Assessment of Involuntary PFM Contractions in Comparison with Existing Literature and IUGA/ICS Terminology Reports

INTRODUCTION AND HYPOTHESIS

Involuntary pelvic floor muscle (PFM) contractions are thought to occur during an increase in intra-abdominal pressure (IAP). Although no studies have assessed their presence in women with normal pelvic floor (PF) function, existing literature links the absence of involuntary PFM contractions to various PF dysfunctions. This study rectifies this lacuna by evaluating involuntary PFM contractions during IAP in healthy nulliparous women with no PF dysfunction, using visual observation and vaginal palpation. Results were compared with the literature and the IUGA/ICS Terminology Reports.

METHODS

Nulliparous (n=149) women performed three sets of three maximal coughs. Visual observation and vaginal palpation were conducted in the standing and supine positions. The women were not instructed to contract their PFMs. Occurrence rates were calculated for each assessment method and position; differences between positions were analyzed using the Chi-squared test.

RESULTS

Rates of occurrence of involuntary PFM contraction were low across both assessments and positions (5-17%). Significant differences were found between standing (5%) and supine (15%) positions for visual observation, but not vaginal palpation (15%, 17% respectively). Occurrence rates also differed compared with the literature and terminology reports.

CONCLUSIONS

Contrary to clinical expectations, rates of occurrence of involuntary PFM contraction among our cohort of nulliparous women were extremely low. Digital palpation results showed high agreement with the terminology reports, but only partial agreement was observed for the visual observation results. Our study underscores the need for more research aimed at defining normal involuntary PF functions, a review of our understanding of involuntary PFM contractions, and better standardized guidelines for involuntary PFM assessment methods.

Study protocol to investigate biomolecular muscle profile as predictors of long-term urinary incontinence in women with gestational diabetes mellitus

BACKGROUND

Pelvic floor muscles (PFM) and rectus abdominis muscles (RAM) of pregnant diabetic rats exhibit atrophy, co-localization of fast and slow fibers and an increased collagen type I/III ratio. However, the role of similar PFM or RAM hyperglycemic-related myopathy in women with gestational diabetes mellitus (GDM) remains poorly investigated. This study aims to assess the frequency of pelvic floor muscle disorders and pregnancy-specific urinary incontinence (PS-UI) 12 months after the Cesarean (C) section in women with GDM. Specifically, differences in PFM/RAM hyperglycemic myopathy will be evaluated.

METHODS

The Diamater is an ongoing cohort study of four groups of 59 pregnant women each from the Perinatal Diabetes Research Centre (PDRC), Botucatu Medical School (FMB)-UNESP (São Paulo State University), Brazil. Diagnosis of GDM and PS-UI will be made at 24-26 weeks, with a follow-up at 34-38 weeks of gestation. Inclusion in the study will occur at the time of C-section, and patients will be followed at 24-48 h, 6 weeks and 6 and 12 months postpartum. Study groups will be classified as (1) GDM plus PS-UI; (2) GDM without PS-UI; (3) Non-GDM plus PS-UI; and (4) Non-GDM without PS-UI. We will analyze relationships between GDM, PS-UI and hyperglycemic myopathy at 12 months after C-section. The mediator variables to be evaluated include digital palpation, vaginal squeeze pressure, 3D pelvic floor ultrasound, and 3D RAM ultrasound. RAM samples obtained during C-section will be analyzed for ex-vivo contractility, morphological, molecular and OMICS profiles to further characterize the hyperglycemic myopathy. Additional variables to be evaluated include maternal age, socioeconomic status, educational level, ethnicity, body mass index, weight gain during pregnancy, quality of glycemic control and insulin therapy.

DISCUSSION

To our knowledge, this will be the first study to provide data on the prevalence of PS-UI and RAM and PFM physical and biomolecular muscle profiles after C-section in mothers with GDM. The longitudinal design allows for the assessment of cause-effect relationships between GDM, PS-UI, and PFMs and RAMs myopathy. The findings may reveal previously undetermined consequences of GDM.

Traditional Gymnastic Exercises for the Pelvic Floor Often Lead to Bladder Neck Descent - a Study Using Perineal Ultrasound

BACKGROUND

The aims of physiotherapy in stress incontinent women are to improve pelvic floor function and the continence mechanism including bladder neck support and urethral closure pressure. In Germany, traditional conservative treatment often includes gymnastic exercises with unclear effects on the bladder neck. The aim of this study was to sonographically assess bladder neck movements during selected exercises.

METHODS

Fifteen healthy, continent women without previous vaginal births, who were able to voluntarily contract their pelvic floor muscels performed the shoulder bridge, the abdominal press, tiptoe and the Pilates clam exercises. The first set was performed without any additional instructions. During the second set directions were given to activate the pelvic floor before beginning each exercise and to maintain the contraction throughout the exercise. Bladder neck movement was measured on perineal ultrasound using a validated method with the pubic symphysis as a reference point.

RESULTS

The median age of participants was 32 years, median BMI was 23. Eight women were nulliparous and seven had given birth to 1 - 2 children via caesarean section. When exercises were performed without voluntary pelvic floor contraction the bladder neck descended on average between 2.3 and 4.4 mm, and with pelvic floor contraction prior to the exercise only between 0.5 and 2.1 mm (p > 0.05 except for abdominal press p = 0.007). The Pilates clam exercise and toe stand stabilised the bladder neck most effectively.

DISCUSSION

Bladder neck descent often occurs during pelvic floor gymnastic exercises as traditionally performed in Germany, and a voluntary pelvic floor contraction during the exercises does not necessarily prevent this.

Development and Validation of a Questionnaire for the Assessment of Pelvic Floor Disorders and Their Risk Factors During Pregnancy and Post Partum

Introduction The aim of this study was to develop and validate a questionnaire for the assessment of pelvic floor disorders, their symptoms and risk factors in pregnancy and after birth including symptom course, severity and impact on quality of life. Methods The validated German pelvic floor questionnaire was modified and a new risk factor domain developed. The questionnaire was initially completed by 233 nulliparous women in the third trimester of pregnancy and at six weeks (n = 148) and one year (n = 120) post partum. Full pyschometric testing was performed. The clinical course of symptoms and the influence of risk factors were analysed. Results Study participants had a median age of 31 (19-46) years. 63 % had spontaneous vaginal deliveries, 15 % operative vaginal deliveries and 22 % were delivered by caesarean section. Content validity: Missing answers never exceeded 4 %. Construct validity: The questionnaire distinguished significantly between women who reported bothersome symptoms and those who did not. Reliability: Cronbach's alpha values exceeded 0.7 for bladder, bowel and support function, and 0.65 for sexual function. The test-retest analysis showed moderate to almost complete concordance. The intraclass coefficients for domain scores (between 0.732 and 0.818) were in acceptable to optimal range. Reactivity: The questionnaire was able to track changes significantly with good effect size for each domain. Risk factors for pelvic floor symptoms included familial predisposition, maternal age over 35 years, BMI above 25, nicotine abuse, subjective inability to voluntarily contract the pelvic floor musculature and postpartum wound pain. Conclusion This pelvic floor questionnaire proved to be valid, reliable and reactive for the assessment of pelvic floor disorders, their risk factors, incidence and impact on quality of life during pregnancy and post partum. The questionnaire can be utilised to assess the course of symptoms and treatment effects using a scoring system.

Diagnosis and Therapy of Female Pelvic Organ Prolapse. Guideline of the DGGG, SGGG and OEGGG (S2e-Level, AWMF Registry Number 015/006, April 2016)

Aims: The aim was to establish an official interdisciplinary guideline, published and coordinated by the German Society of Gynecology and Obstetrics (DGGG). The guideline was developed for use in German-speaking countries. In addition to the Germany Society of Gynecology and Obstetrics, the guideline has also been approved by the Swiss Society of Gynecology and Obstetrics (SGGG) and the Austrian Society of Gynecology and Obstetrics (OEGGG). This is a guideline published and coordinated by the DGGG. The aim is to provide evidence-based recommendations obtained by evaluating the relevant literature for the diagnostic, conservative and surgical treatment of women with female pelvic organ prolapse with or without stress incontinence. Methods: We conducted a systematic review together with a synthesis of data and meta-analyses, where feasible. MEDLINE, Embase, Cinahl, Pedro and the Cochrane Register were searched for relevant articles. Reference lists were hand-searched, as were the abstracts of the Annual Meetings of the International Continence Society and the International Urogynecological Association. We included only abstracts of randomized controlled trials that were presented and discussed in podium sessions. We assessed original data on surgical procedures published since 2008 with a minimum follow-up time of at least 12 months. If the studies included descriptions of perioperative complications, this minimum follow-up period did not apply. Recommendations: The guideline encompasses recommendations for the diagnosis and treatment of female pelvic organ prolapse. Recommendations for anterior, posterior and apical pelvic organ prolapse with or without concomitant stress urinary incontinence, uterine preservation options, and the pros and cons of mesh placements during surgery for pelvic organ prolapse are presented. The recommendations are based on an extensive and systematic review and evaluation of the current literature and include the experiences and specific conditions in Germany, Austria and Switzerland.

[Validation of a pelvic floor questionnaire with improvement and satisfaction scales to assess symptom severity, bothersomeness and quality of life before and after pelvic floor therapy]

BACKGROUND

The aim of this study was to integrate and validate an additional post-treatment module including improvement and satisfaction scales to the validated German pelvic floor questionnaire.

METHODS

The questionnaire contained the domains bladder, bowel prolapse, and sexual symptoms. It was completed by 55 patients before and after specific pelvic floor rehabilitation. A post-therapy module with improvement and satisfaction scales was integrated and tested psychometrically.

RESULTS

Missing data did not exceed 4%. Improvement and satisfaction correlated significantly with bladder and bowel domain scores. Test-retest reliability showed moderate to good agreement. The questionnaire was sensitive to change with a large effect size. The improvement of bladder symptoms in 91% of the women correlated with the domain score.

CONCLUSION

The validated German pelvic floor questionnaire including a post-treatment module assesses symptoms, improvement and satisfaction in a reliable and reproducible fashion.

International indoor and outdoor evaluation of Bacillus sphaericus products: complexity of standardizing outdoor protocols

Only one Bacillus sphaericus strain, strain 2362, is currently used commercially to control Culex larval populations. A reliable methodology, easily used, was developed to identify new strains for field application. Larvicidal activities of 3 highly mosquitocidal strains, strains C3-41, Mal, and LB24, previously selected in the laboratory, were compared with that of strain 2362 in tropical and European countries. The following steps were performed: production and titration of acetonic powders from these 4 strains on local Culex species, survey of initial and residual activity under standardized indoor and outdoor conditions, and evaluation of the efficacy of liquid formulations of the 4 strains in natural breeding sites of Culex. In indoor conditions, strain C3-41 showed the highest activity on both Culex pipiens and Culex quinquefasciatus; strain Mal was the least active. The residual activity causing 80% mortality differed from 20 to 90 days according to the strains and the country. Outdoor experiments with powders (0.02-1.6 mg/liter) were performed and the initial toxicities were similar in all cases. Residual activities were very different, from 6 to 95 days posttreatment. Liquid formulations were applied to larval habitats (from 0.1 to 10 g/m2). In tropical countries, larval recolonization in cesspits or ponds occurred after 10-35 days. In Europe, higher doses were needed in polluted water than in clear water (from 3 to 10 liter/ha) for the same control, and the time before 80% residual activity was reached was less than 9-12 days. However, in cesspits, residual activity could be observed for 12 days to 5 mo. A strain 3-5 times more active than the others in bioassays is not significantly detectable from those strains in field trials.