The evaluation of pelvic floor muscle strength in women with pelvic floor dysfunction: A reliability and correlation study

Aims

The purposes of this study were: (i) to evaluate the reliability of vaginal palpation, vaginal manometry, vaginal dynamometry; and surface (transperineal) electromyography (sEMG), when evaluating pelvic floor muscle (PFM) strength and/or activation; and (ii) to determine the associations among PFM strength measured using these assessments.

Methods

One hundred and fifty women with pelvic floor disorders participated on one occasion, and 20 women returned for the same investigations by two different raters on 3 different days. At each session, PFM strength was assessed using palpation (both the modified Oxford Grading Scale and the Levator ani testing), manometry, and dynamometry; and PFM activation was assessed using sEMG.

Results

The interrater reliability of manometry, dynamometry, and sEMG (both root‐mean‐square [RMS] and integral average) was high (Lin's Concordance Correlation Coefficient [CCC] = 0.95, 0.93, 0.91, 0.86, respectively), whereas the interrater reliability of both palpation grading scales was low (Cohen's Kappa [k] = 0.27‐0.38). The intrarater reliability of manometry (CCC = 0.96), and dynamometry (CCC = 0.96) were high, whereas intrarater reliability of both palpation scales (k = 0.78 for both), and of sEMG (CCC = 0.79 vs 0.80 for RMS vs integral average) was moderate. The Bland‐Altman plot showed good inter and intrarater agreement, with little random variability for all instruments. The correlations among palpation, manometry, and dynamometry were moderate (coefficient of determination [r²] ranged from 0.52 to 0.75), however, transperineal sEMG amplitude was only weakly correlated with all measures of strength (r² = 0.23‐0.30).

Conclusions

Manometry and dynamometry are more reliable tools than vaginal palpation for the assessment of PFM strength in women with pelvic floor disorders, especially when different raters are involved. The different PFM strength measures used clinically are moderately correlated; whereas, PFM activation recorded using transperineal sEMG is only weakly correlated with PFM strength. Results from perineal sEMG should not be interpreted in the context of reporting PFM strength.     

全盆底重建术联合尿道中段悬吊术在盆腔器官脱垂合并压力性尿失禁的作用简

目的 探讨全盆底重建术联合经闭孔阴道无张力尿道中段悬吊术（TVT O）在盆腔器官脱垂（POP）合并压力性尿失禁（SUI）的作用。方法 将78例POP合并SUI患者按照患者家属充分知情自愿原则分为对照组（n=35）与治疗组（n=43）,对照组患者采用无张力尿道中段悬吊术（TVT O）进行保守治疗,治疗组患者采用Prolift 全盆底重建术联合（TVT O）进行治疗,对比两组患者的手术时间、术中出血量、并发症、尿管滞留时间、住院天数及尿动力学、生活质量（I QOL）评分情况。结果 对照组患者的手术时间（112.8±17.9）min、术中出血量（204.8±65.7）mL、尿管滞留时间（2.4±0.5）d、住院天数（5.4±0.6）d 这4个指标均优于观察组［手术时间（152.4±20.9）min、术中出血量（262.5±80.4）mL、尿管滞留时间（2.6±0.5）d、住院天数（5.8±0.7）d］（P均＜005）,但并发症显著高于治疗组（χ 2 =3.864,P=0.049）。治疗组患者的初尿膀胱容量（303.4±26.8）mL、最大膀胱容量（403.1±30.4） mL这2个指标均优于对照组初尿膀胱容量（275.4±19.7）mL、最大膀胱容量（349.8±28.7）mL］（P＜0.05）。术后随访半年的I QOL评分,治疗组与对照组分别为（81.1±12.7）分、（72.9±9.8）分,差异有显著统计学意义（t=4.454,P＜001）。结论 全盆底重建术联合TVT O对POP合并SUI患者疗效确切,拥有更好的近远期疗效,可有效提升患者的生活质量。     

Clinical pathway for tension-free vaginal mesh procedure: Evaluation in 300 patients with pelvic organ prolapse

Objectives:   To evaluate a clinical pathway of discharge on postoperative day 3 for the tension-free vaginal mesh (TVM) procedure in patients with pelvic organ prolapse (POP).
Methods:   Between May 2006 and December 2007, 305 consecutive women with POP quantification stage 3 or 4 were planned to undergo the TVM procedure in a single general hospital. Excluding five patients with concomitant hysterectomy, a pathway (removal of the indwelling urethral catheter on the next morning, discharge on postoperative day 3) was applied to the remaining 300 patients. The perioperative complications and postoperative hospitalization were prospectively evaluated in this case series.
Results:   Perioperative complications were: bladder injury (11 cases, 3.7%), vaginal wall hematoma (two cases, 0.7%), rectal injury (one case, 0.3%) and temporary hydronephrosis (one case, 0.3%). None needed blood transfusion. The indwelling urethral catheters were removed on the next morning as in the pathway in 287 cases (95.6%), and none required clean intermittent catheterization at home. Postoperative hospitalization was within 3 days in 280 cases (93.3%). The six cases (2.0%) with longer hospitalization were due to complications (two cases of bladder injury, one of rectal injury, one of blood loss over 200 mL, one of temporary urinary retention, and one of hydronephrosis). Two patients were re-hospitalized within one month due to vaginal bleeding or gluteal pain.
Conclusions:   Patients generally accepted the pathway of discharge on postoperative day 3 in spite of the Japanese culture preferring a longer hospital stay.     

Basic science and translational research in female pelvic floor disorders: proceedings of an NIH-sponsored meeting

AIMS: To report the findings of a multidisciplinary group of scientists focusing on issues in basic science and translational research related to female pelvic floor disorders, and to produce recommendations for a research agenda for investigators studying female pelvic floor disorders. METHODS: A National Institutes of Health (NIH)-sponsored meeting was held on November 14-15, 2002, bringing together scientists in diverse fields including obstetrics, gynecology, urogynecology, urology, gastroenterology, biomechanical engineering, neuroscience, endocrinology, and molecular biology. Recent and ongoing studies were presented and discussed, key gaps in knowledge were identified, and recommendations were made for research that would have the highest impact in making advances in the field of female pelvic floor disorders. RESULTS: The meeting included presentations and discussion on the use of animal models to better understand physiology and pathophysiology; neuromuscular injury (such as at childbirth) as a possible pathogenetic factor and mechanisms for recovery of function after injury; the use of biomechanical concepts and imaging to better understand the relationship between structure and function; and molecular and biochemical mechanisms that may underlie the development of female pelvic floor disorders. CONCLUSIONS: While the findings of current research will help elucidate the pathophysiologic pathways leading to the development of female pelvic floor disorders, much more research is needed for full understanding that will result in better care for patients through specific rather than empiric therapy, and lead to the potential for prevention on primary and secondary levels.     

Tension‐free vaginal mesh procedure for pelvic organ prolapse: A single‐center experience of 310 cases with 1‐year follow up

Objective: To prospectively evaluate the efficacy of a tension‐free vaginal mesh (TVM) procedure for pelvic organ prolapse (POP). Methods: Between December 2005 and April 2008, 310 female patients (mean age 67.2 years, range 42–84) with POP underwent TVM procedures at our institute. Fifty‐six individuals were qualified as stage 2 according to the POP quantification system and 162 and 92 were stage 3 and 4, respectively. One hundred ninety‐one patients underwent anterior TVM, and seven underwent posterior TVM. One hundred twelve cases underwent both anterior and posterior TVM procedures. Each patient was systematically assessed at 1, 3, 6 and 12 months after surgery. Quality of life (QOL) was also assessed by using the Short Form‐36 and the prolapse‐QOL questionnaires. Results: Perioperative complications were the following: five bladder injuries (1.6%), no rectal injuries and three hemorrhages greater than 400 mL (1.0%). The anatomical cure rate (% stage 0 cases) at 3, 6 and 12 months after surgery were 94.1%, 93.5%, and 92.3%, respectively. Short Form‐36 and prolapse‐QOL parameters were significantly improved, and maintained during the follow‐up period. Postoperative complications were the following: five pelvic hematomas (1.6%), one wound infection (0.3%), 10 vaginal mesh extrusions (3.2%), and three cases of pelvic pain (1.0%). Complications concerning lower urinary tract function were: eight cases of postoperative stress urinary incontinence (2.6%), three cases of transient urinary retention (1.0%), and two cases of de novo overactive bladder (0.6%). Conclusions: The TVM procedure provides a good outcome at 1 year with a low incidence of surgical complications and recurrence. Further evaluation with a longer follow up is needed.     

Laparoscopic promontofixation for pelvic organ prolapse: a 10-year single center experience in a series of 501 patients

Objectives: To assess the long‐term outcomes of laparoscopic promontofixation (LP) for the treatment of pelvic organ prolapse (POP). Methods: A total of 501 consecutive patients with POP were included in this prospective study. The patients' mean age was 63.23 (36–90) years, their mean body mass index was 25.14 (15–36) and their mean number of deliveries was 3.3 (0–14). A POP grade ≥3 was diagnosed in 70.4% of the patients and 38.9% of them had a history of abdominal surgery. The patients underwent a Bonney test and urodynamic study. In cases of stress urinary incontinence (SUI), the patients underwent the simultaneous insertion of a tension‐free vaginal tape. A prolapse quality of life questionnaire was sent to all patients. Results: The mean operative time was 97.4 min (50–210) and there were 1.7% cases of intra‐operative complications. The mean hospitalization time was 3.7 days (1–13 days). During the mean follow‐up of 20.7 months (3–120), 91 (17.8%) complications were recorded, including constipation (5.5%), SUI (3.5%), vaginal erosion (2.4%), and urge incontinence (2%). Recurrences were recorded in 11.5% of the patients within an average time of 37.2 months. Risk factors for recurrence were the use of the polypropylene mesh compared with the polyester mesh (P < 0.0001), an intra‐operative hysterectomy (P = 0.02), and bleeding (P = 0.049). There was a statistical significant (P < 0.001) improvement in most of the symptoms in the prolapse quality of life questionnaire. Conclusions: LP is safe with effective long‐term results, with low recurrence and morbidity rates, and a good quality of life.