Does the size of the vaginal probe affect measurement of pelvic floor muscle strength?

BACKGROUND: The most commonly used method to measure pelvic floor muscle (PFM) strength is vaginal squeeze pressure. There are, however, several apparatuses available for this purpose, and sizes of the probes differ significantly. The aim of the present investigation was to assess whether the size of two commonly used vaginal probes influences measurement of PFM strength. METHODS: Twenty female physical therapy students, mean age 25.1 years (range 21-38), participated in the study. All were able to contract the PFM, as assessed by means of vaginal palpation and observation of inward movement of the perineum. Two measuring devices with different lengths and diameters, the Peritron and the Camtech, were used in order to assess vaginal squeeze pressure. Each woman performed six contractions with each apparatus. RESULTS: Mean maximum squeeze pressure for the whole group with the Camtech was 19.7 cm H(2)O (95% CI: 16.5-22.9) and with the Peritron 36.5 cm H(2)O (95% CI: 31.7-41.3), P < 0.01. Nine women preferred the Camtech, four preferred the Peritron, and seven did not have any specific preferences. CONCLUSIONS: Measurements of vaginal squeeze pressure differ depending on the vaginal probe used. Results from published studies using various probes should, therefore, not be compared or combined in systematic reviews or meta-analysis.     

“Are you doing your pelvic floor?” An ethnographic exploration of the interaction between women and midwives about pelvic floor muscle exercises (PFME) during pregnancy

ObjectiveMany women experience urinary incontinence (UI) during and after pregnancy. Pelvic floor muscle exercises (PFME) can prevent and reduce the symptoms of UI. The objective of the study was to explore challenges, opportunities and concerns for women and health care professionals (HCPs), related to the implementation of PFME training for women in current antenatal care.DesignAn ethnographic study design was used. Researchers also formed and collaborated with a public advisory group, consisting of seven women with recent experiences of pregnancy, throughout the study.ParticipantsSeventeen midwife-woman interactions were observed in antenatal clinics. In addition, 23 midwives and 15 pregnant women were interviewed. Repeat interviews were carried out with 12 of the women postnatally. Interviews were also carried out with other HCPs; four physiotherapists, a linkworker/translator and two consultant obstetricians. Additional data sources included field notes, photographs, leaflets, policy and other relevant documents.SettingData were collected in three geographical areas of the UK spanning rural, urban and suburban areas. Data collection took place in antenatal clinics, in primary and secondary care settings, and the majority of women were interviewed in their homes.FindingsThree broad and inter-related themes of “ideological commitment”, “confidence” and “assumptions, stigma and normalisation” were identified. The challenges, opportunities and concerns regarding PFME implementation were explored within these themes.Conclusions and implications for practiceAlthough HCPs and some women knew that PFME were important, they were not prioritised and the significant benefits of doing PFME may not have been communicated by midwives or recognised by women. There was a lack of confidence amongst midwives to teach PFME and manage UI within the antenatal care pathway and amongst women to ask about PFME or UI. A perceived lack of consistent guidelines and policy at local and national levels may have impeded clear communication and prioritisation of PFME. Furthermore, assumptions made by both women and midwives, for example, women regarding UI as a normal outcome of pregnancy, or midwives’ perception that certain women were more likely to do PFME, may have exacerbated this situation. Training for midwives to help women in the antenatal period to engage in PFME could address challenges and concerns and to help prevent opportunities for women to learn about PFME from being missed.     

Biomechanics of the female pelvic floor: a prospective trail of the alteration of force–displacement-vectors in parous and nulliparous women

Objective  

We hypothesize that the holistic and multiplanar depiction of pelvic floor structures by dynamic MRI is of particular value in rendering information about the extent of functional changes that can lead to pelvic floor dysfunction.     

Can pelvic floor muscle training prevent and treat pelvic organ prolapse?

BACKGROUND AND METHODS: Pelvic floor muscle dysfunction may cause urinary and fecal incontinence, pelvic organ prolapse (POP), pain, and sexual disturbances. The aim of the present study is to review the literature on the effectiveness of pelvic floor muscle training (PFMT) to prevent and treat POP, and the possible theories and mechanisms on how PFMT could prevent or reverse prolapse. RESULTS: No studies were found on prevention of POP. One uncontrolled study and one low-quality RCT were found in the treatment of prolapse. The results showed a positive effect of PFMT in severe, but not in mild prolapse. A review is presented of the main hypothesis of mechanisms on how PFMT may be effective. The two mechanisms are morphological changes occurring after strength training and use of a conscious contraction during increase in abdominal pressure in daily activities. CONCLUSIONS: In addition to the theory of functional anatomy and exercise science, one randomized controlled trial (RCT) is supportive for a positive effect of PFMT in the treatment of POP. There is an urgent need for more RCT with high methodological quality, use of valid and reproducible methods to assess degree of prolapse, and appropriate training protocols to evaluate the effect of PFMT in the prevention and treatment of POP.     

Does water delivery affect pelvic floor? Ultrasound evaluation of perineal function

Objective The aim of the study is to analyse urethral mobility and excursion of the pubo-rectal angle, using perineal ultrasound, after normal vaginal delivery and water delivery. Materials and methods A total of 52 primiparous women were enrolled: 25 who had delivery in water (W Group), 27 who had delivery without using water (NW Group). Every woman underwent perineal ultrasound assessment at 6 months after having given birth. The following parameters were assessed: urethral mobility during Valsalva’s manoeuvre, movement of the pubo-rectal sling angle during contraction of the levator ani muscle. Results Data obtained show that the urethral mobility during Valsalva’s manoeuvre is higher in the W Group (34.9°) in comparison to the NW Group (29.5°), without statistically significant differences. The excursion of the pubo-rectal sling angle resulted lower in the W Group (8.7°) than in the NW Group (11.0°), without statistically significant differences. Conclusion The present study found no statistically differences in pelvic floor, using perineal ultrasound, between water and “non-water” delivery.     

Vulvar disease: a pelvic floor pain disorder?

OBJECTIVE: The purpose of this study was to compare the rates of painful bladder syndrome and functional bowel disorders in women with vulvar disease and control subjects. STUDY DESIGN: In this cross-sectional survey, a questionnaire that contained validated outcome measures was administered to women who were seeking care in a vulvar disease clinic and in general gynecology clinics. RESULTS: Women who were seen at a vulvar disease clinic were 2.18 (95% CI, 1.19, 3.97) times more likely to have painful bladder syndrome and 2.13 (95% CI, 1.35, 3.35) times more likely to have functional bowel disorders than general gynecology clinic control subjects after multivariable analyses. CONCLUSION: Painful bladder syndrome and functional bowel disorders are more prevalent in women who are seen at a vulvar disease clinic than gynecology clinics control subjects. These associations may reflect a common origin for these disorders in certain women. These findings lay the groundwork for future research to investigate a potential "pelvic floor pain disorder," which is a disease entity that would combine the diagnostic criteria for vulvar, bladder, and bowel pain disorders.     

The use of ultrasound-based 'soft markers' for the prediction of pelvic pathology in women with chronic pelvic pain--can we reduce the need for laparoscopy?

OBJECTIVE: To assess the accuracy of new transvaginal ultrasound-scan-based markers and to compare them to conventional ultrasound methods used in the detection of common pelvic pathology in women with chronic pelvic pain (CPP). DESIGN: A prospective observational study. SETTING: Teaching hospital. POPULATION: A total of 120 consecutive women with CPP undergoing transvaginal ultrasonography before either diagnostic or operative laparoscopy. METHODS: Anatomical abnormalities, e.g. endometrioma or hydrosalpinx (hard markers), were documented. The woman was then assessed for the presence or absence of 'soft markers' (reduced ovarian mobility and site-specific pelvic tenderness). MAIN OUTCOME MEASURE: Presence or absence of pelvic pathology noted during laparoscopy. RESULTS: Seventy women had pelvic pathology, of whom 51 had endometriosis alone, 7 both endometriosis and pelvic adhesions, 6 pelvic adhesions, 1 hydrosalpinx with endometriosis and 5 hydrosalpinx and pelvic adhesions. The likelihood ratio for the hard markers was infinity (specificity was 100%), for the soft makers 1.9 (95% CI 1.2-3.1) and for a 'normal' ultrasound 0.18 (0.09-0.34). The pre-test probability of pelvic disease in our population of women with CPP was 58%, and this probability of disease was raised to 100% with the presence of hard markers and to 73% with the presence of soft markers. The pre-test probability of 58% fell to 20% when ultrasound finding was found to be normal. CONCLUSION: This new approach improves the detection and exclusion of significant pathology in women with CPP and may lead to a reduction in the number of unnecessary laparoscopies carried out on women with CPP.     

Does electrical stimulation of the pelvic floor make any change in urodynamic parameters? When to expect a cure and improvement in women with stress urinary incontinence?

OBJECTIVE: Our study aimed at determining the effects of pelvic floor electrical stimulation assessed by the number of leakages per day recorded in a voiding diary over 90 days of treatment and urodynamic parameters. STUDY DESIGN: This prospective study was carried out with 34 patients presenting stress urinary incontinence who were treated and evaluated by voiding diaries and urodynamic tests. The primary outcome measure was the number of leakages during the 90 days of treatment. Urodynamic tests were performed before and after treatment. RESULTS: In our series, average and maximum flow rates and residual urine volume were within normal range in all subjects before and after treatment. Maximum urethral closure pressure and functional profile length on urethral pressure profiles did not change after treatment. In the cystometry, bladder capacities at the first (p < 0.0082) and maximum sensations (p < 0.01) improved significantly after treatment. During the 90 days of treatment, we observed a gradual drop in the number of leakages. This decrease began around day 22. It dropped in half around day 45, tending to zero close to day 90 of treatment (p < 0.01). CONCLUSIONS: The number of incontinent leakage dropped to half around the 8th week, and on average, there was a tendency of the patients to be cured after the 12th week of treatment. At urodynamic studies we observed a significant increase in bladder capacity at the first desire to void and in the maximum cystometric capacity.     

What is the value of preoperative bimanual pelvic examination in women undergoing laparoscopic total hysterectomy?

OBJECTIVE STUDY: To estimate the value of preoperative bimanual examination of the pelvis in women undergoing total laparoscopic hysterectomy (TLH). DESIGN: Prospective observational cohort study. SETTING: Private hospitals and centre. PATIENTS: One hundred fourteen consecutive women undergoing TLH. INTERVENTION: All women who were scheduled to undergo TLH from May 2005 through June 2006 had a bimanual examination of the pelvis performed before surgery and the size of the uterus clinically estimated and recorded as gestational equivalents. The operating time, the estimated blood loss (EBL) during TLH, and the final weight of the uterus at histologic study were recorded. Spearman correlation coefficient analysis was used to determine whether there was a correlation between the estimated uterine size before surgery and actual uterine weight, operating time, and EBL. MEASUREMENTS AND MAIN RESULTS: Of the one hundred fourteen consecutive women eligible for the study, 75 had complete data and therefore were included in the final analysis. The median age was 46 years (range 34-71 years); 22.7% (17/75) had a clinically estimated normal uterus, 10.7% (8/75) had an 8-10/40 uterus, 12% (9/75) had a 10-12/40 uterus, 14.6% (11/75) had a 12-14/40 uterus, 20.0% (15/75) had a 14-16/40 uterus, 9.3% (7/75) had a 16-18/40 uterus, and 10.7% (8/75) had an 18-20/40 uterus. The median operating time was 110 minutes (range 59-240 minutes); the median EBL was 80 mL (range 20-1000 mL); and the median weight of the uterus was 181 g (range 52-1080 g). Histologic diagnoses included leiomyomata in 64.0% (48/75), adenomyosis in 44.0% (33/75), endometriosis in 22.7% (17/75), endocervical polyp in 4.0% (3/75), and normal uterus in 8.0% (6/75). The Spearman correlations between clinical size of the uterus and the weight of the uterus, the EBL, and the operating time were 0.81, 0.33, and 0.29, respectively; that is, the 2 variables tended to increase together. These correlations were all significant (p <.0001, .0044, and .0114, respectively). CONCLUSIONS: This study showed significant correlation between clinical estimate of uterine size and histologic weight of the uterus, operating time, and EBL in women undergoing laparoscopic hysterectomy. These findings are of great value in preoperative counseling in relation to the risk of bleeding and the potential need for blood transfusion, and in operating room planning.     

Is the irritable bladder associated with anterior compartment relaxation? A critical look at the 'integral theory of pelvic floor dysfunction'

The 'integral theory of pelvic floor dysfunction', first proposed by Petros and Ulmsten in 1990, claims that anterior vaginal wall relaxation is associated with symptoms of urgency, frequency, nocturia and urge incontinence. A retrospective study was designed to test this hypothesis. Imaging data and urodynamic reports from 272 women suffering from symptoms of lower urinary tract dysfunction were evaluated. Opening of the retrovesical angle, bladder neck descent, urethral rotation and descent of a cystocele during Valsalva were used to quantify anterior vaginal wall laxity. None of the tested parameters were associated with symptoms and signs of detrusor overactivity On the contrary, patients with higher grades of urethral and bladder descent were less likely to suffer from nocturia and urge incontinence and were less likely to have sensory urgency and detrusor instability diagnosed on urodynamic testing. The findings of this study therefore do not support this hypothesis of the 'integral theory'.     

Pelvic floor trauma in childbirth - myth or reality?

The issue of traumatic damage to the pelvic floor in childbirth is attracting more and more attention amongst obstetric caregivers and laypersons alike. This is partly due to the fact that elective Caesarean section, as a potentially preventative intervention, is increasingly available and perceived as safe. As there are a multitude of emotive issues involved, including health economics and the relative roles of healthcare providers, the discussion surrounding pelvic floor trauma in childbirth has not always been completely rational. However, after 25 years of urogynaecological research in this field it should be possible to determine whether pelvic floor trauma in childbirth is myth or reality. On reviewing the available evidence, it appears that there are sufficient grounds to assume that vaginal delivery (or even the attempt at vaginal delivery) can cause damage to the pudendal nerve, the caudal aspects of the levator ani muscle, fascial pelvic organ supports and the external and internal anal sphincter. Risk factors for such damage have been defined and variously include operative vaginal delivery, a long second stage, and macrosomia. It is much less clear, however, whether such trauma is clinically relevant, and how important it is in the aetiology of pelvic floor morbidity later in life.     

Ultrasound and MRI before and after radical hysterectomy: does the operation affect the pelvic floor muscles?

PURPOSE: To evaluate pelvic floor muscles and bladder neck mobility before and after radical hysterectomy for cervical cancer with magnetic resonance imaging (MRI) and ultrasound. METHODS: A prospective follow-up study of 22 patients studied with MRI and ultrasound preoperatively, three and 12 months after radical hysterectomy was carried out. RESULTS: Bladder neck mobility was decreased three months postoperatively, but one year after the operation, it had almost attained the preoperative level. The size of the pelvic floor muscles was reduced three months after the operation, but one year postoperatively, muscle size had almost returned to the preoperative level. Age and number of deliveries affected the starting point in muscle size and the mobility of the bladder neck, but the development was identical in all the women. CONCLUSIONS: We showed that pelvic floor muscle size and mobility of the bladder neck were reduced three months after radical hysterectomy, and that they regenerated to a level only slightly below the preoperative level one year later.     

Pelvic floor muscle training in the prevention and treatment of urinary incontinence in women - what is the evidence?

Many women suffer from urinary incontinence (UI). During and after pregnancy, women are advised to perform pelvic floor muscle training (PFMT) to prevent the development of UI. In established UI, PFMT is prescribed routinely as first-line treatment. Published studies are small, underpowered and of uneven methodological quality. Variations in study populations, intervention types and outcome measures make comparisons difficult. While further studies are needed, the available evidence suggests a lack of long-term efficacy of peripartum PFMT. In established UI, there seems to be a modest immediate response to PFMT. Based on the available evidence, we believe that a critical reappraisal of PFMT is needed, and judgments on the place of PFMT in current clinical practice should be reserved until further evidence, including cost-benefit analyses, has unequivocally demonstrated a clinically relevant efficacy.     

Correlation of symptoms with degree of pelvic organ support in a general population of women: what is pelvic organ prolapse?

OBJECTIVE: The purpose of this study was to evaluate the correlation between the symptoms of pelvic organ prolapse and the stage of support as determined by the pelvic organ prolapse quantification system. STUDY DESIGN: Four hundred ninety-seven women who were seen for annual gynecologic examinations were recruited. Subjects underwent a pelvic examination and their degree of pelvic support was described according to the pelvic organ prolapse quantification system. They also completed a seven-question questionnaire regarding common symptoms of pelvic organ prolapse. Trend analysis was accomplished with linear regression. RESULTS: Only 477 subjects correctly responded to the questionnaire. They were aged 18 to 82 years (mean age, 44 years). Forty-seven percent were white, 52% were African American, and 1% were of another racial group. The number of subjects with the various pelvic organ prolapse quantification stages were stage 0 (18 subjects), stage I (214 subjects), stage II (231 subjects), and stage III (14 subjects). No subject had stage IV prolapse. The average number of positive responses per subject for the symptoms was 0.27 for stage 0, 0.55 for stage I, 0.77 for stage II, and 2.1 for stage III. This trend did not attain statistical significance. The correlation of symptoms with the leading edge of the prolapse revealed that the average number of symptoms that were reported per subject increased from <1 to >1 when the leading edge of the prolapse extended beyond the hymenal remnants. This trend was statistically significant. CONCLUSION: Women with pelvic organ prolapse with the leading edge of the prolapse beyond the hymenal remnants (some stage II and all stage III) have increased symptoms, which may help define symptomatic pelvic organ prolapse.