Electromyography findings of pelvic floor muscles in patients with anorectal incontinence]

In the presented study the electromyographical signs of the sphincter muscle of 14 patients with incontinence of the faeces are described and compared with those of a group of continent controls. We found significant differences in the duration of the action potential, the average amplitude, the frequency of polarity turns and the integral of the curves. The application of automatic EMG-analysers allows exact differentiation between neurogenic and myogenic disturbances as well as conclusions about the functional integrity of the m. sphincter ani externus and m. puborectalis. The electromyography as a dynamic diagnostic method is a valuable enrichment of the equipment for diagnostic evaluation of the diseases of the pelvic floor. It will be of increasing importance in the differential diagnosis of the incontinence of the faeces and of pudendus nerve lesions as well as in any disease in which a denervation of the parietal or visceral muscles of the pelvic floor is involved.     

Interobserver and interdisciplinary reproducibility of 3D endovaginal ultrasound assessment of pelvic floor anatomy

Introduction and hypothesis  

The study aims were to evaluate (1) the interobserver and (2) the interdisciplinary repeatability of levator hiatus, urethral thickness, and anorectal angle measurements using three-dimensional endovaginal ultrasound (3D-EVUS).     

Residual defects after repair of obstetric anal sphincter injuries and pelvic floor muscle strength are related to anal incontinence symptoms

Introduction and hypothesis

The aim was to analyze the correlation between residual anal sphincter (AS) defects and pelvic floor muscle (PFM) strength on anal incontinence (AI) in patients with a history of obstetric AS injuries (OASIS).

Methods

From September 2012 to February 2015, an observational study was conducted on a cohort of females who underwent repair of OASIS intrapartum. The degree of OASIS was scored intrapartum according to Sultan’s classification. Participants were assessed at 6 months postpartum. Incontinence symptoms were evaluated using Wexner’s score and PFM strength using the Modified Oxford Scale (MOS). 3D-endoanal ultrasound was performed to classify AS defects according to Starck’s system. Correlation between Sultan’s and Starck’s classifications was calculated using Cohen’s kappa and Spearman’s rho (R_s) test. The impact of residual AS defects and PFM strength on AI was analyzed using a multiple regression model.

Results

A total of 95 women were included in the study. Good correlation (κ=?0.72) was found between Sultan’s and Starck’s classifications. Significant positive correlation was observed between Wexner’s score and both Sultan’s (p?=?0.023, R_s =0.212) and Starck’s (p?<?0.001, R_s =0.777) scores. The extent of the residual AS defect was the most relevant factor correlating with AI symptoms. In patients with severe AS injuries, higher MOS values were associated with lower Wexner’s score.

Conclusions

The degree of AS tear measured intrapartum was the most important factor related to AI after primary repair of OASIS. PFM strength was associated with lower incontinence symptoms in the postpartum period.

     

Female stress urinary incontinence and the pelvic floor

Damage to the pelvic floor muscles leads to an altered relationship of the uterus and the urethrovesical unit to the levator plate and creates conditions predisposing to pelvic relaxation associated with stress incontinence. Morphological changes of pelvic floor muscles are age dependent and associated with deterioration of the urethral closure mechanism. Urodynamic assessment and knowledge of the morphology of pelvic floor muscles improves the understanding of pelvic floor function as it relates to the support of the pelvic viscera and the urethral mechanism that maintains continence of urine.     

Cost of pelvic floor repair for faecal incontinence

BACKGROUND: Pelvic floor repair is often unsuccessful for the treatment of incontinence. Some patients undergo repeated operations, and a few may require a stoma that can result in further operations. METHOD: We have examined the cost of two forms of pelvic floor repair: post-anal repair (PAR; n = 47) and total pelvic floor repair (TPFR; n = 32). RESULTS: Persistent incontinence, which had an impact on the quality of life, occurred in 23 patients (29%); this was more common after PAR (21 patients; 45%) than after TPFR (2 patients; 6%), but the follow-up period was longer (9.7 years) after PAR than after TPFR (6.6 years), and incontinence tended to deteriorate with time. Twenty-two patients required repeat operations for incontinence (20 patients having 56 re-operations after PAR, and 2 patients who had repeated operation after TPFR). The average number of admissions was 1.92 (PAR 2.42, TPFR 1.18). The total number of operations was 141 (average 1.78), being greater after PAR (104; average 2.12) than after TPFR (37; average 1.15). The total hospital stay was 1,631 days; average 20.64, being longer following PAR (994 days; average 21.1) than after TPFR (637; average 19.9). The total hospital cost based on hospital stay, number of operations, operating time, complexity of surgery and out-patient visits was Cin 294,216 (average Cin 3,724), being higher after PAR (Cin 190,062; average Cin 4,043) as compared with TPFR (Cin 104,154; average Cin 3,254). The extra financial burden was largely borne by 9 individuals, all requiring a stoma, having repeated procedures (more than 2 operations) in whom the average cost was twice that of the index operation. CONCLUSION: We conclude that end-stage faecal incontinence is a huge burden on hospital budgets, since over time many patients require repeated operations.     

A disposable anal plug electrode for pelvic floor/anal sphincter electromyography

During the last year we developed a disposable anal plug electrode for pelvic floor/external anal sphincter electromyography. The electrode consists of 2 disposable silver chloride surface electrodes mounted on a trochlear-shaped sponge. Testing of the new electrode with simultaneous registration of external anal sphincter electromyography using a coaxial needle electrode showed synchronous electromyographic patterns. In clinical urodynamic studies, including 48 cystometry studies with anal sphincter electromyography and 48 pressure-flow electromyographic studies, the electrode provided technically good and reliable electromyograms. The electrode design secures good contact to the recording surface and a safe fixation of the electrode during recording. The compressibility of the electrode might circumvent the problem of possible detrusor reflex inhibition induced by conventional hard anal plug electrodes. We recommend this technique for anal sphincter electromyography, since it is simple, reliable and without discomfort, and it does not require sterilization of the electrode.     

The role of pelvic floor exercises on post-prostatectomy incontinence

PURPOSE: Post-radical prostatectomy incontinence occurs in 0.5% to 87% of patients. This condition may be attributable to intrinsic sphincteric deficiency, and/or detrusor abnormalities. Previous studies of pelvic floor exercise (PFE) for improving post-prostatectomy incontinence have shown mixed results. We determined whether preoperative and early postoperative biofeedback enhanced PFE with a dedicated physical therapist would improve the early return of urinary incontinence. MATERIALS AND METHODS: A total of 38 consecutive patients undergoing radical prostatectomy from November 1998 to June 1999 were randomly assigned to a control or a treatment group. The treatment group of 19 patients was referred to physical therapy and underwent PFE sessions before and after surgery. Patients were also given instructions to continue PFE at home twice daily after surgery. The control group of 19 men underwent surgery without formal PFE instructions. All patients completed postoperative urinary incontinence questionnaires at 6, 12, 16, 20, 28 and 52 weeks. Incontinence was measured by the number of pads used with 0 or 1 daily defined as continence. RESULTS: Overall 66% of the patients were continent at 16 weeks. A greater fraction of the treatment group regained urinary continence earlier compared with the control group at 12 weeks (p <0.05). Three control and 2 treatment group patients had severe incontinence (greater than 3 pads daily) at 16 and 52 weeks. Of all patients 82% regained continence by 52 weeks. CONCLUSIONS: PFE therapy instituted prior to radical prostatectomy aids in the earlier achievement of urinary incontinence. However, PFE has limited benefit in patients with severe urinary incontinence 16 weeks after surgery. There is a minimal long-term benefit of PFE training since continence rates at 1 year were similar in the 2 groups.     

Rehabilitative ultrasound imaging of pelvic floor muscle function

This commentary provides an overview of the current concepts and evidence related to rehabilitative ultrasound imaging of pelvic floor (levator ani) function. As this is an emerging topic, the goal is to provide a basic understanding of ultrasound imaging applications related to levator ani function: the available quantitative and qualitative information, the limitations, as well as how ultrasound imaging can be incorporated as a form of biofeedback during rehabilitation. Furthermore, as the ability to compile and compare existing evidence depends on the degree of similarity in methodology by investigators, this commentary highlights points of consideration and provides guidelines, as well as an agenda, for future investigation.     

Effectiveness of early pelvic floor rehabilitation treatment for post-prostatectomy incontinence

PURPOSE: Urinary incontinence after radical prostatectomy is a significant clinical problem. In this prospective study we investigate the effectiveness of early pelvic floor muscle training (PFMT) on a large population, that had undergone radical retropubic prostatectomy (RRP) at our department. METHODS: 300 consecutive patients who had undergone RRP for clinically confined prostate cancer were randomized in two groups after catheter removal. One group of 150 patients took part in a structured PFMT program. This began before discharge and consisted of Kegel exercises. The remaining 150 patients constituted the control group, they were not formally instructed in PFMT. Incontinence was assessed objectively using the 1 hour and 24 hour pad test, as well as with the ICS-Male questionnaire. All patients who were incontinent after 6 months underwent urodynamic evaluation. RESULTS: In the treated group, 19% (29 patients) achieved continence after 1 month, and 94.6% (146 patients) after 6 months. In the control group 8% (12 patients) achieved continence after 1 month, and 65% (97 patients) after 6 months (p<0.001). Patient age did not correlate with continence in the control group (p>0.05), although a significant correlation was revealed within the treated group (p<0.01). Overall, 93.3% of the total population achieved continence after one year. CONCLUSIONS: After RRP an early supportive rehabilitation program like PFMT significantly reduces continence recovery time.     

Long-term effect of pelvic floor exercises on female urinary incontinence

In order to assess the permanent effect of pelvic floor exercises on female stress incontinence, 76 incontinent women, referred for incontinence surgery, underwent a 3-month exercise programme conducted by an experienced physiotherapist. The patients were followed up for 1 year. At the last assessment 30% were cured and 17% improved. Altogether 47% avoided surgery. No relapses were seen during the follow-up period. Patients with mild incontinence benefited from intensified training, since 72% could expect to be cured, while patients with severe incontinence and no immediate effect did not benefit from further exercises. Patients with a positive hormone status and those with normal weight had a significantly higher cure rate. The subjective results were confirmed by the 24-h pad test. Anal pressure profilometry was a valid method for instruction and objective control of pelvic floor function. It was concluded that pelvic floor exercises should precede surgery, since exercises had a permanent effect in half of the patients.     

The role of the pelvic floor in female urinary incontinence

This paper presents a review of the various factors believed to be involved in female urinary continence. Components within the wall of the urethra include smooth muscle, the striated muscle of the rhabdosphincter, elastic connective tissue, a subepithelial vascular component, and the urethral epithelium. Extramural factors comprise the fascial support of the bladder neck and proximal urethra, the transmission of intra-abdominal pressure to the urethra, and the periurethral muscles of the pelvic floor. Special emphasis is placed on the periurethral muscles, and the anatomy, innervation, and histochemistry of the levator ani are discussed. This account is followed by consideration of evidence that partial denervation of the levator ani may be an etiological factor in female genuine stress incontinence of urine. Finally, various non-invasive methods for the relief of genuine stress incontinence are discussed, including pelvic floor exercises and the use of intravaginal cones and electrostimulation.     

智能盆底超声联合多平面成像技术在产后压力性尿失禁筛查中的应用

目的探讨智能盆底超声联合多平面成像技术在产后压力性尿失禁(SUI)筛查中的应用。方法选取2016年9月至2018年12月在本院收治90例SUI产后产妇作为SUI组,同期选取90例非SUI的健康产后产妇作为健康组,所有产妇均行静息和Valsalva动作状态下智能盆底超声联合多平面成像技术检查。结果SUI组静息和Valsalva动作状态下膀胱尿道后角、盆膈裂孔面积明显高于健康组,SUI组静息和Valsalva动作状态下耻骨直肠肌厚度明显低于健康组,SUI组膀胱颈移动度、尿道旋转度、尿道内口漏斗发生率明显高于健康组,差异有统计学意义(P<0.05),SUI组和健康组尿道长度、尿道倾斜角比较,差异无统计学意义(P>0.05);智能盆底超声联合多平面成像技术筛查SUI的敏感度、特异度、准确度为90.00%、93.33%、91.67%,与实际结果基本一致(P<0.05)。结论智能盆底超声联合多平面成像技术可有效显示SUI产妇的膀胱颈和尿道支持结构改变,在SUI筛查中具有良好的应用价值,值得临床推广。