A prospective observational trial of pelvic floor muscle training for female stress urinary incontinence

Mechanisms for pelvic floor muscle training: Morphological changes and associations between changes in pelvic floor muscle variables and symptoms of female stress urinary incontinence and pelvic organ prolapse-A narrative review

INTRODUCTION

Today there is Level 1, recommendation A for pelvic floor muscle training (PFMT) to be effective in treatment of stress urinary incontinence (SUI) and pelvic organ prolapse (POP). However, the mechanisms of action are discussed. The aim of the present overview was to give an update of studies evaluating the effect of PFMT on pelvic floor morphology and associations between changes in PFM strength and symptoms of female SUI and POP. MATERIALS AND METHODS: This was a narrative review retrieving studies from systematic reviews of PFMT for SUI and POP. In addition, an open search on PubMed with the search terms PFMT and morphology was conducted. Both randomized controlled trials (RCTs) and pre-posttest design studies were included. PEDro rating scale (0-10) was used to assess risk of bias.

RESULTS

Ten studies were found reporting on morphological changes after PFMT. The four RCTs had PEDro score between 5 and 8/10. The studies found significant higher bladder neck position and narrower levator hiatus dimensions, thicker external urethral sphincter, increased cross-sectional area of PFM, improvement in PFM tears and blood flow. Twenty studies analyzed associations between changes in different PFMT variables and SUI and POP. Eleven studies found a positive weak to moderate association and six studies reported no association. Studies comparing responders and nonresponders to PFMT found statistically significant better PFM variables in responders.

CONCLUSION

PFMT can change pelvic floor muscle and external urethral sphincter anatomy. This contributes to the understanding on how PFMT can be effective in prevention and treatment of SUI and POP.

Urinary Incontinence in Elite Female Athletes

PURPOSE OF REVIEW

To summarize the current understanding on the epidemiology, pathophysiology, and management strategies of urinary incontinence (UI) in female athletes, highlighting findings specific to nulliparous elite athletes.

RECENT FINDINGS

UI occurs in about 20-50% of female athletes of all ages and parity status, around 40% for younger nulliparous athletes, and is more prevalent in high-impact sports. Possible contributing factors to UI in female elite athletes include pelvic floor laxity and bladder neck descent, pelvic floor muscle fatigue, low energy availability, and hypermobility syndrome. In female elite athletes, urinary symptoms negatively affect quality of life, although the effects of symptoms on exercise participation are not well understood. Current management strategies are primarily conservative and centered on behavioral modifications and pelvic floor muscle physiotherapy. UI in female elite athletes appears to be multifactorial. Clarifying how individual factors influence UI in this population will inform athlete counseling, prevention, and treatment strategies.

Relationship between pelvic floor muscle function and changes in lumbar spine and hip motion due to pelvic floor muscle contraction

BACKGROUND

Pelvic floor muscles (PFM) are important for lumbar stability. However, the relationship between lumbar and hip motion angle changes (MAC) caused by PFM contraction and each PFM's function remains unclear.

OBJECTIVE

To clarify the lumbar spine and hip motion changes produced by PFM contraction and the relationship between MAC and PFM function.

METHODS

In 21 healthy females, motion angle was measured for prone hip extension movement using natural movement (NM), PFM contracting movement (PM), and reducing lumbar movement (RM) methods. The PFM functional indices were bladder base elevation distance, continuous bladder base elevation time, and pelvic floor location.

RESULTS

The PM showed no significant difference in lumbar motion angle but had significantly smaller hip motion than the NM (NM; 26.1 ± 8.3, PM; 29.2 ± 11.0). MAC was significantly greater in RM (lumbar spine; 4.4 ± 3.2, hip; 5.9 ± 8.7) than in PM (lumbar spine; 0.4 ± 4.4, hip; 3.1 ± 5.1) for both the lumbar spine and hip. Lumbar spine and hip MAC of PM was significantly correlated with pelvic floor location (lumbar spine; r=-0.44, hip; r= 0.54).

CONCLUSION

PFM contraction does not attenuate lumbar spine motion but reduces hip motion. MAC due to PFM contraction during lumbar movement tasks is related to the PFM functional index.

Never Too Late to Train: The Effects of Pelvic Floor Muscle Training on the Shape of the Levator Hiatus in Incontinent Older Women

Pelvic floor muscle (PFM) training is the first-line treatment for women of all ages with urinary incontinence (UI), but evidence supporting its effects on the functional anatomy of the pelvic floor is scarce in older women. We aimed to evaluate the long-term (one-year) effects of PFM training on the shape of the levator hiatus (LH) in older women with UI and its association with PFM force, incontinence severity, and potential effect modifiers (age, UI severity, BMI, and UI type). This is a secondary analysis of the GROUP study, a non-inferiority RCT assessing the effects of a structured and progressive 12-week PFM training program to treat UI in older women. Data were available from 264/308 participants at the one-year follow-up. PFM training resulted in reduced LH size toward a more "circular" shape, which was consistently associated with greater PFM force and reduced UI severity. Further, no significant interactions were found between LH shape changes and any of the potential effect modifiers, suggesting that women will potentially benefit from PFM training, regardless of age, UI severity, BMI, and UI type (stress or mixed), with changes that can be observed in the functional anatomy of the pelvic floor and sustained in the long-term.

Assessment of the Elastographic and Electromyographic of Pelvic Floor Muscles in Postmenopausal Women with Stress Urinary Incontinence Symptoms

Background. Shear wave elastography is an effective method for studying the condition of various musculoskeletal soft tissues. The primary aim of this study was the objective elastographic and electromyographic assessment of the pelvic floor during the rest and contraction of the pelvic floor muscles (PFM) in postmenopausal women. Methods. This was a prospective observational study that was carried out at the University Hospital in Wroclaw, Poland, between January 2017 and December 2019. Patients. The target group of the study included postmenopausal women with stress urinary incontinence. The primary outcomes were the features of the elastographic assessment of the pelvic floor during rest and contraction of the PFM obtained using shear wave elastography. Results. Based on the inclusion and exclusion criteria for the study, 14 patients took part in the measurements. There was a significant difference between the elastographic assessment of the pelvic floor during rest and contraction of the PFM at all locations in front of the urethra. No statistically significant correlation was found between the results of elastography and the bioelectrical activity of PFM. Conclusion. The elasticity of the periurethral structures is higher during active pelvic floor muscle contraction than at rest, it seems that shear wave elastography is an effective test that objectively assesses the strength of PFM contraction.

What improvements in levator ani motor function lead to improvement in stress urinary incontinence signs and symptoms in females?

INTRODUCTION AND HYPOTHESIS

The objectives were to determine whether levator ani muscle (LAM) motor function is associated with female stress urinary incontinence (SUI) severity, and whether changes in LAM motor function induced through pelvic floor muscle training (PFMT) are associated with improvements in SUI signs and symptoms.

METHODS

Pelvic morphology and LAM function were evaluated using ultrasound imaging and manual palpation using the elements of the PERFECT Scheme (Power, Endurance, Repetitions, Fast contractions, Elevation, Co-contraction and Timing) before and after women with SUI underwent a 12-week PFMT intervention. SUI severity was determined subjectively (ICIQ-FLUTS-UI) and objectively (30-min pad test [30MPT]).

RESULTS

At baseline (n = 97), less leakage on the 30MPT was weakly associated with higher bladder neck position (ρ_s = -0.209,p = 0.044), yet with lower LAM function based on the PERFECT Scheme (overall score: ρ_s = 0.206, p = 0.043; repeated maximum voluntary contractions (MVCs): ρ_s = 0.203, p = 0.046; power/motor control: ρ_s = 0.214, p = 0.035). Lower symptom severity (ICIQ-FLUTS-UI) was associated with observed perineal lift during coughing (U = 34.000; p = 0.042). All measures of SUI severity and LAM function were significantly improved after PFMT intervention. Greater improvements in bladder neck elevation during MVC (ρ_s = -0.261, p = 0.027) and greater reductions in levator plate length during MVC (ρ_s = 0.292, p = 0.016) were weakly associated with greater reductions in leakage (30MPT), the latter also being associated with more improvement symptoms (ICIQ-FLUTS-UI; ρ_s = 0.238, p = 0.041). Greater improvement in the ability to repeat MVCs (ρ_s = 0.303, p = 0.009) was weakly associated with smaller improvements in symptoms (ICIQ-FLUTS-UI).

CONCLUSION

Improvements in bladder neck support and elevation show weak associations with improvement in SUI signs and symptoms. LAM function as measured by the PERFECT Scheme is not associated with SUI severity in women, and improvements in LAM function when measured by the PERFECT Scheme are not associated with improvements in SUI signs and symptoms.

Pelvic floor morphometrical and functional changes immediately after pelvic floor muscle training and at 1-year follow-up, in older incontinent women

AIMS

To compare the effects of group-based and individual physiotherapy for stress or mixed urinary incontinence (UI) on pelvic floor morphometry, pelvic floor muscle (PFM) function, and related self-efficacy, immediately after treatment and at 1 year.

METHODS

This is a planned secondary analysis of the group rehabilitation or individual physiotherapy study, an assessor-blinded, randomized, noninferiority trial. Eligible participants included 362 community-dwelling older women with symptoms of stress/mixed UI. After learning how to contract PFMs, participants completed 12 weeks of PFM training, either individually (one-on-one) or as part of a group (eight women). Pelvic floor transperineal ultrasound volumes (morphometry), PFM intravaginal dynamometric data (function), and self-efficacy in performing PFM exercises were acquired at baseline, posttreatment, and at 1 year.

RESULTS

Groups were comparable at all time points. Immediately posttreatment, both groups demonstrated significant changes in pelvic floor morphometry during coughs, and in PFM function during contractions and coughs. Participants also reported improved self-efficacy in performing PFM exercises. Results were sustained at 1 year. When participants coughed, pelvic floor structures were better supported (reflected by less caudal movement of the puborectalis sling and a smaller opening of the levator hiatus) in a pattern consistent with the "knack" strategy. Furthermore, both interventions resulted in stronger, faster, more coordinated, and more endurant PFMs.

CONCLUSION

In older women with stress or mixed UI, both individual and group-based PFM training resulted in comparable improvements in overall PFM function, pelvic floor morphometry during coughs, and related self-efficacy in performing PFM exercises, which were sustained at 1 year.

Assessment of the Short-Term Effects after High-Inductive Electromagnetic Stimulation of Pelvic Floor Muscles: A Randomized, Sham-Controlled Study

Background: Physiotherapy should be performed by patients with stress or mixed urinary incontinence (SUI and MUI) to increase the strength and endurance of the pelvic floor muscles (PFMs). A method that can positively affect the pelvic floor is stimulation with high-inductive electromagnetic stimulation (HIES). The aim of the study was to evaluate the PFMs after the application of HIES in women with SUI and MUI by using surface electromyography (sEMG). Methods: This was a prospective, randomized, single-blind study with a sham intervention group. The participants were randomly assigned to the HIES group or sham group. The outcomes were features of the bioelectrical PFM activity assessed using sEMG and endovaginal probes. A single-session intervention in the HIES group included 20 min of HIES with an electromagnetic induction intensity of 2.5 T. Results: In the HIES group, there was a statistically significant difference in the PFM sEMG activity during “contractions” (p < 0.001) and “quick flicks” (p = 0.005). In the intergroup comparison, higher PFM sEMG activity after the intervention (“contraction”) was observed in the HIES group than in the sham group (after: p = 0.047; 1 h after: p = 0.017). Conclusions: The assessed HIES method seems effective for SUI and MUI patients in the short term and shows an advantage over the sham intervention in the assessment of PFM contractions.

Utility of 2D-ultrasound in pelvic floor muscle contraction and bladder neck mobility assessment in women with urinary incontinence

INTRODUCTION AND HYPOTHESIS

Assessment of pelvic floor muscle (PFM) contraction and bladder neck (BN) mobility in women with stress urinary incontinence (SUI) is essentially clinical. Ultrasound is increasingly used as a method for evaluating BN mobility and PFM contraction, but has not been standardized. The aim of this study was to review ultrasound technics and parameters that might be relevant for PFM contraction and BN mobility assessment in women with urinary incontinence (UI).

METHODS

We reviewed articles indexed in the MEDLINE database between 1988 and 2018 and selected articles which had a cohort of women with UI who had undergone functional 2D-ultrasound evaluation of PFM or BN mobility.

RESULTS

Transperineal ultrasound provides a panoramic view of the pelvic organs without modifying the anatomical relationship between the urethra and surrounding structural landmarks. One of the measurements used to assess urethral mobility is bladder neck descent (BND), which has been shown to be extremely reliable. Measuring the anteroposterior diameter (APD) of the urogenital levator hiatus can also reliably quantify PFM contraction in women. The more recently developed technique of elastography could be an additional useful non-invasive method for measuring periurethral striated muscle stiffness.

CONCLUSIONS

Several ultrasound parameters such as BND, anorectal angle displacement and periurethral stiffness as measured by elastography are relevant for investigating UI in women undertaking pelvic floor muscle training. Our hypothesis is that these ultrasound parameters can be correlated with urinary symptoms and clinical contraction assessment. They need to be validated for clinical use.

Electromyographic evaluation of synergist muscles of the pelvic floor muscle depending on the pelvis setting in menopausal women: A prospective observational study

BACKGROUND

Pelvic floor muscle (PFM) training is recommended to increase their strength and endurance. Muscles which act synergistically with PFM are taken into consideration in the therapeutic management of weakened PFM.

RESEARCH QUESTION

how does electromyography activity of the synergists muscle to PFM change concerning pelvis position and does the greater bioelectric activity of synergist muscles affect PFM function?

METHODS

A prospective, observational study evaluating the surface electromyography (sEMG) activity of selected synergist muscles of the PFM depending on the orientation of the pelvis. One hundred thirty-one menopausal women registered for the study were screened for inclusion and exclusion criteria, and by the results, eighty-two participants were enrolled for measurements. The comparisons of results between the values obtained in different positions of the pelvis (anterior pelvic tilt - P1, posterior pelvic tilt - P2 and neutral pelvic tilt - P3) were performed using Kruskal-Wallis test. A multivariate linear regression analysis was used to assess relationships between the bioelectrical activity of PFM and activity of all tested muscles - rectus abdominis (RA), gluteus maximus (GM), and adductor magnus (AM).

RESULTS

Higher RA, GM, AM bioelectrical activity was observed in the P2 as compared to P3 (during resting and functional PFM activity)(p < 0.05). Multivariate linear regression did not find the association between the bioelectrical activity of PFM and the activity of all synergist muscles in each position.

SIGNIFICANCE

sEMG activity of selected muscles acting synergistically with PFM differ depending on the pelvis position and is the highest in the posterior pelvic tilt. Greater activity of the synergists, resulting from the pelvic position, does not affect the myoelectric activity of PFM. It seems that muscles that act synergistically with PFM may not play such a significant role in the therapeutic management of PFM.

The impact of pelvic floor muscle training on the quality of life of women with urinary incontinence: a systematic literature review

Purpose

The purpose of this review was to assess the effectiveness of pelvic floor muscle training (PFMT) in the treatment of urinary incontinence (UI) in women, with a particular focus on the impact of this form of therapy on the patients' quality of life (QoL).

Methods

The following electronic databases were searched: PubMed, Embase, and Cochrane Library (articles only in English, 1990-2017). Search terms were as follows: urinary incontinence, pelvic floor muscle training, pelvic floor exercises, quality of life. Systematic review methods were based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement.

Results

The assessment of the impact of PFMT on the QoL of women with UI was conducted among 2,394 women in 24 selected studies. After the end of treatment, the majority of patients in the experimental groups noted a statistically significant improvement in QoL.

Conclusion

The results of this literature review demonstrate that PFMT is an effective treatment for UI in women. PFMT significantly improves the QoL of women with UI, which is an important determinant of their physical, mental, and social functioning.

Assessment of the effect of pelvic floor exercises on pelvic floor muscle strength using ultrasonography in patients with urinary incontinence: a prospective randomized controlled trial

[Purpose] The aim of this study was to evaluate whether the effect of pelvic floor exercises on pelvic floor muscle strength could be detected via ultrasonography in patients with urinary incontinence. [Subjects and Methods] Of 282 incontinent patients, 116 participated in the study and were randomly divided into a pelvic floor muscle training (n=65) group or control group (n=51). The pelvic floor muscle training group was given pelvic floor exercise training for 12 weeks. Both groups were evaluated at the beginning of the study and after 12 weeks. Abdominal ultrasonography measurements in transverse and longitudinal planes, the PERFECT scheme, perineometric evaluation, the stop test, the stress test, and the pad test were used to assess pelvic floor muscle strength in all cases. [Results] After training, the PERFECT, perineometry and transabdominal ultrasonography measurements were found to be significantly improved, and the stop test and pad test results were significantly decreased in the pelvic floor muscle training group, whereas no difference was observed in the control group. There was a positive correlation between the PERFECT force measurement scale and ultrasonography force measurement scale before and after the intervention in the control and pelvic floor muscle training groups (r=0.632 and r=0.642, respectively). [Conclusion] Ultrasonography can be used as a noninvasive method to identify the change in pelvic floor muscle strength with exercise training.

Pelvic floor muscle displacement during voluntary and involuntary activation in continent and incontinent women: a systematic review

INTRODUCTION

Investigations of the dynamic function of female pelvic floor muscles (PFM) help us to understand the pathophysiology of stress urinary incontinence (SUI). Displacement measurements of PFM give insight into muscle activation and thus help to improve rehabilitation strategies. This systematic review (PROSPERO 2013: CRD42013006409) was performed to summarise the current evidence for PFM displacement during voluntary and involuntary activation in continent and incontinent women.

METHODS

MEDLINE, EMBASE, Cochrane and SPORTDiscus databases were searched using selected terminology reflecting the PICO approach. Screening of Google Scholar and congress abstracts added to further information. Original articles investigating PFM displacement were included if they reported on at least one of the aims of the review, e.g., method, test position, test activity, direction and quantification of displacement, as well as the comparison between continent and incontinent women. Titles and abstracts were screened by two reviewers. The papers included were reviewed by two individuals to ascertain whether they fulfilled the inclusion criteria and data were extracted on outcome parameters.

RESULTS

Forty-two predominantly observational studies fulfilled the inclusion criteria. A variety of measurement methods and calculations of displacement was presented. The sample was heterogeneous concerning age, parity and continence status. Test positions and test activities varied among the studies.

CONCLUSIONS

The findings summarise the present knowledge of PFM displacement, but still lack deeper comprehension of the SUI pathomechanism of involuntary, reflexive activation during functional activities. We therefore propose that future investigations focus on PFM dynamics during fast and stressful impact tasks.

The effect of pelvic floor muscle training in urinary incontinent elderly women: a sistematic review

Introduction The International Continence Society (ICS) determines that the pelvic floor muscles training (PFMT) is the first-choice treatment of urinary symptoms in women. Objective The aim of this study was to systematize randomized controlled clinical trials that address the effects of PFMT in the treatment of urinary symptoms in older women using objective outcome measures. Method Systematic review search was performed eletronic the following databases: Medline, Pubmed, Lilacs, PEDro and manual research conducted in the references of the studies. Were considered eligible women aged over 60 years who performed PFMT in isolation, without the involvement of another technique. The PFMT performed in clinic or at home, with or without the supervision of a therapist and with or without the use of biofeedback as an adjunct. Considered as outcome measures urodynamic studies, voiding diary that assesses daytime urinary frequency, nocturnal urinary frequency, urinary incontinence and exchange absorbent, and, finally, the absorbent test that quantifies loss urinary grams. The assessment of methodological quality of the studies was conducted by PEDro scale. Results Three studies were reviewed in full. Only one trial was rated high methodological quality. There was significant improvement in urinary symptoms after treatment proposed in the three selected studies. Conclusion Considering the studies available so far are weak the evidence for the use of PFMT in the treatment of urinary symptoms in elderly women.

Ultrasound assessment of urethral support in women with stress urinary incontinence during and after first pregnancy

OBJECTIVE

To investigate the association of bladder neck position, bladder neck mobility, and levator hiatal dimensions with symptoms of stress urinary incontinence (SUI) using transperineal ultrasonography in women during and after their first pregnancy.

METHODS

In this prospective observational study, 280 nulliparous pregnant women were evaluated at 12 weeks of gestation, 36 weeks of gestation, and 6 months postpartum. At each visit, symptoms of SUI were assessed and transperineal ultrasound examination was performed at rest, on pelvic floor contraction, and on Valsalva maneuver. Bladder neck position, bladder neck mobility, and levator hiatal dimensions were determined offline. Independent-samples t tests were used to compare ultrasound data between women with and without SUI. Because multiple t tests were performed, the statistical significance level was corrected using the Bonferroni method.

RESULTS

There were 18.8% women who reported symptoms of SUI at 12 weeks of gestation, 47.2% at 36 weeks of gestation, and 37.5% at 6 months postpartum. During pregnancy, women with SUI had a significantly larger hiatal area compared with women without SUI (P=.001-.003). After childbirth, women with SUI had a significantly more caudal and dorsal position of the bladder neck on Valsalva maneuver than women without SUI (P=.004 and P=.001, respectively). There were no significant differences in bladder neck mobility between women with and without SUI.

CONCLUSION

Stress urinary incontinence during first pregnancy is associated with a larger hiatal area. After childbirth, SUI is associated with a more caudal and dorsal position of the bladder neck on Valsalva maneuver.

Pelvic floor muscle training in women with stress urinary incontinence causes hypertrophy of the urethral sphincters and reduces bladder neck mobility during coughing

AIMS

The purpose of this study was to determine the effect of a 12-week pelvic floor muscle (PFM) training program on urethral morphology and mobility in women with stress urinary incontinence (SUI).

METHODS

Forty women with SUI were randomly assigned to one of two groups: the treatment group received 12 weekly physiotherapy sessions during which they learned how to properly contract their pelvic floor muscles (PFMs) and a home exercise program was prescribed, reviewed, and progressed; the control group received no treatment. Before and after the 12-week study period, ultrasound imaging was used to evaluate bladder neck position and mobility during coughing and Valsalva maneuver in supine and in standing, as well as urethral morphology. Secondary outcome measures included a 3-day bladder diary, 30-min pad test, the Incontinence Impact Questionnaire (IIQ-7) and the Urogenital Distress Inventory (UDI-6).

RESULTS

The women in the treatment group demonstrated reduced bladder neck mobility during coughing and increased cross-sectional area of their urethra after as compared to before the training. These changes were not evident in the control group. No differences in the resting position of the bladder neck or in bladder neck excursion during Valsalva maneuver were noted in either group. Concomitantly the women in the treatment group demonstrated significant improvements in the 3-day bladder diary and IIQ-7 after the PFM training and improved significantly more than the control group.

CONCLUSION

Physiotherapist-supervised PFM training reduces bladder neck motion during coughing, and results in hypertrophy of the urethral sphincter in women who present with SUI.

Pelvic floor muscle training decreases hip adductors isometric peak torque in incontinent women: an exploratory study

INTRODUCTION: The pelvic floor muscle (PFM) training is the most common treatment for urinary incontinence (UI), however many women performed the contraction of PFM with associated contraction of abdominal, gluteus and hip adductors muscles. OBJECTIVE: To assess the effects of pelvic floor muscle (PFM) training on isometric and isokinetic hip adductors peak torque (PT) among women suffering from urinary incontinence (UI). MATERIALS AND METHODS: It is a longitudinal and prospective exploratory study. This study included 15 physically active women aged 45 years old and over, who presented complaints of UI. The PFM function (digital evaluation and perineometry), isometric and isokinetic hip adductors PT and one hour pad test were performed before and after treatment. The PFM training was performed in group, one hour once a week for 12 sessions. RESULTS: Significant improvement of PFM function and pressure level (p = 0.003), and significant decrease of hip adductors isometric PT and one-hour pad test, were found post-treatment. Moderate negative correlations between PFM contraction pressure and hip adductors isokinetic PT for dominant side (DS) (r = -0.62; p = 0.03) and non-dominant side (NDS) (r = -0.64; p = 0.02); and between PFM fast fibers contraction and hip adductors isometric PT for DS (r = -0.60; p = 0.03) and NDS (r = -0.59; p = 0.04) were also found. CONCLUSIONS: The PFM training decreased hip adductors PT and improved PFM functions and UI.

Are pelvic floor muscle thickness and size of levator hiatus associated with pelvic floor muscle strength, endurance and vaginal resting pressure in women with pelvic organ prolapse stages I-III? A cross sectional 3D ultrasound study

AIMS

To investigate if pelvic floor muscle (PFM) thickness and area of levator hiatus (LH) are associated with manometry measured PFM function in 109 women with pelvic organ prolapse (POP) stages I-III.

METHODS

In this cross-sectional study pubovisceral muscle thickness and LH area were assessed with three-dimensional transperineal ultrasound at rest and analyzed in the axial plane. PFM function was assessed with manometry and included strength, endurance, and vaginal resting pressure. Relationships were investigated using univariate linear logistic regressions models, Pearson product-moment correlation coefficient and hierarchical multiple regression.

RESULTS

The mean age was 49 (SD 12). There was a significant positive moderate association between muscle thickness and PFM strength (r = 0.49, P < 0.001) and endurance (r = .45, P < 0.001). A moderate negative association was found between LH area and vaginal resting pressure (r = -0.46, P < 0.001), strength (r = -0.41, P < 0.001) and endurance (r = -0.40, P < 0.001). Multivariate analyses included PFM strength, endurance, vaginal resting pressure, age, parity, BMI and socioeconomic status. Muscle thickness was best explained by PFM strength and LH area was best explained by vaginal resting pressure. However, PFM function explained only 20.0% and 26.4% of the variance in muscle thickness and LH area after controlling for age, parity, BMI, and socioeconomic status.

CONCLUSION

There are moderate associations between measurements using ultrasound and manometry in POP women. Thicker muscles and smaller LH were associated with higher strength and endurance. Smaller LH was additionally associated with higher vaginal resting pressure. Ultrasound and manometry measure different aspects of the PFM and cannot be used interchangeably.

[Effects of pelvic floor muscle training on quality of life of a group of women with urinary incontinence: randomized controlled trial]

OBJECTIVE

To evaluate the effects of Kinesiotherapy on function and level of pressure of pelvic floor muscle and quality of life (QOL) of a group of women with urinary incontinence (UI).

MATERIALS AND METHODS

This is a randomized controlled pilot trial. Thirty women (age 60.87±9.05 years) were evaluated, before and after 12 weeks of treatment, for urinary loss, pelvic floor muscle function and pressure; and quality of life (QOL). Volunteers were randomly allocated into two groups: Kinesiotherapy Group and Control Group. The Kinesiotherapy Group protocol consisted of 12 1-hour sessions with exercises to strengthen pelvic floor muscle and information for UI. The Control Group did not receive any treatment during the corresponding time. The data were analyzed by non-parametric Wilcoxon and Mann-Whitney test. The significance level was 5%.

RESULTS

The Kinesiotherapy Group presented a significant improvement in urinary loss (p=0.053), pelvic floor muscle function (p<0.006) and pressure (p=0.0014) and in some domains of Kinǵs Health Questionnaire for QOL assessment: incontinence impact (p=0.034), limitations of daily activities (p=0.025), sleep and disposition (p=0.018) and also gravity domains (p=0.004). No differences were found in the control group for any variables.

CONCLUSION

The protocol to strengthen the pelvic floor muscle used by the Kinesiotherapy Group was effective to improve the UI, QOL, function and pressure of pelvic floor muscle contraction.

Effect of pelvic-floor muscle strengthening on bladder neck mobility: a clinical trial

BACKGROUND

Pelvic-floor muscle (PFM) strengthening has been widely used to treat people with urinary incontinence (UI). However, its effect on bladder neck position and stiffness is unknown.

OBJECTIVE

The aim of the study was to investigate the effect of PFM strengthening on bladder neck mobility for women with stress UI (SUI) or mixed UI (MUI).

DESIGN

This study was conducted as a single-group pretest-posttest design.

SETTING

This study was conducted mainly at the Life Quality & Health Promotion Laboratory at National Taiwan University and partly in the Ultrasonography Room of the Department of Obstetrics and Gynecology at National Taiwan University Hospital. Patients Twenty-three patients (mean age=51.9 years, SD=6.1) participated in the study.

INTERVENTION AND MEASUREMENTS

Each participant underwent a PFM strengthening program for 4 months. Bladder neck position at rest and during a cough, the Valsalva maneuver, and a PFM contraction was assessed by transperineal ultrasonography before and after the intervention. Severity Index score, self-reported improvement, PFM strength (force-generating capacity), and vaginal squeeze pressure were assessed for treatment effect.

RESULTS

The position of the bladder neck at PFM contraction and bladder neck mobility for maximal incursion from rest to PFM contraction were elevated, with effect sizes of 0.48 and 0.84, respectively. Bladder neck position and bladder neck mobility were not changed during a cough and the Valsalva maneuver. All participants reported diminution of incontinence, and PFM strength and maximal vaginal squeeze pressure were improved after the intervention. Limitations The limitations of the present trial included the pretest-posttest design and the absence of intra-abdominal pressure measuring and exercise adherence recording.

CONCLUSIONS

Four months of daily PFM strengthening can significantly improve the ability of the PFM to elevate the bladder neck voluntarily, but may not improve its stiffness during a cough and the Valsalva maneuver for women with SUI and MUI.

Evaluation of a behavioral treatment for female urinary incontinence

Urinary incontinence is a medical, psychological, social, economic, and hygienic problem. Although it is difficult to state its prevalence, all authors agree that it is related to age and gender. This study aimed to carry out a urinary incontinence behavioral treatment in order to reduce urine leakages in 14 participants recruited from a senior center. The program consists of daily training of the pelvic floor muscles with a weekly control by a supervisor during a 2-month period and follow-up of results 2 months after the last control session. Urinary incontinence episodes were reduced by 75.67% after program completion. It appears that pelvic floor muscles training, carried out under controlled and constant supervision, significantly reduces urinary leakage. Moreover, maintaining this improvement after treatment depends on the continuation of the exercises as well as on the urinary leakage frequency baseline and the urinary leakage frequency during the last treatment session.

Pelvic floor exercise for urinary incontinence: a systematic literature review

Urinary incontinence is a common problem among adults and conservative management is recommended as the first-line treatment. Physical therapies, particularly pelvic floor muscle exercise, are the mainstay of such conservative management. The purpose of this review is to summarise current literature and describe trends in the use of pelvic floor muscle exercise in the management of urinary incontinence in women. Our review confirms that pelvic floor muscle exercise is particularly beneficial in the treatment of urinary stress incontinence in females. Studies have shown up to 70% improvement in symptoms of stress incontinence following appropriately performed pelvic floor exercise. This improvement is evident across all age groups. There is evidence that women perform better with exercise regimes supervised by specialist physiotherapists or continence nurses, as opposed to unsupervised or leaflet-based care. There is evidence for the widespread recommendation that pelvic floor muscle exercise helps women with all types of urinary incontinence. However, the treatment is most beneficial in women with stress urinary incontinence alone, and who participate in a supervised pelvic floor muscle training programme for at least three months.

Morphological changes after pelvic floor muscle training measured by 3-dimensional ultrasonography: a randomized controlled trial

OBJECTIVE

To investigate morphological and functional changes after pelvic floor muscle training in women with pelvic organ prolapse.

METHODS

This randomized controlled trial was conducted at a university hospital and a physical therapy clinic. One hundred nine women with pelvic organ prolapse stages I, II, and III were randomly allocated by a computer-generated random number system to pelvic floor muscle training (n=59) or control (n=50). Both groups received lifestyle advice and learned to contract the pelvic floor muscles before and during increases in intraabdominal pressure. In addition the pelvic floor muscle training group did individual strength training with a physical therapist and daily home exercise for 6 months. Primary outcome measures were pelvic floor muscle (pubovisceral muscle) thickness, levator hiatus area, pubovisceral muscle length at rest and Valsalva, and resting position of bladder and rectum, measured by three-dimensional ultrasonography.

RESULTS

Seventy-nine percent of women in the pelvic floor muscle training group adhered to at least 80% of the training protocol. Compared with women in the control group, women in the pelvic floor muscle training group increased muscle thickness (difference between groups: 1.9 mm, 95% confidence interval [CI] 1.1-2.7, P<.001), decreased hiatal area (1.8 cm, 95% CI 0.4-3.1, P=.026), shortened muscle length (6.1 mm, 95% CI 1.5-10.7, P=.007), and elevated the position of the bladder (4.3 mm, 95% CI 2.1-6.5, P<.000) and rectum (6.7 mm, 95% CI 2.2-11.8, P=.007). Additionally, they reduced the hiatal area and muscle length at maximum Valsalva indicating increased pelvic floor muscle stiffness.

CONCLUSION

Supervised pelvic floor muscle training can increase muscle volume, close the levator hiatus, shorten muscle length, and elevate the resting position of the bladder and rectum.

CLINICAL TRIAL REGISTRATION

www.clinicaltrials.gov, NCT00271297.

LEVEL OF EVIDENCE

I.

Diabetes mellitus and geriatric syndromes

Diabetes mellitus is associated with an increased prevalence and incidence of geriatric syndrome: functional disabilities, depression, fall, urinary incontinence, malnutrition and cognitive impairment. Geriatric syndrome not only leads to frailty, loss of independence and low quality of life, but also becomes a major obstacle in the treatment and care of diabetic people. The risk factors or contributing factors of geriatric symptoms are micro- and macrovascular complications, age-rated comorbid disease and aging per se. Comprehensive geriatric assessment of geriatric syndrome, including basic activities of daily living, instrumental activities of daily living, gait and balance, visual acuity, the Mini-Mental State Examination, depression scores, history and risk of fall, urination and nutrition, should be performed as part of the care of elderly diabetic patients, in particular old-old patients. Because geriatric syndromes are multifactorial and share risk factors, diabetic people with any geriatric symptoms should be treated with a common concentric strategy, such as supervised exercise therapy including muscle-strengthening training, psychological support, social support for adherence, and good glycemic control with avoidance of hypoglycemia.

Stem cells for stress urinary incontinence: the adipose promise

Stress urinary incontinence (SUI), the most common type of incontinence in women, is a frequent and costly ailment responsible for an alteration in the quality of life. Although medical treatment gives some rather deceiving results, surgical techniques that include colposuspension or tension-free vaginal tape, employed in cases of urethral support defect, give a 5-year cure rate of more than 80%. However, these techniques could lead to complications or recurrence of symptoms. Recently, the initiation of urethral cell therapy has been undertaken by doctors and researchers. One principal source of autologous adult stem cells is generally used: muscle precursor cells (MPCs) which are the progenitors of skeletal muscle cells. Recently, a few research groups have shown interest in the MPCs and their potential for the treatment of urinary incontinence. However, using MPCs or fibroblasts isolated from a striated muscle biopsy could be questionable on several points. One of them is the in vitro cultivation of cells, which raises issues over the potential cost of the technique. Besides, numerous studies have shown the multipotent or even the pluripotent nature of stromal vascular fraction (SVF) or adipose-derived stem cells (ASCs) from adipose tissue. These cells are capable of acquiring in vitro many different phenotypes. Furthermore, recent animal studies have highlighted the potential interest of SVF cells or ASCs in cell therapy, in particular for mesodermal tissue repair and revascularization. Moreover, the potential interest of SVF cells or ASCs for the treatment of urinary incontinence in women is supported by many other characteristics of these cells that are discussed here. Because access to these cells via lipoaspiration is simple, and because they are found in very large numbers in adipose tissue, their future potential as a stem cell reservoir for use in urethral or other types of cell therapy is enormous.

Evidence for benefit of transversus abdominis training alone or in combination with pelvic floor muscle training to treat female urinary incontinence: A systematic review

AIMS

Pelvic floor muscle training (PFMT) has Level A evidence to treat female urinary incontinence (UI). Recently, indirect training of the pelvic floor muscles (PFM) via the transversus abdominis muscle (TrA) has been suggested as a new method to treat UI. The aim of this article is to discuss whether there is evidence for a synergistic co-contraction between TrA and PFM in women with UI, whether TrA contraction is as effective, or more effective than PFMT in treating UI and whether there is evidence to recommend TrA training as an intervention strategy.

METHODS

A computerized search on PubMed, and hand searching in proceedings from the meetings of the World Confederation of Physical Therapy (1993-2007), International Continence Society and International Urogynecology Association (1990-2007) were performed.

RESULTS

While a co-contraction of the TrA normally occurs with PFM contraction, there is evidence that a co-contraction of the PFM with TrA contraction can be lost or altered in women with UI. No randomized controlled trials (RCTs) were found comparing TrA training with untreated controls or sham. Two RCTs have shown no additional effect of adding TrA training to PFMT in the treatment of UI.

CONCLUSIONS

To date there is insufficient evidence for the use of TrA training instead of or in addition to PFMT for women with UI. Neurourol. Urodyn. 28:368-373, 2009. (c) 2009 Wiley-Liss, Inc.

Influência da atividade física na qualidade de vida e auto-imagem de mulheres incontinentes

Nosso objetivo foi verificar a influência de uma proposta de atividades físicas na qualidade de vida e na auto-imagem de mulheres incontinentes. Constituiu-se de um estudo comparativo e exploratório realizado durante 16 semanas. Participaram 37 mulheres com e sem incontinência urinária (IU). Após o estudo observamos melhora significativa nos domínios relacionados com a percepção geral de saúde (p < 0,001), impacto da IU (p = 0,035), limitações físicas (p = 0,015), relações pessoais (p = 0,048), sono e disposição (p = 0,012) e em relação às medidas de gravidade (p = 0,011). Na auto-imagem não foram verificadas alterações quanto à aparência; todavia, quanto à satisfação corporal, observamos que as mulheres passaram a sentir-se menos satisfeitas com seu corpo (p = 0,007). Foi relatada diminuição no número de regiões onde sentiam dores (p = 0,0003) e de que não gostavam (p = 0,0017). Conclui-se que os profissionais de Educação Física, por meio de uma proposta de atividades físicas sistematizada e integrada, podem levar mulheres com IU a melhora significativa na percepção de sua qualidade de vida e de sua saúde, em aspectos relacionados à sua auto-imagem e à melhora nos sintomas de IU, com a diminuição da frequência e quantidade da perda urinária.

"Diagnostic investigation of the pelvic floor": a helpful tool in the approach in patients with complaints of micturition, defecation, and/or sexual dysfunction

INTRODUCTION

Pelvic floor dysfunction is recognized to be related to lower urinary tract dysfunction and to lower gastrointestinal symptoms, and is an influential factor in dysfunction and subsequent behavior of the genital system in both men and women. Caregivers should be informed regarding normal pelvic floor function in general and should be able to identify specific aspects of pelvic floor dysfunction in patients with related symptoms. In our hospital, this diagnostic consultation is indicated as Diagnostic Investigation of Pelvic Floor Function (DIPFF).

AIM

This study looked at pelvic floor dysfunction related to specific complaints.

METHODS

DIPFF consists of a medical history, a physical examination, including the International Continence Society (ICS) pelvic organ prolapse quantification system in female patients, and a biofeedback registration using a vaginal or anal probe. Based on our experience, we defined an elevated rest tone as greater than 2 microV using intravaginal or intra-anal electromyography.

MAIN OUTCOME MEASURES

Stratification of patients with a single complaint, a combination of two or three complaints of the micturition, defecation or sexual (all compartments of the pelvic floor) resulted in subgroups of respectively 30, 74, and 133 patients.

RESULTS

A total of 238 patients with complaints of micturition, defecation, and/or sexual function were included in this study. Electromyographic analysis revealed an elevated rest tone of the pelvic floor in 141 patients. In 184 patients, we found an involuntary relaxation of the pelvic floor.

CONCLUSION

In our retrospective study, we found that 77.2% of patients who presented to the clinic with urinary, gastro or sexual complaints had measurable pelvic floor dysfunction (69.3% overactive rest tone and 7.9% under active rest tone). In relation to the ICS terminology, there is a need for a well-defined normal vs. elevated rest tone of the pelvic floor.

A randomised partially controlled trial to assess the impact of self-help vs. structured help from a continence nurse specialist in women with undiagnosed urinary problems in primary care

AIMS

To identify women in primary care aged 45-64 years with urinary problems using the Female Urinary Symptom Score (FUSS) assessment tool, and to compare the effectiveness of a self-help leaflet with structured help from a continence nurse.

METHODS

The women were sent a questionnaire and grouped according to FUSS score as mild moderate or severe. The mild group received no intervention. The moderate group was randomised into three: one received no intervention, one receiving a self-help leaflet and one receiving an offer of structured help. The severe group was randomised into two: structured help at a continence clinic or a self-help leaflet. The women were followed up on two occasions to assess effects of the interventions.

RESULTS

A total of 1175 women participated in the study and were categorised at baseline into mild (n = 764), moderate (n = 325) or severe (n = 86). Response rates to initial follow-up varied from 50% to 86% across the study. Intervention groups reported significant reduction in mean FUSS score ranging from 1.2 points (moderate leaflet group) to 7.8 points (severe structured help group). The two non-intervention groups reported low levels of FUSS change (mild + 0.7 and moderate non-intervention -0.4). There was a strong association between quality of life (QoL) and FUSS score, with improvement in QoL when FUSS score fell. At follow-up improvement was sustained.

CONCLUSION

The trial has shown that the FUSS questionnaire has potential for identifying women with bothersome urinary symptoms and can be utilised in primary care. Both leaflet and structured help were effective.

Test–retest and intra-observer repeatability of two-, three- and four-dimensional perineal ultrasound of pelvic floor muscle anatomy and function

The aims of the present study were to evaluate test-retest intra-observer repeatability of ultrasound measurement of the morphology and function of the pelvic floor muscles (PFMs). Seventeen subjects were tested twice. Two-, three- and four- dimensional ultrasound recorded cough, huff, muscle morphology and PFM contraction, respectively. Analyses were conducted offline. Measurements of levator hiatal dimensions demonstrated intra-class correlation coefficient (ICC) values of 0.61, 0.72, 0.86 and 0.92, for the anterior-posterior dimension, transverse dimension, resting area and narrowing during contraction, respectively. Muscle thickness showed variable reliability. ICC values for measurement of the position of the bladder neck were 0.86 and 0.82 at rest, in the vertical and horizontal direction. Displacement of the bladder neck during contraction, huff and cough demonstrated ICC values of 0.56, 0.59 and 0.51, respectively. Perineal ultrasound is a reliable method for measuring most of the tested parameters of morphology and function of the PFMs.