Can stronger pelvic muscle floor improve sexual function?

Introduction and hypothesis

This study aims to evaluate the association between pelvic floor muscle (PFM) strength and sexual functioning.

Methods

Retrospective chart review of consecutive all women who were referred with a primary complaint of sexual dysfunction. Women underwent standardized clinical evaluation including pelvic muscle strength which was ranked from 0 (weak) to 2 (strong). The duration of pelvic muscle contraction was also recorded in seconds. Sexual function was evaluated by using a validated questionnaire, the Female Sexual Function Index (FSFI).

Results

One hundred seventy-six women with a mean age of 37?±?11 years were included. Women with strong or moderate PFM scored significantly higher on the FSFI orgasmic and arousal domains than women with weak PFM (5.4?±?0.8 vs. 2.8?±?0.8, and 3.9?±?0.5 vs. 1.7?±?0.24, respectively; P?<?0.001). The duration of PFM contraction was correlated with FSFI orgasmic domain and sexual arousal (r?=?0.26, P?<?0.001; r?=?0.32, P?<?0.0001, respectively).

Conclusions

Our findings suggest that both the orgasm and arousal function are related to better PFM function.     

Can pelvic floor injury secondary to delivery be prevented?

The number of women suffering from pelvic floor disorders (PFD) is likely to grow significantly in the coming years with a growing older population. There is an urgent need to investigate factors contributing to the development of PFD and develop preventative strategies. We have reviewed the literature and analyzed results from our own study regarding the association between delivery mode, obstetrical practice and fetal measurements, and damage to the pelvic floor. Based on our findings, we have suggested a flowchart helping the obstetrician to conduct vaginal delivery with minimal pelvic floor insult. Primiparity, instrumental delivery, large fetal head circumference, and prolonged second stage of delivery are risk factors for PFD. Pelvic floor integrity should always be seriously considered in every primiparous woman. All efforts should be aimed at minimizing any insult, which might have a significant impact on the woman’s pelvic integrity and future quality of life.     

Can pelvic floor dysfunction after vaginal birth be prevented?

Introduction and hypothesis

Significant breakthroughs in our understanding of pelvic floor dysfunction have occurred in the past two decades. The next step is to translate this understanding into effective preventative and early intervention strategies to minimize maternal morbidity from vaginal birth. We have learned enough to chart a course toward prevention.

Methods

This article outlines some major advances in understanding the pathophysiology of pelvic floor dysfunction and suggests strategies for future prevention research.

Results

Vaginal birth is the primary risk factor for the development of pelvic floor disorders and this is compounded by forceps use. Age, race, and genetics are also risk factors. Steps to prevent or minimize the development of pelvic floor problems include moderating forceps use and utilizing risk assessment tools to offer cesarean delivery to those at greatest risk.

Conclusion

These actions would represent one giant step forward in advancing the practice of obstetrics into the modern age of personalized medicine.

     

Robot-assisted surgery:—impact on gynaecological and pelvic floor reconstructive surgery

The da Vinci? Surgical System dominates robotic surgery, as the only robotic device to have FDA approval in gynaecology. The benefits of robot-assisted surgery include decreased length of stay, decreased blood loss and analgesic requirements. Ergonomic improvements allow the surgeon to operate with less risk of neck and back injury. Unfortunately the initial economic impact of purchasing and maintaining a robot are great but must be balanced with the potential savings from reduced length of stay and earlier return to normal activity. This review looks at the uses for the robot in both gynaecology and urogynaecology, assessing the efficacy of this modality compared to both straight stick (laparoscopy) and open procedures. We assess the benefits to both patient and surgeon from the available literature. Within the current economic environment we appraise the costs associated with the robot.     

Can we correlate pelvic floor dysfunction severity on MR defecography with patient-reported symptom severity?

MR defecography (MRD) is an alternative to conventional defecography (CD) which allows for dynamic visualisation of the pelvic floor. The aim of this study was to assess whether MRI features indicative of pelvic floor dysfunction correlated with patient-reported symptom severity. MR proctograms were matched to a prospectively-maintained functional database. Univariate and multivariate analyses were performed using pre-treatment questionnaire responses to the Birmingham Bowel, Bladder and Urinary Symptom Questionnaire (BBUSQ), Wexner Incontinence Score (WIS), and modified Obstructed Defecation Symptom (ODS) Score. 302 MRI proctograms were performed between January 2012 and April 2015. 170 patients were included. Patients with a rectocele > 2 cm (p = 0.003; OR 5.756) or MRD features suggestive of puborectalis syndrome (p = 0.025; OR 8.602) were more likely to report a higher ODS score on multivariate analysis. Lack of rectal evacuation was negatively associated with an abnormal WIS (p = 0.007; OR 0.228). Age > 50 (p = 0.027, OR 2.204) and a history of pelvic floor surgery (p = 0.042, OR 0.359) were correlated with an abnormal BBUSQ incontinence score. Lack of rectal evacuation (p = 0.027, OR 3.602) was associated with an abnormal BBUSQ constipation score. Age > 50 (p = 0.07, OR 0.156) and the presence of rectoanal intussusception (p = 0.010, OR 0.138) were associated with an abnormal BBUSQ evacuation score. Whilst MRD is a useful tool in aiding multidisciplinary decision making, overall, it is poorly correlated with patient-reported symptom severity, and treatment decisions should not rest solely on results.     

Do we need meshes in pelvic floor reconstruction?

Objectives

Transvaginally placed mesh in pelvic reconstructive surgery for women with pelvic organ prolapse has gained popularity because of excellent anatomical outcomes, but postoperative mesh-related complications have lead to a number of cautious reviews and warnings. This review focuses on functional outcomes after synthetic transvaginal mesh placement.

Methods

MEDLINE database was searched from 2010 to August 2011 for original articles on transvaginal mesh surgery for pelvic organ prolapse not included in recent reviews. The following search terms were used: pelvic organ prolapse, genital prolapse, cystocele, rectocele and mesh, synthetic graft, and repair. Studies were assessed and appropriate data extracted and tabularized. Studies were excluded if the follow-up time was less than 12?months and if studies did not contain original data or data on subjective outcome.

Results

Eleven studies irregularly reported functional outcomes. After trocar-guided transobturator vaginal mesh surgery, symptomatic recurrence of pelvic organ prolapse was reported between 7 and 33%. If analyzed cumulatively, 76 of 370 patients (21%) complained of prolapse symptoms postoperatively. De novo stress urinary incontinence occurred in 12–17% and persisted in up to 68% after trocar-guided mesh surgery. De novo dyspareunia was present between 2 and 15%, worsened or de novo dyspareunia between 25 and 44%. Deteriorating coital incontinence was described in 6 of 16 women after anterior Prolift in one trial.

Conclusions

When counseling women for pelvic reconstructive surgery, we should provide them with evidence-based information on functional outcomes and subsequently take the patient’s concerns and preferences into account. Pelvic floor symptoms were scarcely reported in reviewed trials, but demonstrated a worse scenario than anatomical outcomes.     

Can maximal voluntary pelvic floor muscle contraction reduce vaginal resting pressure and resting EMG activity?

Introduction and hypothesis

The purpose of the present study was to assess whether attempts at a maximal voluntary pelvic floor muscle (PFM) contraction can reduce vaginal resting pressure (VRP) and surface EMG activity in women with and without provoked vestibulodynia (PVD).

Method

An assessor blinded comparison study included 35 women with and 35 women without PVD. VRP and PFM strength were measured with a high precision pressure transducer connected to a vaginal balloon (Camtech AS, Sandvika Norway). PFM activity was measured before and after three MVCs with surface EMG (NeuroTrac ETS?; Verity Medical, Romsey, UK). Paired sample t test was used to analyze differences within groups and independent sample t test to analyze differences between groups. p value was set at <0.05.

Results

Mean age of the participants was 24.3 years (SD 4.7) and mean BMI was 22.0 kg/m² (SD 2.6). There were no significant differences between the groups in any background variables. PFM contraction led to a statistically significant reduction of VRP in both the PVD (p?=?0.001) and the control group (p?=?0.027). Surface EMG activity was significantly reduced in the PVD group only (p?=?0.001).

Discussion

Young, nulliparous women with PVD had significantly lower vaginal resting pressure and sEMG activity after three maximum contractions of the PFM. The results indicate that attempts at voluntary maximal contractions may be investigated as a method of reducing PFM hypertonicity.

     

Breathing with the pelvic floor? Correlation of pelvic floor muscle function and expiratory flows in healthy young nulliparous women

Introduction and hypothesis

The aim of this cross-sectional study was to determine correlations between pelvic floor muscle (PFM) function and expiratory function in healthy young nulliparous women.

Methods

In 40 volunteers, PFM function was assessed by vaginal palpation. Forced expiration patterns were evaluated visually and by palpation of the suprapubic insertion region of the anterolateral abdominal muscles. Forced vital capacity (FVC) and forced expiratory flows (FEF) were determined by spirometry.

Results

Incremental positive correlation was found between voluntary PFM contraction strength and forced expiratory flow at 25%, 50% and 75% (FEF_25%, FEF_50%, FEF_75%) of the FVC, respectively. Positive correlation was also found between PFM contraction strength and forced expired volume in 1 s (FEV₁). No correlation was found between PFM contraction strength and FVC or peak expiratory flow (PEF).

Conclusions

Despite some limitations of this study, the observed correlation between PFM contraction strength and forced expiratory flows may serve as theoretical background for a potential role of coordinated abdominal and PFM training in diseases with expiratory flow limitations.