Primary care providers practice patterns regarding female pelvic floor disorders

INTRODUCTION

Pelvic floor disorders (PFDs) pose substantial physical and psychological burdens for a growing number of women. Given the ubiquity of these conditions and known patient reluctance to seek care, primary care providers (PCPs) have a unique opportunity to increase treatment and provide appropriate referrals for these patients.

METHODS

An online survey was administered to PCPs to assess provider practices, knowledge, comfort managing and ease of referral for PFDs. Logistic regression was used to assess the association between demographic/practice characteristics of PCPs and two primary outcomes of interest: discomfort with management and difficulty with referral of PFDs.

RESULTS

Of the 153 respondents to the survey, more felt comfortable managing stress urinary incontinence (SUI) and overactive bladder (OAB), compared with pelvic organ prolapse (POP) and faecal incontinence (FI) and were less likely to refer patients with urinary symptoms. Few providers elicited symptoms for POP and FI as compared with SUI and OAB. Provider variables that were significantly associated with discomfort with management varied by PFD, but tended to correlate with less exposure to PFDs (eg, those with fewer years of practice, and internal medicine and family physicians as compared with geriatricians); whereas the factors that were significantly associated with difficulty in referral, again varied by PFD, but were related to practice characteristics (eg, specialist network, type of practice, practice setting and quantity of patients).

CONCLUSION

These findings highlight the need to increase PCPs awareness of PFDs and develop effective standardised screening protocols, as well as collaboration with pelvic floor specialists to improve screening, treatment and referral for patients with PFDs.

Psychometric evaluation and cross-cultural adaptation of the Australian Pelvic Floor Questionnaire (APFQ-IR) in Iranian reproductive age women

Pelvic floor disorders (PFDs), as a silent alert, is one of the pervasive debilitating health concerns among women all over the world, such that in developed countries, one in four women, suffers from PFDs. Validity and reliability of the Australian Pelvic Floor Questionnaire (APFQ) has not been determined in Iran, so to determine APFQ's psychometric characteristics, we decided to conduct this study on women of reproductive age in Tabriz city, Iran. This methodological cross-sectional study was intended to determine the psychometric properties of the Persian version of the APFQ-IR in 5 steps including "translation process, content validity, face validity, construct validity (exploratory and confirmatory factor analyses and examination of ceiling and floor effects) and reliability" on 400 reproductive age women referring to health centers in Tabriz city, Iran, with cluster random sampling method in the period between May 2022 to September 2022. The translation process was done based on two approaches, Dual panel, and Beaton et al.'s five steps. Then, in order to evaluate content validity, face validity, and construct validity, 10 instrument and PFDs experts, 10 women from the target group investigated the instrument's items, and 400 eligible women completed the instrument. Finally, to determine the reliability, two internal consistency methods, (Cronbach's alpha and McDonald's omega) and test-retest method (ICC) were used. In the present study, content validity assessment of APFQ-IR, showed a good level of validity (CVR = 0.96, CVI = 0.94). To assess construct validity, exploratory factor analysis results on 36 items, led to the identification of 4 factors including bladder function, bowel function, prolapse symptom and sexual function, which explained 45.53% of the cumulative variance and indicated the sufficiency of the sample size (Kaiser-Meyer-Olkin = 0.750). Implementing confirmatory factor analysis, (RMSEA = 0.08, SRMR = 0.08, TLI = 0.90, CFI = 0.93, χ2/df = 3.52) confirmed the model fit indices. Finally the internal consistency and reliability was high for the entire instrument (Cronbach's alpha = 0.85; McDonald's omega (95% CI) = 0.85 (0.83-0.87) and Intraclass Correlation Coefficient (95% CI) = 0.88 (0.74-0.94)). The Persian version of the APFQ-IR, has a good validity and reliability and has acceptable psychometric properties, thus can be used both for research purposes and for clinical evaluation of pelvic floor disorders symptoms in health centers.

Pelvic Floor Health Index: Initial validation of a practical postpartum tool for busy clinicians

OBJECTIVE

To design a primary care clinical tool (Pelvic Floor Health Index [PFHI]) to screen for postpartum pelvic floor disorders, as well as complete its psychometric validation.

DESIGN

Prospective cohort study.

SETTING

Two tertiary care obstetric centres in Vancouver, BC.

PARTICIPANTS

Primiparous women older than 19 years of age who were in the immediate postpartum period.

MAIN OUTCOME MEASURES

The PFHI was administered to 74 primiparous women immediately postpartum and at 2, 4, and 6 months postpartum. For evaluation of convergent and divergent construct validity, participants also completed several validated questionnaires, including the Female Sexual Functioning Index, the Pelvic Floor Distress Inventory, the 36-Item Short Form Health Survey, and the Edinburgh Postnatal Depression Scale. Fifteen women repeated their 6-month questionnaires 2 weeks later in order to determine test-retest reliability. Responsiveness was assessed by measuring the PFHI score change from baseline to 6 months postpartum.

RESULTS

Pelvic Floor Health Index score was inversely correlated with subscale scores on the Pelvic Floor Distress Inventory at all time points. There were moderate correlations between PFHI score and the Female Sexual Functioning Index and 36-Item Short Form Health Survey scores at several time points. There were weak correlations with postpartum depression scores. The intraclass correlation coefficient for test-retest reliability was 0.78 (95% CI 0.47 to 0.92). The PFHI mean total score significantly improved by 1.8 (95% CI 1.0 to 2.6) at 6 months postpartum.

CONCLUSION

The PFHI is a 10-item, newly validated, and psychometrically robust questionnaire that can be administered to patients in the postpartum period to screen for pelvic floor dysfunction.

Investigation of the effects of pelvic floor training on pain, sexual dysfunction, and quality of life in female patients with primary Sjögren syndrome

AIM

To investigate the effects of pelvic floor training on pain, sexual dysfunction and quality of life in female patients with primary Sjögren syndrome (pSS) and determine whether pelvic floor training was superior to an education program.

METHODS

Forty-six pSS patients (all women) with an average age of 47.78 ± 9.18 years were included in the study. Patients were divided into two groups as a pelvic floor training group and control group for 8 weeks. Visual Analog Scale (VAS), Pelvic Pain Impact Questionnaire (PPIQ), Female Sexual Function Scale (FSFI), Health Assessment Questionnaire (HAQ), Pelvic Floor Disability Index-20 (PFDI-20), and Pelvic Floor Impact Questionnaire (PFIQ-7) were used to evaluate the outcomes. All evaluations were performed at baseline and at the end of the 8th week.

RESULTS

When the groups were compared before training, there was no significant difference (p > .05). In post-training comparisons, there were significant differences in VAS, PPIQ, FSFI, PFIQ-7, and PFDI-20 in the pelvic floor training group (p values between .02 and .00), and in FSFI-lubrication, PFIQ-7, and PFDI-20 (p values between .00 and .03) in the control group. According to Δ values, the pelvic floor training group was found to be superior in terms of FSFI orgasm, pain, and lubrication scores (p = .00) and all sub-parameters of PFDI-20 (p = .00).

CONCLUSION

Pelvic floor training has a positive effect on the sexual dysfunction and discomfort caused by pelvic symptoms in patients with pSS. Pelvic floor training should be included in rehabilitation programs to improve sexual function and pelvic floor dysfunctions for patients with pSS.

Validation of the short forms of the Pelvic Floor Distress Inventory and the Pelvic Floor Impact Questionnaire in Estonian

INTRODUCTION AND HYPOTHESIS

Pelvic Floor Distress Inventory (PFDI-20) and the Pelvic Floor Impact Questionnaire (PFIQ-7) are reliable instruments for evaluating the quality of life in women with pelvic organ prolapse (POP). They have been translated and validated in many languages. The study was aimed at validating the Estonian translations of the PFDI-20 and PFIQ-7 tools.

METHODS

The questionnaires were translated into Estonian using a multistep translation method. A total of 132 women were enrolled: patients with diagnosed POP (n=57) were allocated to test-retest reliability analyses, and those with no POP signs (n=88) completed the questionnaire only once. The total scores of questionnaires and their subscales of both patient and reference groups were compared. Item response rate, floor and ceiling effects, corrected item-total correlations, internal consistency, and convergent and discriminant validity were analyzed. The study was approved by the Ethics Committee of Human Research of the University Clinic of Tartu, Estonia, and informed consent was obtained from each participant.

RESULTS

The translated questionnaires demonstrated good internal consistency (Cronbach's α values 0.77-0.93). The item response rate was 99%. Intra-class correlations (ICC) were strong for PFDI-20 and PFIQ-7 and their subscales ranged from 0.86 to 0.96. Construct validity of the tools demonstrated by manyfold higher scores among patients with POP compared with women without POP (p<0.0001).

CONCLUSIONS

The Estonian versions of the PFDI-20 and PFIQ-7 tools are reliable and valid instruments for assessing the quality of life in women with POP.

Validation of online delivery of the Australian Pelvic Floor Questionnaire in an Irish obstetric population

INTRODUCTION AND HYPOTHESIS

Childbirth remains an important risk factor for the development of pelvic floor disorders, regardless of the mode of delivery. To accurately assess these symptoms, accurate, woman-centric assessments are needed. Online versions of these assessments may be especially useful in the COVID-19 era. Women may potentially answer questions differently in an online format, and this study aimed to validate an online version of the paper-based self-administered Australian Pelvic Floor Questionnaire (APFQ).

METHODS

The questionnaire was completed antenatally and at 3 months postpartum by 647 and 481 women respectively. Test- validity was assessed in subgroups of 61 and 57 women in each period, using intraclass correlation coefficients and Cohen's kappa. Sensitivity to change was assessed by comparing responses during pregnancy to those at 3 months postpartum. Internal consistency was assessed using Cronbach's alpha. Construct validity was assessed by comparing women with and without subjective bothersomeness.

RESULTS

Intraclass correlation coefficients were above 0.9 for all domains and the overall questionnaire. Cohen's kappa for individual questions ranged from 0.71-1.00 across the antenatal and postnatal questionnaires. Cronbach's alpha was acceptable for all domains except the prolapse domain. The APFQ was sensitive to changes occurring between antenatal recruitment and 3 months postpartum. Effect sizes ranged from 0.83-7.99.

CONCLUSIONS

This online version of the APFQ is valid for assessing pelvic floor disorders in an Irish obstetric population. The APFQ is reproducible and responsive to change occurring with childbirth, and can be used to research longitudinal changes in pelvic floor disorders. As an online tool, this questionnaire may be useful in increasing response rates to clinical research.

Pelvic floor disorder assessment of knowledge and symptoms: an educational intervention for Spanish-speaking women (PAKS study)

INTRODUCTION AND HYPOTHESIS

Educational interventions have been effective in improving postpartum knowledge, performance of pelvic floor exercises, and bowel-specific quality-of-life. Our primary objective was to determine if a video-based educational intervention on pelvic floor disorders (PFDs) would increase Spanish-speaking women's knowledge of PFDs, and secondarily to assess if it would decrease pelvic floor symptoms. We hypothesized that Spanish-speaking women would improve their pelvic floor knowledge and symptoms post-intervention.

METHODS

Inclusion criteria included women age 18 years and older and self-reported as a predominantly Spanish-speaker or equally bilingual English- and Spanish-speaker. Changes in knowledge were assessed with the Prolapse and Incontinence Knowledge Questionnaire (PIKQ). Changes in symptoms were assessed with the Pelvic Floor Distress Inventory-20 (PFDI-20). Linear regression assessed for independent effects.

RESULTS

One hundred and fourteen women were enrolled and 112 completed the pre- and post-intervention PIKQ. Mean (standard deviation [SD]) age was 50 (14) years. Immediate post-intervention scores showed significant improvement in knowledge. Total PIKQ score improved by 5.1 (4.7) points (p < 0.001). POP subscore improved by 2.7 (2.7) points (p<0.001) and UI subscore improved by 2.3 (2.5) points (p < 0.001). Improvement in knowledge continued after four weeks (p < 0.001). PFDI-20 prolapse (p=0.02), colorectal-anal (p < 0.001) and urinary (p = 0.01) scores significantly improved only for the most symptomatic women at baseline. Using linear regression, total PIKQ (p = 0.03) and total PFDI-20 scores (p = 0.04) were associated with predominantly Spanish-speakers versus fully bilingual.

CONCLUSION

Findings support the efficacy of a video-based educational intervention to improve knowledge of PFDs in Spanish-speaking women. The most symptomatic women benefitted from this intervention.

Differences in help-seeking behaviour between men and women with multiple pelvic floor symptoms: a qualitative study

BACKGROUND

Pelvic floor symptoms, such as lower urinary tract symptoms, defecation problems, sexual dysfunction, pelvic pain, and pelvic organ prolapse in females, are common and frequently co-occur. Despite negatively affecting quality of life, few patients seek help. Most studies assessing help-seeking behaviour have focused on a single pelvic floor symptom.

AIM

We aimed to explore the barriers and facilitators of help-seeking behaviour in males and females with at least two pelvic floor symptoms.

METHOD

This interview study included participants based on age and symptoms (number and type) from a larger group taking part in a survey on pelvic floor symptoms in the general population. Two researchers independently encoded and analysed the semi-structured interviews, continuing until saturation for both the male and female cohorts.

RESULTS

Of the 25 participants (13 male, 12 female), 9 sought help for all of their pelvic floor symptoms, 10 did not seek help for any symptom, and 6 sought help for some of their pelvic floor symptoms. We identified themes in domains related to the patient, healthcare professional, environment, and symptom. Although most themes applied to both males and females, some had greater sex specificity.

CONCLUSION

Males and females have more similarities than differences in help-seeking behaviour. Healthcare providers should be aware that patients who seek help for one symptom probably have multiple pelvic floor symptoms that the patient has not reported.

Translation and measurement properties of the pelvic floor distress inventory-short form (PFDI-20) in Iranian reproductive age women

BACKGROUND

Every year, millions of women worldwide suffer in silence from pelvic floor disorders (PFDs) as an annoying health problem. Despite the high prevalence rate and negative effects of PFDs on the quality of life, the validity and reliability of pelvic floor distress inventory-short form (PFDI-20) has not been confirmed for Iranian women of reproductive age. Hence, this study aimed to determine measurement properties of PFDI-20 among women of reproductive age in Tabriz, Iran.

METHODS

The current study was cross-sectional research that selected 400 women of reproductive age referring to health centers in Tabriz City, by using cluster random sampling from May 2022 to September 2022. Measurement properties of the Persian version of PFDI-20 were determined and evaluated through five steps, including content and face validity within two quantitative and qualitative parts, structural validity by using exploratory factor analysis (EFA) and confirmatory factor analysis (CFA), and reliability testing through internal consistency, test-retest reliability, and measurement error. Moreover, ceiling and floor effects were investigated.

RESULTS

In this research, CVI (content validity index) and CVR (content validity ratio) of PFDI-20 equaled 0.94 and 0.97, respectively. In addition, the EFA process was applied to 20 items and derived the structure of three factors, which explained 58.15% of the total variance. In CFA phase, values of fit indicators (RMSEA = 0.07, SRMR = 0.07, TLI = 0.97, CFI = 0.99, x2/df = 3.19) confirmed the model validity. To determine reliability, Cronbach's alpha = 0.84; McDonald's omega (95% CI) = 0.84 (0.82 to 0.87) and Intraclass Correlation Coefficient (95% CI) = 0.98 (0.97 to 0.99) were obtained. Also, the SEM was 2.64, and the SDC indicating the smallest individual change was 8.91. Regarding the inventory feasibility, the ceiling effect was not observed in total value and subscales, while the floor effect in the total score of PFDI-20 equaled 24.0. The latter rate equaled 45.8, 38.3, and 50.8 for subscales POPDI-6, CRADI-8, and UDI-6, respectively.

CONCLUSIONS

Persian version of PFDI-20 is a valid and reliable scale used to evaluate PFDs in Iranian women of reproductive age. Healthcare professionals can use this scale to screen PFDs, and researchers can consider it a reliable tool for their studies.

An International Continence Society (ICS)/ International Urogynecological Association (IUGA) joint report on the terminology for the assessment and management of obstetric pelvic floor disorders

AIMS

The terminology of obstetric pelvic floor disorders should be defined and reported as part of a wider clinically oriented consensus.

METHODS

This Report combines the input of members of two International Organizations, the International Continence Society (ICS) and the International Urogynecological Association (IUGA). The process was supported by external referees. Appropriate clinical categories and a sub-classification were developed to give coding to definitions. An extensive process of 12 main rounds of internal and 2 rounds of external review was involved to exhaustively examine each definition, with decision-making by consensus.

RESULTS

A terminology report for obstetric pelvic floor disorders, encompassing 357 separate definitions, has been developed. It is clinically-based with the most common diagnoses defined. Clarity and user-friendliness have been key aims to make it usable by different specialty groups and disciplines involved in the study and management of pregnancy, childbirth and female pelvic floor disorders. Clinical assessment, investigations, diagnosis, conservative and surgical treatments are major components. Illustrations have been included to supplement and clarify the text. Emerging concepts, in use in the literature and offering further research potential but requiring further validation, have been included as an Appendix. As with similar reports, interval (5-10 year) review is anticipated to maintain relevance of the document and ensure it remains as widely applicable as possible.

CONCLUSION

A consensus-based Terminology Report for obstetric pelvic floor disorders has been produced to support clinical practice and research.

Prevalence of urinary incontinence and other pelvic floor disorders in women with myotonic dystrophy type 1

Myotonic dystrophy type 1 (DM1) is a neuromuscular disease that can affect the pelvic floor muscles but few studies have investigated pelvic floor disorders, including urinary incontinence. The main purpose of this study was to document the prevalence, characteristics, and impacts of urinary incontinence and other pelvic floor disorders in women with DM1. Associations between pelvic floor disorders and phenotypes, considering age and parity, were explored. Eighty adult women aged 47,1±13,7 years old participated in a cross-sectional study using validated questionnaires, including the International Consultation Incontinence Questionnaire - Urinary Incontinence short form (ICIQ-UI-SF)), the Pelvic Floor Disorder Inventory (PFDI), and the Pelvic Floor Impact Questionnaire short form (PFIQ-SF). The mean score for the ICIQ-UI-SF was 4.3. The mean scores for the subscales of the PFDI were 36.8 for the urinary distress inventory, 74.1 for the colorectal-anal distress inventory, and 43.8 for the pelvic organ prolapse distress inventory. A total of 60% of women reported urinary incontinence and 56.3% anal incontinence. Pelvic prolapse symptoms (>1 symptom) were reported by 25% of women. Findings reveal high prevalence and significant related impacts of these disorders. This provides evidence regarding the importance of screening for these disorders in a clinical setting and the need to explore treatment approaches.

Cross-cultural adaptation and psychometric evaluation of the Brazilian Portuguese version of the Vulvovaginal Symptoms Questionnaire

OBJECTIVE

The aims of this study were to perform a cross-cultural adaptation of the Vulvovaginal Symptoms Questionnaire (VSQ) into Brazilian Portuguese (VSQ-Br) and evaluate its measurement properties (structural validity, construct validity, internal consistency, and reliability).

METHODS

Cross-cultural adaptation was conducted through the translation, synthesis, and back-translation of the VSQ-Br. Subsequently, 314 women completed the Pelvic Floor Impact Questionnaire, Pelvic Floor Disorders Inventory, Medical Outcomes Study 36-Item Short-Form Health Survey, and VSQ-Br. Seven to 10 days later, participants completed the VSQ-Br for the second time. Data were submitted for confirmatory factor analysis. Cronbach α was used to verify internal consistency, and construct validity was assessed using Pearson correlation coefficient ( r ). Reliability was calculated using the intraclass correlation coefficient.

RESULTS

Confirmatory factor analysis showed that the questions were grouped into four domains (symptoms, emotions, life impact, and sexual impact). The model showed good fit (>0.95). The Cronbach α in this study was 0.85, reflecting adequate internal consistency. Adequate reliability was confirmed, with an intraclass correlation coefficient total score of 0.80. The VSQ-Br had a weak correlation with the pelvic domain of the Pelvic Floor Disorders Inventory, the pelvic organ prolapse domain of the Pelvic Floor Impact Questionnaire, and pain, vitality, and the social aspect domains of the Medical Outcomes Study 36-Item Short-Form Health Survey.

CONCLUSIONS

The VSQ-Br was validated and had acceptable measurement properties for assessing vulvovaginal symptoms in Brazilian women.

Recent advances in the pelvic floor assessment and rehabilitation of Women with Pelvic Floor Dysfunction

Pelvic Floor Dysfunctions (PFDs) are a group of disorders characterized by inter-related symptoms of urology, gynaecology, colorectal or general pelvic pain. These mainly cause voiding or defecation disorders, pelvic organ prolapses, sexual dysfunctions and pelvic pain. PFDs adversely impact various domains of women's life including psychological, physical, social and sexual well-being. Pelvic Floor Rehabilitation (PFR) has been recommended as part of a multidisciplinary approach for evaluation and management of the multiple PFDs. The assessment of PFD has improved with utilization of new measurement tools and specific outcome measures for PFDs. PFR is a first-line treatment approach effective for PFDs. However, robust research is needed to test standardised assessment and physical therapy treatment protocols with long term efficacy. In this review, we discuss a range of PFDs, impairment-based classification, recent updates, and advances in the evaluation of PFDs, physical therapy tools and techniques for the treatment of PFDs.

Validation of a Chinese version for the global Pelvic Floor Bother Questionnaire

PURPOSE

The Pelvic Floor Bother Questionnaire (PFBQ) is a self-administered instrument for determining pelvic floor dysfunction (PFD). The PFBQ was validated in English, but lately in other languages. However, a Chinese version has not been established. Thus, we aimed at validating a Chinese PFBQ version.

METHODS

We used a translation-back method to develop a PFBQ Chinese version and validated in 102 women, 51 with at least one PFD symptom participated in the patient group, and 51 without PFD in the control group. Construct validity was assessed by comparing groups and a content validity index (CVI) determined. For test-retest reliability, participants completed the questionnaire twice within 1-week interval and the interclass correlation coefficient (ICC) was determined. Internal consistency was calculated using Cronbach's statistics.

RESULTS

Missing information after applying the translated PFBQ did not exceed 4% of any questions. Total scores between control and PFD women were significantly different (2.94 ± 1.84 vs. 10.29 ± 6.64; P < 0.001). The CVI for all items ranged from 0.800 to 1.000, and a good reliability was corroborated (α = 0.677, ICC = 0.938).

CONCLUSION

The Chinese PFBQ version is a valid and reliable tool to identify the existence and severity of bothersome symptoms in Chinese women with PFD.

Vaginal symptoms in women who are affected by gynecologic cancer

PURPOSE OF REVIEW

Pelvic floor disorders are common among gynecologic cancer survivors. With improvements in survivorship, quality of life conditions in these women need greater attention and care. This review focuses specifically on vulvovaginal symptoms, which are common and have a negative impact on sexual health and quality of life in women affected by gynecologic cancer.

RECENT FINDINGS

We review publications on treatment-specific sexual health outcomes, screening and treatment of vulvovaginal symptoms and sexual pain, and surgical management options. Recent evidence regarding the safety of concomitant prolapse repair at the time of surgery for gynecologic malignancies and CO2 laser therapy is discussed and areas needing further research and innovation are highlighted.

SUMMARY

Pelvic floor disorders, including vaginal and sexual health concerns, are common in women affected by gynecologic cancer due to both common risk factors and as a side effects of cancer treatment. Gynecologists play a critical role in screening, treatment, and collaboration with other specialists to provide comprehensive care for these women throughout their lifetime.

[Multidisciplinary pelvic floor team: 5 year experience.]

INTRODUCTION

Pelvic floor dysfunction (PFD) is expressed by many different symptoms that can affect pelvic floor organs. These symptoms can appear alone or associated. The involvement of different organs and the wide variety of symptoms we have to deal with, has become teamwork essential for diagnosis and treatment of PFD. Currently, multidisciplinary pelvic floor teams are essential when dealing with PFD.

OBJECTIVE

The main objective of the article is to analyze characteristics and pathologies of the patients discussed during these multidisciplinary meetings.

MATERIAL AND METHODS

This is a descriptive study. Patients followed in the multidisciplinary pelvic floorteam at Galdakao-Usansolo Hospital were recruited. We analyzed the patients discussed at the meetings from January 2014 until March 2019.

RESULTS

We recruited 55 patients. 89.09% were female and the mean age of the analyzed patients was 55.36 years. The most frequent reasons for medicalconsultation were pelvic floor prolapses in female (22.45%) and pelvic floor pain in male (33.33%). Association between symptoms occur in 78.18% of the patients.41.82% of patients were referred to more than 2 specialists and 21.82% needed associated treatments.

CONCLUSIONS

Pelvic floor dysfunction is manifested by a combination of  symptoms which need different specialists, not only for diagnosis, but also for treatment. This is why multidisciplinary teams have become important for the management of pelvic floor disfunction.

Pelvic floor disorders in women who consult primary care clinics: development and validation of case definitions using primary care electronic medical records

BACKGROUND

To date, there has been no validated method to identify cases of pelvic floor disorders in primary care electronic medical record (EMR) data. We aimed to develop and validate symptom-based case definitions for urinary incontinence, fecal incontinence and pelvic organ prolapse in women, for use in primary care epidemiologic or clinical research.

METHODS

Our retrospective study used EMR data from the Southern Alberta Primary Care Research Network (SAPCReN) and the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) in southern Alberta. Trained researchers remotely reviewed a random sample of EMR charts of women aged 18 years or older from 6 rural and urban clinics to validate case definitions for urinary incontinence, fecal incontinence and pelvic organ prolapse. We calculated sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV), and estimated SAPCReN prevalence as appropriate.

RESULTS

Charts of 900 women were included. Sensitivity was 81.9% (95% confidence interval [CI] 75.1-87.2) for urinary incontinence, 61.2% (95% CI 46.2-74.5) for fecal incontinence, and 51.8% (95% CI 40.6-62.8) for pelvic organ prolapse. Corresponding specificity values were 71.9% (95% CI 68.4-75.1), 99.2% (95% CI 98.2-99.6) and 98.8% (95% CI 97.7-99.4), PPVs 40.6% (95% CI 35.4-46.0), 81.1% (95% CI 64.3-91.4) and 81.1% (95% CI 67.6-90.1), and NPVs 94.4% (95% CI 92.1-96.1), 97.8% (95% CI 96.5-98.6) and 95.3% (95% CI 93.6-96.6). The SAPCReN-observed prevalence for urinary incontinence was 29.7% (95% CI 29.3-30.0), but the adjusted prevalence was 2.97%.

INTERPRETATION

The case definition for urinary incontinence met our standard for validity (sensitivity and specificity > 70%), and the case definitions for fecal incontinence and pelvic organ prolapse had PPVs greater than 80%. The urinary incontinence definition may be used in epidemiologic research, and those for fecal incontinence and pelvic organ prolapse may be used in quality-improvement studies or creation of disease registries. Our symptom-based case definitions could also be adapted for research in other EMR settings.

Magnetomyographic Recordings of Pelvic Floor Activity During Pregnancy and Postpartum: A Novel Non-invasive Approach

The levator ani muscles (LAM) are integral to pelvic floor support and injury to this muscle complex has been associated with pelvic floor disorders, but our ability to evaluate their neuromuscular integrity is limited. During pregnancy, gravidas undergo systemic functional and anatomic modifications, including pelvic floor muscular adaptations. Magnetomyography (MMG) is a novel and non-invasive tool to passively measure the magnetic fields generated by depolarization activity of muscles and offers a unique method to evaluate the LAM. We collected serial MMG data in a pregnant woman with singleton gestation. Pregnant woman performed LAM contractions (Kegels) with intervening rest periods. Kegel signals were isolated by using the frequency dependent subtraction (SUBTR) and independent component analysis (ICA) methods. Concurrent body-surface electromyography (EMG) was used to evaluate for accessory-muscle recruitment by placing bipolar electrodes on the perineum, abdomen, and thigh. Amplitude and spectral-related indicators were computed across moderate intensity MMG Kegel epochs: root-mean square (RMS) amplitude, power spectrum density (PSD) and relative PSD (rPSD) in three frequency bands. Indicators were extracted from two pregnancy recordings and one postpartum. Parameters were represented in terms of gestation and postpartum weeks. We observed that postpartum RMS Kegel amplitudes had lower values than seen in pregnancy. Changes in spectral indicators were observed between pregnancy and postpartum.

Primary Care Physician Perceptions of Female Pelvic Floor Disorders

Primary care physicians (PCPs) play a major role in patient access to appropriate health care. This study examines PCPs' perceptions and management of female pelvic floor disorders. Surveys were mailed to family medicine and internal medicine physicians associated with the Hawai'i Medical Service Association. A total of 150 respondents were included. Only 34%, 38%, and 9% of respondents correctly identified the prevalence of urinary incontinence (UI), overactive bladder (OAB), and pelvic organ prolapse (POP), respectively. For disease-specific screening, the highest response was that PCPs "sometimes" screen for UI (36%) and OAB (45%) but "hardly ever" screen for POP (43%). With regards to management of UI and OAB, respondents would either treat (30% UI, 39% OAB) or start treatment then refer (53% UI, 49% OAB). For POP, nearly all of respondents (81%) would immediately refer. When consultation is necessary, there was a similar rate of referral to urology and urogynecology for UI (38% urology, 42% urogynecology), and a similar rate of referral to gynecology and urogynecology for POP (47% gynecology, 48% urogynecology). For OAB, PCPs would refer to urology (54.0%), then urogynecology (31%), and lastly gynecology (13%). A majority of respondents were "somewhat familiar" (56%) with urogynecology as a subspecialty, while 27% were "very familiar", 13% were "slightly unfamiliar", and 3% were "very unfamiliar". This study shows that most PCPs are not comfortable managing common urogynecologic problems and would likely benefit from education on how to diagnose, treat, and refer for these conditions in order to optimize patient care.

Anal incontinence after caesarean and vaginal delivery in Sweden: a national population-based study

BACKGROUND

Elective caesarean delivery is increasing rapidly in many countries, and one of the reasons might be that caesarean delivery is widely believed to protect against pelvic floor disorders, including anal incontinence. Previous studies on this issue have been small and with conflicting results. The aim of present study was to compare the risk of developing anal incontinence in women who had a caesarean delivery, in those who had a vaginal delivery, and in two age-matched control groups (nulliparous women and men).

METHODS

In this observational population-based study, we included all women in the Swedish Medical Birth Register who gave birth by caesarean delivery or vaginal delivery during 1973-2015 in Sweden and were diagnosed with anal incontinence according to ICD 8-10 in the Swedish National Patient Register during 2001-15. Exclusion criteria were multiple birth delivery, mixed vaginal and caesarean delivery, and four or more deliveries. We compared the diagnosis of anal incontinence between women previously delivered solely by caesarean delivery and those who solely had delivered vaginally. We also compared it with two age-matched control groups of nulliparous women and men from the Swedish Total Population Register. Finally, we analysed risk factors for anal incontinence in the caesarean delivery and vaginal delivery groups.

FINDINGS

3 755 110 individuals were included in the study. Between 1973 and 2015, 185 219 women had a caesarean delivery only and 1 400 935 delivered vaginally only. 416 (0·22 %) of the 185 219 women in the caesarean delivery group were diagnosed with anal incontinence compared with 5171 (0·37%) of 1 400 935 women in the vaginal delivery group. The odds ratio (OR) for being diagnosed with anal incontinence after vaginal delivery compared with caesarean delivery was 1·65 (95% CI 1·49-1·82; p<0·0001). When the combination vaginal delivery and caesarean delivery was compared with the nulliparous control group, the OR of being diagnosed with anal incontinence was 2·05 (1·92-2·19; p<0·0001). For the nulliparous women compared with men, the OR for anal incontinence was 1·89 (1·75-2·05; p<0·0001). The strongest risk factors for anal incontinence after vaginal delivery were high maternal age, high birthweight of the child, and instrumental delivery. The only risk factor for anal incontinence after caesarean delivery was maternal age.

INTERPRETATION

The risk of developing anal incontinence increases after pregnancy and delivery. Women with known risk factors for anal incontinence should perhaps be offered a more qualified post-partum examination to enable early intervention in case of injury. Further knowledge for optimal management are needed.

FUNDING

County Council of Jämtland.

Evaluation of the effect of an antenatal pelvic floor muscle exercise programme on female sexual function during pregnancy and the first 3 months following birth: study protocol for a pragmatic randomised controlled trial

BACKGROUND

Sexual dysfunction can have a negative impact on women's quality of life and relationships. There is limited information about female sexual function and treatment, particularly during pregnancy and the postpartum period. The effect of pelvic floor muscle exercise (PFME) on sexual function (SF) has not been studied adequately. The purpose of this study is to investigate the effect of antenatal PFME on female SF during pregnancy and the first 3 months following birth.

METHODS/DESIGN

This is a pragmatic, randomised controlled trial which will compare a structured antenatal PFME programme combined with standard antenatal care to standard antenatal care alone. Eligible women who are less than 22 weeks' gestation will be recruited from the antenatal clinics of one hospital located in Western Sydney, Australia. A sample of 200 primiparous pregnant women who meet the inclusion criteria will be randomised to either control or intervention groups. This sample size will allow for detecting a minimum difference of 9% in the female SF score between the two groups. The duration of the PFME programme is from approximately 20 weeks' gestation until birth. Female SF will be measured via questionnaires at < 22 weeks' gestation, at 36 weeks' gestation and at 3 months following birth. Baseline characteristics, such as partner relationship and mental health, will be collected using surveys and questionnaires. Data collected for secondary outcomes include the effect of PFME on childbirth outcomes, urinary and faecal incontinence symptoms and quality of life.

DISCUSSION

The findings of this study will provide more information on whether a hospital-based antenatal PFME has any effect on female SF, urinary and faecal incontinence during pregnancy and the first 3 months following birth. The study will also provide information on the effectiveness of antenatal PFME on childbirth outcomes.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials registry, ACTRN12617001030369 . Registered on 17 July 2017.

The minimal important difference of the Australian Pelvic Floor Questionnaire

INTRODUCTION AND HYPOTHESIS

The aim of this study was to establish the minimal important difference (MID) of the Australian Pelvic Floor Questionnaire (APFQ) in women undergoing surgery for stress urinary incontinence or symptomatic pelvic organ prolapse. A further aim was to estimate dysfunction scores dependent on the bothersomeness in a community cohort.

METHODS

The APFQ was completed before and 6 weeks after pelvic floor surgery by 183 women (n = 80 suburethral tape insertion; n = 103 laparoscopic sacrocolpopexy). Distribution and anchor-based methods were used to establish the effect size, standardised response mean and MID (calculated as the difference between women who stated no change or a little better in the Patient Global Impression of Improvement [PGI-I]). In a community cohort of 470 women aged 42-80 years, the APFQ was analysed according to disclosed bothersomeness.

RESULTS

For the suburethral tape group, the effect size in the bladder domain was 1.5 and the PGI-I-based MID 1.3. For the POP surgery, group the effect size in the prolapse domain was calculated at 2.2 and the PGI-I-based MID at 1.0. The domain scores for women who declared no bother were significantly different from those who were a little bothered (bladder domain 2.2 vs 4.0, bowel 0.6 vs 1.7, POP 0.1 vs 3.2, sex 1.8 vs 3.0) with wide variations.

CONCLUSIONS

The MID of the APFQ ranged from 1.0 to 1.3 in the domains after POP or continence surgery respectively. This is corroborated by the differences in domain scores from community-based women who were bothered versus not bothered by pelvic floor symptoms.

[Symptom distribution of female pelvic floor dysfunction patients with constipation as chief complaint]

OBJECTIVE

To observe the multiple symptom distribution, severity and quality of life of female pelvic floor dysfunction(FPFD) patients with constipation as chief complaint.

METHODS

One hundred FPFD patients with constipation as chief complaint from Speciaty Outpatient Clinic, Pelvic Floor Center of Nanjing Municipal Hospital of Traditional Chinese Medicine between September 2015 and February 2017 were retrospectively enrolled in this study. A comprehensive medical history questionnaire survey and systematical evaluation of severity and quality of life of these patients with constipation was conducted. Constipation scoring system scale (CSS) and patient-assessment of constipation quality of life questionnaire (PAC-QOL) were applied to evaluate the constipation. Other scales included: (1)pain visual analogue scale (VAS) and short form-36 questionnaire (SF-36): if combined with chronic functional anal rectal pain; (2) international consultation on incontinence questionnaire-short form (ICIQ-SF) and urinary incontinence quality of life questionnaires (I-QOL):if combined with urinary incontinence; (3) fecal incontinence severity score scale (Wexner-FIS) and fecal incontinence quality of life questionnaire (FI-QOL):if combined with fecal incontinence.

RESULTS

The mean age of 100 FPFD patients was (57.9±13.9) (24-89) years and the mean disease course was (7.0±8.2)(0.5-40.0) years. Seventy-five cases (75%) were complicated with anal pain, 70 with urinary incontinence, 37 with rectocele, 19 with nocturia, 11 with urinary frequency, 10 with defecation incontinence. Complication with only one symptom was observed in 20 cases (20%), and with two or more symptoms was observed in 80 cases (80%). Pelvic floor relaxation syndrome patients were dominant (58 cases, 58%). The severity of constipation (CSS) was 6-22 (13.89±3.79) points and the quality of life (PAC-QOL) was 45-133 (87.13±18.57) points in FPFD patients. VAS and SF-36 of patients combined with chronic functional anal rectal pain were 1-8 (3.0±1.9) points and 14.4-137.0(71.5±31.4) points respectively. ICIQ-SF and I-QOL of patients combined with urinary incontinence were 1-17 (6.1±3.6) points and 52-110 (90.0±15.8) points respectively. Wexner-FIS and FI-QOL of patients combined with fecal incontinence were 1-11 (4.4±3.0) points and 52-116 (83.4±23.3) points respectively.

CONCLUSIONS

The symptoms of FPFD patients with constipation as chief complaint are complex. They are mainly complicated with anal diseases, then urinary incontinence, and mostly with more than 2 symptoms. Their quality of life is poor.

Dutch translation and validation of the pelvic organ prolapse/incontinence sexual questionnaire-IUGA revised (PISQ-IR)

INTRODUCTION AND HYPOTHESIS

Condition-specific sexual questionnaires are important patient-reported outcome measures. The aim of this study was to translate and validate the Pelvic Organ Prolapse/Incontinence Sexual Questionnaire-International Urogynecology Association Revised (PISQ-IR) into Dutch.

METHODS

The translated PISQ-IR was linguistically validated, followed by psychometrical validation among women presenting with symptoms of pelvic floor dysfunction in urogynecology clinics. For analysis of the criterion validity, the Pelvic Floor Dysfunction Inventory-20 (PFDI-20) and Female Sexual Function Index (FSFI) were used. Descriptive statistics, floor and ceiling effects, internal consistency using Cronbach's alpha coefficient and Pearson's and Spearman's correlations were calculated for all PISQ-IR subscales.

RESULTS

The PISQ-IR was completed by 220 women, of whom 61 (27.7%) considered themselves not sexually active (NSA) and 159 (72.3%) sexually active (SA). The mean age of participating women was 57 years; 49.5% reported symptoms of pelvic organ prolapse (POP), 66.8% urinary incontinence and 2.3% anal incontinence. The PISQ-IR subscales were analyzed separately for SA and NSA women with Cronbach's alpha coefficient ranging from 0.61 to 0.87. Moderate to high correlations were observed between PISQ-IR subscales and corresponding FSFI subscales and a moderate correlation between urinary distress and the condition impact (CI) subscale among NSA subjects.

CONCLUSIONS

The Dutch PISQ-IR demonstrated a good internal consistency and criterion validity compared with the FSFI, but criterion validity compared with the PFDI-20 was poor except for urinary distress in NSA women and needs further attention.

Physical Examination for Men and Women With Urologic Chronic Pelvic Pain Syndrome: A MAPP (Multidisciplinary Approach to the Study of Chronic Pelvic Pain) Network Study

OBJECTIVE

To examine the feasibility of implementing a standardized, clinically relevant genitourinary examination for both men and women, and to identify physical examination findings characteristic of urologic chronic pelvic pain syndrome (UCPPS).

MATERIALS AND METHODS

This study analyzed 2 samples: men and women with UCPPS who participated in the Multidisciplinary Approach to the Study of Chronic Pelvic Pain (MAPP) Research Network Epidemiology and Phenotyping (EP) Study, and age-matched controls who were either positive for chronic fatigue syndrome or healthy (pain-free). We compared physical examination findings in both positive and healthy controls with UCPPS cases: findings from both the EP examinations and from an extended genitourinary examination.

RESULTS

EP and extended examinations were performed on 143 participants: 62 UCPPS cases (30 women, 32 men), 42 positive controls (15 women, 27 men), and 39 healthy controls (22 women, 17 men). EP examinations showed that pelvic floor tenderness was more prevalent in cases (55.0%) than in positive (14.6%) or healthy controls (10.5%). Extended examinations revealed specific areas of tenderness in the pelvic floor musculature. Cases were also more likely than healthy controls to report tenderness in multiple areas, including suprapubic, symphysis pubis, and posterior superior iliac spine, and on bimanual examination. No comparative findings were specific to biological sex, and no evidence of pudendal neuropathy was observed on extended examination of cases or controls.

CONCLUSION

The extended genitourinary examination is an easily administered addition to the assessment of men and women during evaluation for UCPPS. Physical findings may help to better categorize patients with UCPPS into clinically relevant subgroups for optimal treatment.

Temporary successful results of ventral rectopexy for enterocele surgical correction, about 138 patients

PURPOSE

This work aimed to analyse short- and long-term results of enterocele surgical treatment by ventral rectopexy.

METHODS

All females who underwent ventral rectopexy for enterocele in our department were included. All patients underwent standardized preoperative evaluation. Data was retrospectively collected, after examination of patients or by telephone survey. Postoperative evaluation was performed by an independent observer.

RESULTS

One hundred thirty-eight females (median age = 63 years [21-86 years]) were included. They were postmenopausal and multiparous in 94 and 70% of cases, respectively. Pelvic pressure, vaginal prolapse, or the both were observed in 28, 16 or 56% of the patients, respectively. The most frequent associated symptoms were dyschezia (63%) and faecal incontinence (30%). On preoperative workup, enterocele was isolated in two cases. Rectocele, internal rectal prolapse and cervicocystoptosis were the most frequently associated pelvic floor disorders. Ventral rectopexy was performed through laparoscopy in 128 patients (93%). In the short term, all pelvic symptoms were significantly improved, except urinary incontinence. At the end of follow-up (56 months [7-125]), specific symptoms and dyschezia were still significantly improved. Secondary failure was reported in 31% of patients. By multivariate analysis, two predictive factors for long-term failure were found: diagnosis of rectocele on preoperative MRI (odd ratio = 15; 95% CI 1.4-163; p = 0.03) and conversion into open surgery (odd ratio = 8; 95% CI 1.4-43; p = 0.02).

CONCLUSION

This study suggests that ventral rectopexy is an effective treatment of enterocele, but secondary failure can be observed. Patients should be informed of the potential risk of long-term degradation.

[Cultural adaptation of the female pelvic floor questionnaire (FPFQ) into French]

AIMS

The Female Pelvic Floor Questionnaire (FPFQ) is a self-administered tool on pelvic floor function. Our aim was to carry out a cultural adaptation of the FPFQ into French and to assess its psychometric properties.

METHODS

After cross-cultural adaptation into French, acceptability and reliability of the questionnaire were assessed through a sample of 56 women in a test-retest. Discriminative construct validity was evaluated by comparing the results obtained by the FPFQ to those of other validated questionnaires. Longitudinal follow-up of the 282 pregnant women included in the PreNatal Pelvic floor Prevention trial (3PN) was used to analyze responsiveness.

RESULTS

The proportion of missing data did not exceed 4 % for questions about bladder function, bowel function and pelvic organ prolapse; 10 % for issues related to sexual function. Question 9 was considered difficult to understand by 14 % of women. After rewriting, this issue was retested in a new sample of 52 women and presented no further problems. The intra-class correlation coefficient was greater than or equal to 0.7 for all domains during the test-retest. The FPFQ was strongly and significantly correlated (Spearman r>0.5) with the other validated questionnaires. The French version of FPFQ recorded changes in urinary and sexual symptoms for the women involved in 3PN trial with a standardized response mean equal to 0.83 and 0.44, respectively.

CONCLUSION

The French version of the FPFQ is self-administered, reliable, valid, and can detect a change in symptoms during follow-up.

LEVEL OF EVIDENCE

Level 4.

ICS Educational Module: Electromyography in the assessment and therapy of lower urinary tract dysfunction in adults

AIM

To present the teaching module "Electromyography in the assessment and therapy of lower urinary tract dysfunction in adults." This teaching module embodies a presentation, in combination with this manuscript. This manuscript serves as a scientific background review; the evidence base made available on ICS website to summarize current knowledge and recommendations.

METHODS

This review has been prepared by a Working Group of The ICS Urodynamics Committee. The methodology used included comprehensive literature review, consensus formation by the members of the Working Group, and review by members of the ICS Urodynamics Committee core panel.

RESULTS

Electromyography (EMG) is a method to record spontaneous or artificially induced electrical activity of the nerve-muscle unit or to test nerve conductivity. EMG of the anal sphincter using surface electrode is most widely used screening technique to detect detrusor-sphincter dyssynergia in urology. It is non-invasive and easy to perform. EMG methods using needle electrodes are reserved for diagnostics in well selected group of mainly neurogenic patients. These methods require expertise in the field of general EMG and are usually performed by neurologist and neuro-physiologist. The evidence in many aspects of use of EMG in urology remains sparse.

CONCLUSIONS

Currently EMG methods rarely play a decision making role in selecting proper treatment of lower urinary tract dysfunction. With the current efforts to improve phenotyping of these patients in order to provide individualized treatment, the role of EMG could increase.

[Not Available]

Zusammenfassung. Die funktionelle Urologie befasst sich mit der Diagnostik und Therapie von Störungen der Harnblasen- und Beckenbodenfunktion und der Harninkontinenz. Die urodynamische Funktionsdiagnostik als zentrale diagnostische Methode ermöglicht durch die Messung einfacher physiologischer Parameter eine direkte Beurteilung der Funktion des unteren Harntraktes. Die Urodynamik dient dazu, klinische Symptome quantitativ zu reproduzieren, die Änderung physiologischer Parameter während der Messung in einen pathophysiologischen Zusammenhang zu stellen, eine Diagnose abzuleiten, eine Behandlung einzuleiten und im Verlauf deren Erfolg zu kontrollieren. Facetten der funktionellen Urologie sind die Neurourologie, die Urologie der Frau, die funktionelle Kinderurologie, die psychosomatische Urologie und die Behandlung der Harninkontinenz bei Frauen und Männern jeglichen Alters.

The investigation and treatment of female pelvic floor dysfunction

BACKGROUND

25% of all women report involuntary loss of urine, and 7% may require treatment.

METHODS

This review is based on a selection of pertinent literature, including guidelines and Cochrane reviews.

RESULTS

The assessment of pelvic floor dysfunction in women begins with a basic evaluation that is followed by special diagnostic tests if indicated. The physician taking the clinical history should inquire about the patient's behavior, personality, social and other stressors, and eating and drinking habits, as well as any mental disorders that may be present, including anxiety disorders, depression, somatization disorders, and disorders of adaptation. Conservative treatment consists mainly of lifestyle changes, physiotherapy, and medication. Stress incontinence is most commonly treated with pelvic floor exercises, with a documented success rate of 56.1% vs. 6% without such treatment (relative risk 8.38, 95% confidence interval 3.67-19.07). If incontinence persists, surgery may be indicated ( implantation of suburethral tension-free slings, or colposuspension). Feedback and biofeedback training can be used to treat an overactive bladder. If these techniques and drug therapy are unsuccessful, botulinum toxin injections can be considered.

CONCLUSION

Well-validated treatments for pelvic floor dysfunction are available. Psychosomatic factors must be taken into account and can have a major effect on treatment outcomes.

Characterizing female pelvic floor conditions by tactile imaging

Introduction and hypothesis

Tactile imaging (TI) is the high-definition pressure mapping technology which allows recording pressure patterns from vaginal walls under applied load and during pelvic floor muscle contraction. The objective of this study was to identify new tactile imaging and muscle contraction markers to characterize female pelvic floor conditions.

Methods

The study subjects included 22 women with normal and prolapse conditions. They were examined by a new vaginal tactile imaging probe that images the entire vagina, the pelvic floor support structures, and pelvic floor muscle contractions.

Results

We identified 11 parameters as potential markers to characterize the female pelvic floor conditions. These parameters correlate with prolapse conditions, patient age, and parity.

Conclusions

Our findings suggest that the tactile imaging markers such as pressure, pressure gradient, and dynamic pressure response during muscle contraction may be used for further quantitative characterization of female pelvic floor conditions.

Electronic supplementary material

The online version of this article (doi:10.1007/s00192-014-2549-9) contains supplementary material, which is available to authorized users. This video is also available to watch on http://videos.springer.com/. Please search for the video by the article title.

Pelvic Floor Dysfunction and Associated Lower Urinary Tract Symptoms--A Case Study

Lower urinary tract symptoms are a common complaint for women who present with a myriad of symptoms. A thorough history and physical examination, as well as specific diagnostic testing, can help determine the underlying cause and direct the best treatment option as presented in this case study.

Magnetic resonance imaging of pelvic floor disorders

Physical examination alone is often inadequate for evaluation of pelvic floor dysfunction. Magnetic resonance imaging (MRI) is a robust modality that can provide high-quality anatomic and functional evaluation of the pelvic floor. Although lack of standardized technique and radiologist inexperience may be relative deterrents in universal acceptance of pelvic floor MRI, the role of MRI is increasing as it is technically feasible on most magnets and offers some advantages over the traditional fluoroscopic defecography. This review focuses on the technical and interpretational aspects of anatomic and functional pelvic floor MRI.

Pelvic floor muscle activity, quality of life, and sexual function in peri- and recently postmenopausal women with and without dyspareunia: a cross-sectional study

Pelvic floor alterations during menopausal years, resulting from aging and hormonal decline, may lead to several forms of sexual dysfunction. Dyspareunia-pain during sexual intercourse-is among the most frequent. Nevertheless, few studies so far have evaluated pelvic floor muscle function in postmenopausal women with dyspareunia. The authors thus carried out a cross-sectional study to assess myoelectric activity in pelvic floor muscles in peri- and postmenopausal women with and without dyspareunia receiving routine care at an outpatient clinic. In addition, sexual function (using the Female Sexual Function Index) and quality of life (using the Cervantes Scale) were assessed. Fifty-one peri- and postmenopausal women between 45 to 60 years of age (M = 52.1, SD = 4.9) were evaluated, 27 with and 24 without dyspareunia. There were no statistically significant differences in resting muscle activity, maximal voluntary contraction, and sustained contraction between women with and without dyspareunia. There were statistically significant between-group differences on the Cervantes Scale (p =.009) and in all Female Sexual Function Index domains except desire and satisfaction (arousal, p =.019; lubrication, p =.030; orgasm, p =.032; pain, p <.001; desire, p =.061; satisfaction, p =.081), indicating that women with dyspareunia experience worse quality of life and less satisfactory sexual function as compared with women without dyspareunia.

[Pelvic floor disorders from the surgeon's viewpoint]

Pelvic floor disorders present very differently with regard to symptoms and manifestation. Both diagnostic and treatment options require specific experience and an interdisciplinary approach. Diagnostic work-up is primarily based on medical history, physical examination and procto-rectoscopy. Furthermore, endosonography and perineal sonography have also gained importance. In almost all cases following these basic examinations conservative therapy options should be considered. As the interdisciplinary concept is very important, for careful diagnosis of pelvic floor disorders it became crucial to find an adequate form of treatment. Every decision for surgical therapy should not only focus on the results of previous examinations but should also consider the individual situation of each patient. In pelvic floor disorders a large variety of symptoms are confronted with a vast number of different and often highly specific procedures. The decisions on who to treat and how to treat are not only based on individual patient requests and desires but also on the experience and preference of the surgeon.

Entero-colpo-defecography vs supine entero-MRI: which one is the best tool in the differentiation of enterocele, elytrocele and edrocele?

Pelvic floor disorders represent a significant cause of morbidity associated with a severe reduction of quality of life. It represents a very common clinical problem that afflicts women three to seven time more often than men. The purpose of this study was to assess the diagnostic tools available to define the imaging strategy in patients with pelvic floor dynamic dysfunctions and to investigate their abilities in the diagnosis of enterocele, elytrocele and edrocele. From January 2008 to May 2011, 614 patients with symptoms related to pelvic floor dynamic dysfunctions were enrolled in our retrospective study. After anamnesis and clinical examination, entero-colpo-defecography (ECD) and supine entero-magnetic resonance (SE-MR) exams were performed in all patients. This study showed that the diagnostic efficacy of ECD is higher than that of SE-MR in the detection of enterocele and edrocele. Furthermore, elytrocele can be visualized only with ECD considering the position of patient during SE-MR examination. In addition, in patients planned for surgery, SE-MR is more useful to clarify the intra-pelvic interaction of multiple organ prolapse and to better define the pelvic anatomy and functioning.

Recognition and management of nonrelaxing pelvic floor dysfunction

Nonrelaxing pelvic floor dysfunction is not widely recognized. Unlike in pelvic floor disorders caused by relaxed muscles (eg, pelvic organ prolapse or urinary incontinence, both of which often are identified readily), women affected by nonrelaxing pelvic floor dysfunction may present with a broad range of nonspecific symptoms. These may include pain and problems with defecation, urination, and sexual function, which require relaxation and coordination of pelvic floor muscles and urinary and anal sphincters. These symptoms may adversely affect quality of life. Focus on the global symptom complex, rather than the individual symptoms, may help the clinician identify the condition. The primary care provider is in a position to intervene early, efficiently, and effectively by (1) recognizing the range of symptoms that might suggest nonrelaxing pelvic floor dysfunction, (2) educating patients, (3) performing selective tests when needed to confirm the diagnosis, and (4) providing early referral for physical therapy.