Role of behavioral changes and biofeedback in urology

Voiding disorders are common in urological patients. Pelvic floor dysfunction may result from overtraining pelvic floor muscles in an attempt to prevent leaking. This can further cause bladder dysfunction or weakening the pelvic floor muscles. Pelvic floor dysfunction or insufficient relaxation of the pelvic floor results in hesitancy, intermittency, and high postvoid residuals (PVR). Behavioral changes and biofeedback play a key role in urologic problems including pelvic pain, irritative voiding symptoms, recurrent urinary tract infections, and incontinence. Biofeedback involves using electrodes to transduce muscle potentials into auditory or visual signals; patients learn to increase or decrease voluntary muscle activity. Conservative behavioral and biofeedback treatments are safe and effective interventions that should be more readily available to patients as a first-line treatment for voiding dysfunction. Patient education may take time but has higher long-term success and makes the patient more responsible and less passive regarding their condition.     

Clinical application of electrodiagnostic studies of female pelvic floor neuropathy

Pelvic floor disorders resulting in urinary and/or fecal incontinence have been shown to be related to neuropathy. Electrodiagnostic studies of the pelvic floor when associated with an understanding of pelvic floor anatomy and physiology may have clinical application in the field of Urogynecology. Possible clinical applications are discussed.     

Urethral sphincter electromyography

Electromyography of the pelvic floor muscles may be used to assess their innervation using the technique of motor unit analysis. Prolongation of motor unit duration and an increase in motor unit amplitude reflects denervation and reinnervation of these muscles. This principle may be used to detect and investigate nerve damage in a variety of disorders which affect the musculature of the pelvic floor, including multiple system atrophy. It has also been used to investigate the effects of childbirth on the pelvic floor and to investigate the relationship between damage to the innervation of the pelvic floor and stress incontinence. Finally, urethral sphincter electromyography has detected abnormal electrical activity in some women with obstructed voiding, which may reflect abnormal relaxation of the striated urethral sphincter.     

Female sexual dysfunction following vaginal surgery: a review

PURPOSE: Depending on age it has been estimated that up to 40% of women have complaints of sexual problems, including decreased libido, vaginal dryness, pain with intercourse, decreased genital sensation and difficulty or inability to achieve orgasm. In this review we address the etiologies and incidence, evaluation and treatment of female sexual dysfunction following vaginal surgery for indications such as stress urinary incontinence and pelvic organ prolapse; anterior/posterior colporrhaphy, perineoplasty and vaginal vault prolapse. MATERIALS AND METHODS: Literature on the mechanisms by which vaginal surgery affects female sexual function are discussed along with related pathophysiology to potential causes. The anatomy, neurovascular supply of the clitoris and introitus, and intrapelvic nerve supply are discussed as related to vaginal surgery. Techniques to avoid neurovascular damage during pelvic floor surgery were corroborated by supporting literature. Literature regarding female sexual dysfunction following other procedures, such as vaginal hysterectomy, Martius flap interposition, and vesicovaginal and rectovaginal fistula repair were also discussed. RESULTS: Current literature does not support an association between vaginal length following vaginal surgery and sexual function. The proportion of women who are sexually active does not appear to be affected by vaginal surgery. Sling surgery for urinary incontinence does not appear to adversely affect overall sexual function, although individual parameters of sexual function scores may vary, eg a significant percent of women report pain during intercourse. Some patients experience improved overall sexual function due to complete relief from coital incontinence CONCLUSIONS: Symptomatic vaginal narrowing is rare even in women undergoing simultaneous posterior repair. Overall sexual satisfaction appears to be independent of therapy for urinary incontinence or prolapse. Data indicate that defect specific posterior colporrhaphy with the avoidance of levator ani plication may improve sexual function. The possible etiological factors for sexual dysfunction following vaginal surgery deserve further investigations.     

Awareness and education to support sexual health after urologic cancer

One of the most common side effects of urologic cancer and its treatment is sexual dysfunction. This negative consequence can occur because of changes in anatomy and/or the physiologic response to sexual stimuli, but also due to the psychological impact of those physical changes and the cancer experience. Sexual health is a key part of survivorship, but it is under-emphasized in training and can be overlooked in clinical practice. To support the sexual health of the urologic cancer survivor, the urologic oncologist should: 1) acknowledge and educate the patient about the potential effects, 2) be sensitive to identifying sexual issues as they arise, and 3) be aware of treatment strategies and be able to access the team members needed to provide these strategies. As sexual function requires a complex interplay of anatomy, physiology, and psychology, so does addressing sexual dysfunction resulting from cancer treatment. In this special Seminars issue, we review the sexual dysfunction consequences of urologic cancers in both men and women and strategies to maximize sexual health.     

Review of current status of female sexual dysfunction evaluation in urogynecology

Sexual dysfunction is a highly prevalent condition in women attending urogynecological services. However, only a minority of urogynecologists screen all patients for female sexual dysfunction. Lack of time, uncertainty about therapeutic options and older age of the patient have been cited as potential reasons for failing to address sexual complaints as part of routine history. Evidence from large prospective studies have shown that prolapse and/or incontinence adversely affect sexual function. Assuming that the physical effect of prolapse and incontinence is one of the contributing factors for sexual dysfunction, one could logically assume that an intervention leading to their improvement should improve sexual function. Current evidence of the effect of conservative and surgical management of pelvic floor disorders on sexual function is encouraging. More research is needed using standardised assessment tools to define clear endpoints in sexual function.     

A urogynecologist’s view of the pelvic floor effects of vaginal delivery/cesarean section for the urologist

Pregnancy and parturition have been implicated in the development of pelvic floor dysfunction. These disorders include urinary incontinence, fecal incontinence, pelvic organ prolapse, and other pelvic and sexual dysfunctions. The urologist caring for women with urinary dysfunction needs to be familiar with the causes of pelvic floor dysfunction and their implications. Defects of the pelvic floor have clearly resulted from the traumatic effect of vaginal delivery. The likely mechanisms of injuries during vaginal delivery involve stretching and compression of the pudendal nerve and peripheral branches, as well as an additional tearing of muscles and connective tissue. Optimal management of labor and optimal techniques of repair of unavoidable sphincteric lacerations, ante- and postpartum pelvic floor muscle conditioning, and timely and proper indications for cesarean delivery will minimize the effect of incidental traumatic delivery.     

Morphology and neuropathology of the pelvic floor in patients with stress incontinence

Urinary incontinence imposes a considerable workload on urological and gynecological practice. Many treatments exist, but recurrent stress incontinence remains a significant problem and the reasons remain unclear. Pathological and electrophysiological studies have shown that significant pelvic nerve damage and consequent denervation and reinnervation are associated with stress incontinence, and furthermore there are collagenous changes in the pelvic floor which are related to childbirth, endogenous hormone changes and the effects of increasing age. These changes include increased nerve fiber density and pudendal nerve terminal motor latency, hypertrophy of fiber types 1 and 2, type 1 fiber predominance and fiber type grouping. Connective tissue changes involve a reduction in hydroxyproline excretion, increased cross-linking and increased muscle collagen. It is only through a better understanding of the anatomy and pathophysiology of the pelvic floor that we will be able to improve outcome in women with stress incontinence and identify patients that may not be appropriate for surgical therapy. This paper reviews recent advances in the understanding of the etiology of stress incontinence.     

Sexual health in women with pelvic floor disorders: measuring the sexual activity and function with questionnaires—a summary

The integration of sexual health into the health care services is important. In women attending urogynecological clinics, the urinary function, anorectal function, and anatomical defects are more often evaluated than those related to sexual activity and function. A group of experts in urogynecology, sexuality, and patient reported outcome development, met in a roundtable with the final objective of reviewing what is currently available and what is needed to accurately evaluate sexual function in women with pelvic floor dysfunction. An article was prepared for each of the issued presented during the roundtable and combined into this supplement. This article is a summary of all articles included in this supplement. The pathophysiology of sexual dysfunction as related to pelvic floor disorders has not been well established. Sexuality questionnaires and scales play an integral role in the diagnosis and treatment of female sexual dysfunction. The Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ) is the only validated female sexual function questionnaire specifically developed to assess sexual function in women with urinary incontinence and/or pelvic organ prolapse; however, the PISQ does not screen for sexual activity. The effects of treatments for pelvic floor problems on sexual function have received little attention. There is a need for a validated sexual function measure that evaluates not only the impact of pelvic floor dysfunction on sexual function but also the impact on sexual activity.     

Should Asymptomatic Anterior Pelvic Organ Prolapse Be Corrected to Treat Irritative Urinary Symptoms?

In clinical practice, women seen with pelvic organ prolapse (POP) often present with a variety of pelvic floor symptoms: urinary incontinence, irritative or overactive bladder symptoms, fecal urgency or incontinence, obstructive voiding, sexual disorders, pelvic and perineal pain, and vaginal bulging. Among these, the only symptom reliably associated with clinically relevant POP that will resolve following vaginal reconstructive surgery is the visualization and/or sensation of a vaginal bulge. Most other symptoms often attributed to POP at best have only weak correlations with worsening pelvic anatomical support. Specifically, with respect to the anterior and/or apical vaginal compartment, there does not appear to be a correlation between irritative overactive bladder symptoms and the presence or degree of anterior vaginal wall prolapse. Furthermore, no other symptoms, urinary or otherwise, are reliably influenced by correction of anatomical defects of pelvic support, especially in the otherwise asymptomatic patient with POP without vaginal bulge. A review of the recent literature underscores the realization that the relationship between pelvic floor symptoms and anatomy is incompletely and poorly understood. With this in mind, there does not seem to be any absolute justification for the surgical correction of otherwise asymptomatic pelvic support defects.     

The effect of pelvic floor training on sexual function of treated patients

The aim of this study was to determine the effects of improvements in urinary incontinence resulting from pelvic floor rehabilitation on the sexual function of patients. The study involved 42 clinic patients who received pelvic floor rehabilitation treatment. Their sexual histories were obtained through face-to-face interviews. Pelvic muscle strength was measured with a perineometer. Improvement in incontinence was measured with the pad test. Seventeen women reported decreased sexual desire before the treatment; 5 of these indicated improvement after treatment. Nine of 17 women who experienced dyspareunia prior to treatment reported an improvement afterwards, and four women reported complete relief from pain. Five of 15 women who complained of difficulty in reaching climax before the treatment experienced improvement in this area. In conclusion, an improvement in sexual desire, performance during coitus and achievement of orgasm were observed in women who received pelvic floor muscle rehabilitation. No change was seen in the arousal and resolution stages of sexual activity.Abbreviation FES Functional electrical stimulationEditorial Comment: Previous studies suggest that the prevalence of sexual dysfunction is high amongst women with urinary incontinence. Some data exist about the effect of surgical treatment of urinary incontinence and its effect on sexual function. Data also exist that women with sexual dysfunction due to painful conditions improve with pelvic floor therapy. It could be expected that women with urinary incontinence and sexual dysfunction show better overall improvement of both conditions when treated with pelvic floor therapy rather than with surgery. Patients in this study showed improvement in urinary incontinence with pelvic floor therapy. They also had a marked decrease in dyspareunia. Overall, there was improvement in sexual function, particularly an increase in desire. Unfortunately, the study does not address whether this improvement appears to be related to a decrease in incontinence, a decrease in pain with intercourse or an additive effect.     

Depression and incontinence

 The urologic literature suggests that there is an association between a variety of psychiatric disorders and incontinence. Most notably, depression is found in a significant percentage of patients with urinary incontinence. Depression also occurs in other conditions associated with urinary urge incontinence, such as aging and dementia, and in neurologic disorders such as normal pressure hydrocephalus. Correction of some neurologic disorders eliminates both depression and urge incontinence. Although chronic medical disorders such as urge incontinence may lead to depression, an alternative hypothesis is that these two conditions share a common neurochemical pathogenesis. Lowering monoamines such as serotonin and noradrenaline in the central nervous system (CNS) leads to depression and urinary frequency and a hyperactive bladder in experimental animals. Thus, depression may not only be the result of persistent urinary incontinence, but individuals with altered CNS monoamines could manifest both depression and an overactive bladder. The latter condition may lead to urge incontinence, urinary frequency, urgency, or enuresis. Uncovering further evidence for such a linkage could serve as the basis for the development of genetic markers and novel therapeutic interventions for these two conditions.     

Sexual health in women with pelvic floor disorders: measuring the sexual activity and function with questionnaires—a summary

Sexual health is a right for the healthy or sick individual human being. The effects of the illness on sexual function may be mediated directly by physiological mechanisms or by psychological factors related to the illness. Treatment of the illness itself can affect sexual function. Comorbidity in women with sexual dysfunction is common. When we evaluate sexual dysfunction, it is important to determine the role of the illness as a factor that predisposes, precipitates, and maintains the sexual problem. In the context of urogynecological clinical practice we have patients sexually active or inactive, with a self perceived “normal sexual life”, or with sexual problems that may be related or not with their pelvic floor dysfunction (PFD). Most physicians admit that this is important to detect sexual dysfunction, but only half of them regularly screen for it. Considering pelvic floor dysfunction as a comorbidity of women’s sexual dysfunction and in spite of the inherent complexity of women’s sexuality, future research would merit focusing on this comorbidity as well as a bio-psychosocial approach. In the twenty-first century, in general, we still have a great deal to learn about female sexuality.     

Der Beckenboden der Frau: eine Schwachstelle der Evolution

The pelvic floor can be described as a weak point in the evolution of mankind. Three functions can suffer injury: the bladder (urine incontinence 16?%), the rectum (anal incontinence 5–9?%) and the vagina (cystocele and rectocele, sensation of downward pressure 20–25?% and loss of sexual drive). The causes for these weaknesses are giving birth, overweight, lack of activity and ageing. Competent help can be offered in pelvic floor centers (rejuvenation centers) although sexuality is not considered. In cases of facultative disorders of the pelvic floor there are promising therapeutic developments with the intravaginal use of the erbium:YAG laser and radiofrequency.     

Reconsideration of pelvic floor muscle training to prevent and treat incontinence after radical prostatectomy

Urinary incontinence is common after radical prostatectomy. Pelvic floor muscle training provides a plausible solution. Although early trials provided promising results, systematic reviews have questioned the efficacy of this intervention. A major consideration is that most clinical trials in men have applied principles developed for pelvic floor muscle training for stress urinary incontinence in women, despite differences in anatomy between sexes and differences in the mechanisms for continence/incontinence. Literature regarding continence control in men has been conflicting and often based on erroneous anatomy. New understanding of continence mechanisms in men, including the complex contribution of multiple layers of striated pelvic floor muscles, and detailed consideration of the impact of radical prostatectomy on continence anatomy and physiology, have provided foundations for a new approach to pelvic floor muscle training to prevent and treat incontinence after prostatectomy. An approach to training can be designed to target the pathophysiology of incontinence. This approach relies on principles of motor learning and exercise physiology, in a manner that is tailored to the individual patient. The aims of this review are to consider new understanding of continence control in men, the mechanisms for incontinence after radical prostatectomy, and to review the characteristics of a pelvic floor muscle training program designed to specifically target recovery of continence after prostatectomy.     

Pelvic floor anatomy and imaging

The pelvic floor is a complex, three-dimensional mechanical apparatus that consists of several components: the pelvic organs and endopelvic fascia, the ligament and perineal membrane, the levator ani muscles and superficial perineal muscles, and the pelvic nerves. The support for the pelvic organs comes from connections to the bony pelvis and its attached muscles. Any damage to the structural and functional interactions of the pelvic floor elements can potentially cause multicompartmental dysfunction. Surgical management of pelvic floor disorders depends on a comprehensive understanding of the structural integrity and function of the pelvic floor. As a result of technological progress, dedicated imaging modalities including static and dynamic 3D and 4D transvaginal, endoanal and transperineal ultrasound, dynamic Magnetic Resonance, and evacuation proctography have been introduced. The “integrated” use of these techniques provides outstanding visualization of the anatomy of the pelvic floor, allowing for accurate assessment of the major disorders—urinary and fecal incontinence, pelvic organ prolapse, and obstructed defecation syndrome.     

Séquelles fonctionnelles des traumatismes anopérinéaux

Severe perineal trauma is rare and the consequence after a long-term follow-up is poorly reported in the literature. Anorectal complaints include fecal incontinence, pelvic floor prolapse and obstructed defecation syndrome. Urinary disorders and sexual dysfunctions may be associated. The functional result depends on the initial severity grade, the management and particularly the neurological injuries.     

Urodynamics: role in incontinence and prolapse: a urology perspective

Changes in pelvic floor as well as urethral anatomy and function occur with aging, which can result in prolapse and urinary incontinence. Aside from the socially debilitating impact incontinence has on patient's lives, it significantly affects the health care systems economically. Rates of incontinence and pelvic organ prolapse (POP) in women of this age demographic is estimated to be 30% to 94%, and 1 in 8 women may require surgical repair for POP or incontinence by their eighth decade, with a reoperation rate of 30%. This article reviews the role of UDS in the evaluation of urinary incontinence and POP.     

The Prevalence of Urinary and Fecal Incontinence in Canadian Secondary School Teenage Girls: Questionnaire Study and Review of the Literature

The purpose of this study was to examine the prevalence of pelvic floor dysfunction and incontinence in the Canadian nulligravid secondary school female teenage population. During the University of Toronto day in 1996, female visitors to the Obstetrics and Gynecology Department booth were asked to complete anonymous pelvic floor and continence questionnaires, which were thoroughly explained to them and completed during their visit. Out of the 332 completed forms, 69% were completed by nulligravid teenagers in secondary school. These students formed our study population. The prevalence of urgency urinary incontinence (UUI) symptoms was 17% and of stress urinary incontinence (SUI) symptoms was 15%. In all candidates these reported symptoms were mild, occurring less than once a week. Occasional minor fecal incontinence (involuntary loss of flatus or fecal staining) was 38%; of these, 92% reported loss of flatus. Major fecal incontinence with loose bowel movements was reported by 3% of the study population. Two girls (1%) reported nocturnal enuresis. Weight directly correlated with SUI symptoms and fecal incontinence, but not with UUI. Fecal incontinence correlated with SUI symptoms (P = 0.0152), but not with UUI. Ten per cent of the study population were sexually active, but sexual activity did not correlate with incontinence problems. Voiding habits were markedly variable: 30% were infrequent voiders (three times or fewer per day). Nocturia was reported by 3%. We concluded that in nulligravid teenage female students minor fecal incontinence appears to be the most common incontinence type; urge incontinence was slightly more common than SUI. Unlike UUI, SUI symptoms were more prevalent with fecal incontinence, which were affected by weight. There appears to be a problem with a high prevalence of poor voiding habits.     

Pelvic floor rehabilitation

Pelvic floor disorders can be improved by various methods of conservative treatment. Urogynecologic rehabilitation involves pelvic floor physiotherapy, functional electrical stimulation and biofeedback. Recent urodynamic studies have revealed obstetric risk factors, and restoration of pelvic floor musculature after vaginal deliveries is essential. It would appear that urogynecologic rehabilitation should also be routinely prescribed during the months preceding some surgical procedures. Biofeedback has been used successfully in urologic disorders such as instability and enuresis. It is probably the most efficient therapy for learning perineal blockage at stress, which gives the patient functional control of the pelvic floor muscles during daily activities. Functional electrical stimulation, either on an outpatient basis or as a home program, is a practical and successful method for improving or curing incontinence. Physiotherapy has to be recommended more frequently to young nulliparous women as a preventive measure and to mothers after childbirth.