Improving the Technique of Pelvic Floor Muscle Contraction in Active Nulliparous Women Attending a Structured High-Low Impact Aerobics Program-A Randomized Control Trial

Learning the correct technique of performing pelvic floor muscle (PFM) exercises is a very important factor influencing the effectiveness of this muscle group training. Correctly performed PFM contractions are involved in the urinary continence mechanism. In this study, we tested the hypothesis that a six-week high-low impact aerobics program, supported by one EMG biofeedback session and pelvic floor muscle training, improves the technique of PFM contraction. Participants were 42 active nulliparous women (age 22 ± 2 years, mean ± SD), randomly allocated into intervention (n = 18) and control (n = 24) groups. We analyzed the technique of PFM contractions, taking into account the order in which selected muscle groups were activated, so called 'firing order'. In both groups, we assessed the PFM contraction technique using surface electromyography (sEMG) and intravaginal probes, before and after six weeks of intervention. The intervention group received one biofeedback session on how to properly contract PFM and afterwards participated in a high-low impact aerobics program supplemented by PFM training. The control group did not receive any intervention. In the pre-test, 67% of the intervention group activated PFM first in order in short, quick contractions. After six weeks of training, this task was correctly performed by 100% of this group (p = 0.04). The proper performance of PFM short contraction in the control group was 75% and 67%, before and after intervention, respectively. In the intervention group we also observed statistically significant improvement in the PFM contraction technique in 10-s contractions. The presented intervention was beneficial for the improvement of PFM contraction. High-low impact aerobics, supplemented by one EMG biofeedback session and pelvic floor muscle training can be recommended for active nulliparous women.

Evaluation of the effect of levator ani muscle contraction on post-prostatectomy urinary incontinence using cine MRI

AIM

Post-prostatectomy urinary incontinence (PPI) is the greatest concern for urologists after radical prostatectomy (RP). It is thought that PPI is composed of multiple factors including static and dynamic components. The purpose of this study is to show visually levator ani muscle (LAM) contraction during pelvic floor muscle contraction and to evaluate the dynamic differences in its contraction between men with and without PPI.

METHODS

This study was a case-control study of the urinary continent or incontinent men. It investigated whether LAM contraction was involved in urinary leakage based on examination of LAM contraction by cine magnetic resonance imaging.

RESULTS

The LAM contracted from the coccyx to the pubis in the same manner before and after surgery. The degree of contraction of the LAM in post-prostatectomy groups was smaller than that in the healthy adult group. The contraction distances of each part of the pelvic floor were decreased by 50%-70% in the incontinence group compared to those in the continence group. The bladder neck moved 2.5-fold further in the continence group and the direction of movement was more vertical than in the incontinence group. Urethral compression was attenuated by about 40% in the incontinence group compared to that in the continence group.

CONCLUSIONS

RP can cause damage to the LAM. LAM contraction is reduced after RP compared with that in healthy adult men. In men with PPI, the reduced muscle contraction might not compress the urethra sufficiently when abdominal pressure is raised. Pelvic floor muscle training might provide a meaningful method for the recovery of LAM contraction in patients with PPI.

Levator ani muscle morphology and function in women with obstetric anal sphincter injury

OBJECTIVES

To estimate the prevalence of, and explore the risk factors for, levator ani muscle (LAM) injury in women with clinically diagnosed obstetric anal sphincter injury (OASI). The secondary aim was to assess the association between LAM injury and pelvic floor muscle contraction, anal incontinence (AI) and urinary incontinence (UI) in women with OASI.

METHODS

This was a cross-sectional study of 250 women with OASI, recruited between 2013 and 2015 from a tertiary referral center at Croydon University Hospital, UK. AI symptoms were assessed using the modified St Mark's incontinence score and UI was assessed using the International Consultation on Incontinence modular Questionnaire for Urinary Incontinence - Short Form. All participants underwent three/four-dimensional transperineal ultrasound at rest and on maximum pelvic floor muscle contraction. Major LAM injury was defined as a unilateral or bilateral defect in all three central slices on tomographic ultrasound imaging. Muscle contraction was assessed using the modified Oxford scale (MOS) and measured on ultrasound as the proportional change in the anteroposterior (AP) levator hiatal diameter between rest and contraction. Multivariable logistic regression analysis was used to study risk factors for LAM injury. Differences in contraction and AI and UI symptoms between women with intact and those with injured LAM were studied using multivariable ANCOVA and the Mann-Whitney U-test.

RESULTS

Of the 248 women with OASI for whom ultrasound volumes of adequate quality were available, 29.4% were found to have major LAM injury. The prevalence of LAM injury was 23.6% after normal vaginal delivery and 40.2% after operative vaginal delivery (adjusted odds ratio, 4.1 (95% CI, 1.4-11.9); P = 0.01). LAM injury was associated with weaker pelvic floor muscle contraction, with an adjusted mean difference for proportional change in AP diameter of 5.0 (95% CI, 3.0-6.9) and MOS of 0.6 (95% CI, 0.3-0.9) (P < 0.001 for both). AI and UI symptom scores were similar between women with intact and those with injured LAM.

CONCLUSIONS

Operative vaginal delivery was a risk factor for LAM injury in women with OASI. LAM injury was associated with weaker pelvic floor muscle contraction. Special attention is recommended for women with OASI and LAM injury, as they are at high risk for future pelvic floor disorders. The benefits of implementation of an intensive, focused and structured pelvic floor rehabilitation program need to be evaluated in these women. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Association between pelvic floor muscle trauma and contraction in parous women from a general population

OBJECTIVE

To study possible associations between pelvic floor muscle contraction, levator ani muscle (LAM) trauma and/or pelvic organ prolapse (POP) ≥ Stage 2 in parous women recruited from a general population.

METHODS

This was a secondary analysis of data from a cross-sectional study of 608 parous women from a general population examined using the POP quantification system (POP-Q) and three-dimensional/four-dimensional transperineal ultrasound for identification of LAM macrotrauma (avulsion) and microtrauma (distension of levator hiatal area > 75^th percentile on Valsalva maneuver). Muscle contraction was assessed using the modified Oxford scale (MOS), perineometry and ultrasound measurement of proportional change of anteroposterior hiatal diameter and levator hiatal area at rest and on pelvic floor muscle contraction. The Mann-Whitney U-test was used to study associations between pelvic floor muscle contraction, LAM trauma and POP.

RESULTS

Women with macrotrauma (n = 113) had significantly weaker median pelvic floor muscle contraction, as measured using MOS and perineometry, than did women with an intact LAM (n = 493) (contraction strength was 1.5 (range, 0.0-5.0) vs 3.5 (range, 0.0-5.0) on MOS, and vaginal squeeze pressure was 15.0 (range, 0.0-78.0) cmH₂ O vs 28.0 (range, 0.0-129.0) cmH₂ O on perineometry; P < 0.001). This was also demonstrated by ultrasound measurement, with a proportional change in hiatal area of 19.9% (range, 4.1-48.0%) vs 34.0% (range, 0.0-64.0%) (P < 0.001) and proportional change in anteroposterior diameter of 16.2% (range, -5.7 to 42.6%) vs 26.0% (range, -3.4 to 49.4%) (P < 0.001). No statistically significant difference between women with (n = 65), and those without (n = 378), microtrauma was found after excluding women with macrotrauma. Women with POP had weaker muscle contraction than those without; in those with POP-Q ≥ 2 (n = 275) compared with those with POP-Q < 2 (n = 333), muscle contraction strength was 3.0 (range, 0.0-5.0) vs 3.5 (range, 0.0-5.0) on MOS, vaginal squeeze pressure was 21.0 (range, 0.0-98.0) cmH₂ O vs 28.0 (range, 3.0-129.0) cmH₂ O on perineometry, proportional change in hiatal area was 29.6% (range, 0.0-60.9%) vs 33.8% (range, 0.0-64.4%) and proportional change in anteroposterior diameter was 22.8% (range, -5.7 to 49.4%) vs 25.7% (range, -3.4 to 49.4%) (P < 0.001 for all).

CONCLUSIONS

LAM macrotrauma was associated with weaker pelvic floor muscle contraction measured using palpation, perineometry and ultrasound. Women with POP had weaker contraction than did women without POP. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Is it necessary to diagnose levator avulsion on pelvic floor muscle contraction?

OBJECTIVE

Avulsion of the levator ani muscle commonly occurs at vaginal birth. This condition is usually diagnosed by translabial ultrasound (TLUS) during pelvic floor muscle contraction (PFMC). Some patients are unable to achieve a satisfactory PFMC and in these cases avulsion is assessed at rest. The aim of this study was to validate the diagnosis of levator avulsion by means of TLUS at rest.

METHODS

This was a retrospective study of 233 women seen at a tertiary urogynecological center. All women underwent four-dimensional TLUS in the supine position and after voiding. Volumes were obtained on maximal PFMC and at rest. Analysis of the volumes was performed with the observer blinded against all clinical data. Avulsion was defined as an abnormal levator ani muscle insertion that was visible in at least three consecutive axial plane slices, at and above the level of minimal hiatal dimensions, at 2.5-mm intervals. We examined the correlation between both assessment methods using Cohen's kappa coefficient and tested the association of each method with female pelvic organ prolapse on clinical examination, organ descent on ultrasound and hiatal ballooning.

RESULTS

In total, datasets from 202 women were available for analysis. The correlation between a diagnosis of avulsion in volumes obtained at rest and those on PFMC was moderate, with a kappa value of 0.583 (95% CI, 0.484-0.683). Agreement for defects visualized on single slices was moderate, with a kappa value of 0.556 (95% CI, 0.520-0.591). When avulsion diagnoses at rest and on PFMC were tested against symptoms of prolapse, and prolapse on clinical examination and on ultrasound, neither of the two methods was superior.

CONCLUSION

Although tomographic ultrasound imaging during PFMC enhances tissue discrimination, this may not translate to superior diagnostic performance. Hence, volumes obtained at rest may be used in women unable to contract their pelvic floor. The diagnosis of levator avulsion by tomographic pelvic floor ultrasound is equally valid when performed at rest or on PFMC. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Assessment of pelvic floor muscle contraction with palpation, perineometry and transperineal ultrasound: a cross-sectional study

OBJECTIVE

To study the correlation between palpation, perineometry and transperineal ultrasound for assessment of pelvic floor muscle contraction and to define a contraction scale for ultrasound measurements.

METHODS

This was a cross-sectional study of 608 women examined with palpation of pelvic floor muscle contraction, using the Modified Oxford Scale, and measurement of the vaginal squeeze pressure with a vaginal balloon connected to a fiber-optic microtip transducer (perineometry). Transperineal ultrasound was used for measurements of levator hiatal area and anteroposterior (AP) diameter in the plane of minimal hiatal dimensions, at rest and on contraction. The pelvic floor muscle contraction was expressed as the percentage difference between values at rest and on contraction. Spearman's rank was used to test for correlation between the different methods of assessment.

RESULTS

Significant correlations were found between all assessment methods (P < 0.001). Palpation correlated with perineometry (rs = 0.74) and with proportional change in hiatal area (rs = 0.67) and AP diameter (rs = 0.69) on ultrasound. Perineometry correlated with proportional change in hiatal area (rs = 0.60) and AP diameter (rs = 0.66) on ultrasound. We defined a contraction scale based on the proportional change in AP diameter. In this population, a change in AP diameter of < 7% corresponded to absence of contractions, 7-18% corresponded to weak contractions, 18-35% corresponded to normal contractions and > 35% corresponded to strong contractions.

CONCLUSIONS

We found moderate to strong correlation between ultrasound measurements, palpation and perineometry for assessing pelvic floor muscle contraction. The proportional change in levator hiatal AP diameter was the ultrasound measurement with strongest correlation to palpation and perineometry and formed the basis for the contraction scale for ultrasound measurements. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.