therapy of urethral diseases]

AIM

To describe drugs targeting urethra and prostate to treat dysfunctions such LUTS related to BPH, primary bladder neck obstruction (PBNO), detrusor sphincter dyssynergia (DSD) or sphincter deficiency (SD).

METHOD

Pubmed search for efficacy, mode of action and side effects for each molecule. Additional data were searched from the French regulatory agencies web sites (HAS and ANSM).

RESULTS

To treat LUTS related to BPH alpha-blockers (AB) and 5-alpha reductase inhibitors (5ARIs) have a clearer efficacy than plant extract. Daily Phosphodiesterase 5 inhibitors (PDE5Is) alone or in association with AB also demonstrate efficacy in this indication. AB are an option in PBNO and DSD related to multiple sclerosis. Although Botulinum toxin A derived molecules decrease urethral pressure in patient with DSD related to spinal cord injury or multiple sclerosis, efficiency remains to be demonstrated. Duloxetine a serotonin reuptake inhibitor increases urethral sphincter pressure and reduce stress urinary incontinence in women and men. Nevertheless, moderate efficacy combine with frequent side effects lead French regulation agency to reject its agreement.

CONCLUSION

Armamenterium to treat urethral dysfunctions has recently increases. Two new therapeutic classes emerge: PDE5Is to treat LUTS related to BPH and an SRIs (Duloxetine) to treat stress urinary incontinence. Efficacy and safety evaluation of all the possible associations between drugs targeting urethra and/or bladder is needed to a subtler and more efficient pharmacologic modulation of lower urinary tract dysfunction.

Functional and morphological differences following Monarc and TVT-O procedures

OBJECTIVE

To explore function of the lower urinary tract and morphology of tape and urethra following Monarc or TVT-O suburethral tape placement for urodynamic stress incontinence (USI).

METHODS

We recruited prospectively women undergoing either Monarc or TVT-O placement for USI. Before and 3 months after the procedure, participants were evaluated by a question-directed interview, the measures of Sandvik Incontinence Severity Index (SISI), Incontinence Bother Scale (IBS), Ingelman-Sundberg Score (ISS) and short forms of Urogenital Distress Inventory (UDI-6) and Incontinence Impact Questionnaire (IIQ-7), physical examination, a cough stress test and 4D ultrasound investigation. The primary outcome was participants' responses to clinical assessments and the secondary outcome was ultrasound findings.

RESULTS

A total of 67 women with Monarc procedures and 60 women with TVT-O procedures completed the survey both preoperatively and 3 months postoperatively. There were significant improvements in scores of SISI, IBS, ISS, UDI-6 and IIQ-7 after both Monarc and TVT-O procedures. At the 3-month follow-up, both procedures had similar success rates, SISI scores, IBS scores, ISS scores, UDI-6 scores and IIQ-7 scores, and similar incidences of postoperative voiding difficulty and overactive bladder symptoms. After Bonferroni correction, all ultrasound parameters representing tape location, tape tension and urethral mobility were similar between the two procedures.

CONCLUSIONS

At short-term follow-up, Monarc and TVT-O procedures are comparable in both functional outcome of the lower urinary tract and morphology on ultrasound as assessed by parameters representing tape location, tape tension and urethral mobility.