The effect of abdominal and pelvic floor muscle activation patterns on urethral pressure

Purpose

Urethral pressure increases during voluntary pelvic floor (PF) muscle contractions in healthy women. As PF and abdominal muscle activity is coordinated, this study aimed to determine whether specific abdominal muscle actions also change urethral pressure.

Methods

Urethral pressures were measured in seven healthy women during lower abdominal in-drawing, abdominal bulging and PF muscle contractions, with the bladder empty and filled to 250 ml. A repeated measures multiple analysis of variance compared vesical, rectal and urethral pressure changes between bladder volumes and the three tasks.

Results

Urethral pressures increased by a similar amount during PF muscle contractions and abdominal in-drawing (p = 0.94) and did not differ between bladder status. During abdominal bulging, urethral pressures decreased by 12.6 (18.2) cmH₂O (full bladder) and 18.1 (11.5) cmH₂O (empty bladder) and were different from the other two manoeuvres (p < 0.001).

Conclusions

This study shows that specific abdominal actions are associated with increased or decreased urethral pressures, consistent with strategies for continence and voiding.     

Does vaginal delivery cause more damage to the pelvic floor than cesarean section as determined by 3D ultrasound evaluation? A systematic review

Introduction and hypothesis

Pregnancy and delivery are well-established risk factors for pelvic floor dysfunction (PFD), but the physiopathology, such as the delivery route, is not well understood. This study evaluated the impact of delivery route on the pelvic floor muscles via 3D ultrasound.

Methods

This review is registered in the PROSPERO database. The criteria for inclusion were prospective studies with 3D translabial ultrasound assessment in primigravida women during pregnancy and postpartum published in English, Spanish or Portuguese between 1980 and 2016. We excluded studies that did not include the topic of urogenital hiatus measurement and literature reviews. The MeSH terms were obstetric delivery, postpartum period, labor, parturition, three-dimensional images, ultrasonography, pelvic floor, and pelvic floor disorders.

Results

The search retrieved 155 articles. After analysis, 6 articles were included. Four studies showed that vaginal delivery (VD) was associated with a larger hiatal area. One study associated the hiatal area with levator ani muscle (LAM) defects in VD. Four articles evaluated the bladder neck, 3 of which showed a significant increase in bladder neck mobility associated with VD and 1 showed decreased bladder neck elevation, not associated with the delivery mode; the first 3 articles all evaluated LAM injuries and showed an association between VD and LAM injury. Women who underwent VD presented defects of the puborectalis muscle.

Conclusions

Vaginal delivery was associated with a higher number of LAM injuries, puborectalis defects, increased bladder neck mobility, and enlargement of the hiatal area.

     

Two- and three-/four dimensional perineal ultrasonography in men with urinary incontinence after radical prostatectomy

Study Type – Diagnostic (case control) Level of Evidence 4 What’s known on the subject? and what does the study add? We know that perineal ultrasound is a well accepted method for women with stress incontinence. We evaluated feasibility of this method for men with stress incontinence after radical prostatectomy. We find differences between continent and incontinent men in amount of fibrosis, mobility of the proximal urethra, bladder neck opening and ability to contract pelvic floor muscles in a sufficient and correct way.

OBJECTIVE

? To investigate the feasibility and inter‐investigator reproducibility of perineal ultrasonography in men with and without post‐prostatectomy urinary incontinence (PPI).

PATIENTS AND METHODS

? This clinical pilot study involved 33 male patients, with a mean (range) age of 67.8 (51–76) years, who underwent radical prostatectomy (RP) ≥1 year ago. ? We investigated 21 men with clinically and urodynamically proven grade ≥2 PPI and compared them with 12 men without PPI in objective testing as well as in validated questionnaires. ? We used an abdominal 3.5–5 MHz ultrasound probe, which was placed at the perineum between scrotum and anus. With the help of three‐/four‐dimensional (3D/4D) multislice imaging we obtained good visualization of the bladder neck, the urethra and pelvic floor muscle contraction. ? The data from all 33 men was evaluated by two investigators and archived images and videos were also analysed by two independent investigators not present at the actual investigation.

RESULTS

? Using perineal ultrasonography we were able to visualize hypermobility of the proximal urethra, funnelling of the bladder neck, voluntary pelvic floor contraction, urethral and paraurethral fibrosis, and suture or sling material. ? Men with and without PPI differed mainly in the degree of hypermobility of the proximal urethra and opening of the bladder neck. ? Inter‐investigator agreement was 100% in assessing paraurethral tissue and voluntary muscle contraction and 94% in quantifying mobility of the proximal urethra. ? We were able to evaluate the bladder neck opening in 85% of the men. There was 82% agreement between the initial investigators in evaluation of the bladder neck and 76% in quantifying mobility of the proximal urethra using retrospective analysis of stored images.

CONCLUSIONS

? Two‐dimensional and 3D/4D perineal ultrasonography provides more insight into the diagnosis of men with PPI ? Perineal ultrasonography can be used further as a visual aid for biofeedback to teach correct muscle contraction of men with stress incontinence after radical prostatectomy.     

The effect of abdominal and pelvic floor muscle activation on urine flow in women

Introduction and hypothesis

Interruption of urine flow during micturition has been used as an assessment of ability to voluntarily contract the pelvic floor muscles (PFM). However, the PFM are also activated during specific abdominal manoeuvres. This study aimed to assess the effect of similar abdominal manoeuvres on urine flow and compare this with the effect of PFM contraction.

Methods

Eight healthy women, of mixed parity, contracted the abdominal muscles and the PFM during urine flow on separate occasions. Differences in urine flow were compared using paired t tests.

Results

All participants were able to interrupt the urine stream using both muscle activation patterns. There was no difference in the time taken to interrupt urine flow (p?=?0.78) between the two patterns.

Conclusions

These data provide evidence that specific abdominal muscle manoeuvres influence urethral closure in continent women, and this is probably mediated by concurrent activation of PFM during the abdominal task.     

Assessment of pelvic hemodynamics during an open repair of an infrarenal abdominal aortic aneurysm

Purpose  

To assess the pelvic circulation during abdominal aortic aneurysm (AAA) repair by measuring the inferior mesenteric artery stump pressure (IMA-SP), penile blood flow, and gluteal blood flow.     

Angioembolization and laparotomy for patients with concomitant pelvic arterial hemorrhage and blunt abdominal trauma

Background  

Treatment of patients with concomitant pelvic arterial hemorrhage and blunt abdominal trauma (BAT) is challenging. Controversies remain over the diagnostic approach and the priority of available treatment resources.     

Structured behavioral treatment research protocol for women with mixed urinary incontinence and overactive bladder symptoms

Aims

The primary aim is to provide detailed rationale and methodology for the development and implementation of a perioperative behavioral/pelvic floor exercise research protocol for women who self‐chose surgical intervention and who may or may not have been offered behavioral treatments initially. This protocol is part of the ESTEEM trial (Effects of Surgical Treatment Enhanced with Exercise for Mixed Urinary Incontinence Trial) which was designed to determine the effect of a combined surgical and perioperative behavioral/pelvic floor exercise intervention versus surgery alone on improving mixed urinary incontinence (MUI) and overactive bladder (OAB) symptoms.

Methods

As part of a multi‐site, prospective, randomized trial of women with MUI electing midurethral sling (MUS) surgical treatment, participants were randomized to a standardized perioperative behavioral/pelvic floor exercise intervention + MUS versus MUS alone. The specific behavioral intervention included: education on voiding habits, pelvic floor muscle training (PFMT), bladder training (BT), strategies to control urgency and reduce/prevent urinary symptoms, and monitoring/promoting adherence to behavioral recommendations. To ensure consistency across all eight research sites in the pelvic floor disorders network (PFDN), selective behavioral treatments sessions were audiotaped and audited for protocol adherence.

Results

The behavioral intervention protocol includes individualization of interventions using an algorithm based on pelvic floor muscle (PFM) assessment, participant symptoms, and findings from the study visits. We present, here, the specific perioperative behavioral/pelvic floor exercise interventions administered by study interventionists.

Conclusions

This paper details a perioperative behavioral/pelvic floor exercise intervention research study protocol developed for women undergoing surgery for MUI.     

Pelvic‐floor imaging using three‐dimensional ultrasonography and magnetic resonance imaging in the long term follow‐up of the bladder‐exstrophy‐epispadias complex

Study Type – Therapy (case control)
Level of Evidence 3b

OBJECTIVE

To investigate whether established pelvic floor variables can be used to predict the risk of uterine prolapse after surgery and to compare two different operative strategies, pelvic adaptation with functional reconstruction and an open pelvis with urinary diversion, as a congenital bony pelvis and pelvic floor defect predisposes females with bladder‐exstrophy‐epispadias complex (BEEC) to uterine prolapse.

PATIENTS, SUBJECTS AND METHODS

We conducted a cross‐sectional study using perineal three‐dimensional ultrasonography (3D‐US) and magnetic resonance imaging (MRI) to describe pelvic floor anatomy in 19 women with BEEC (mean age 27.3 years) and five controls, with the outcome evaluated by a semi‐structured interview. The analysis of 3D‐US and MRI was conducted by two independent investigators.

RESULTS

Of the 19 women with BEEC, 13 initially had a functional bladder reconstruction, six a urinary diversion with removal of the exstrophic bladder, and 12 women had closure of the pelvis either by traction bandage or osteotomy, and in the other seven the symphysis was not approximated. Four patients had a complete and one a mild uterine prolapse. After a mean follow‐up of 24 years, the mean symphyseal diastasis was 4.5 cm after symphyseal approximation, 9.0 cm without symphyseal approximation in BEEC and 0.49 cm in controls. The mean levator hiatus was 4.9 cm on 3D‐US and 4.1 cm on MRI after symphyseal approximation, 5.9 and 7.6 cm without symphyseal approximation and 4.2 and 3.2 cm in controls, respectively. The respective mean levator angle was 86.6° and 87.3° after symphyseal approximation, 104.1° and 101.3° without and 71.3° and 45.5 in controls. Prolapse was statistically significantly more common in patients with no symphyseal approximation.

CONCLUSION

This is the first study showing that perineal 3D‐US is useful for pelvic floor imaging in BEEC. Established pelvic floor variables might be useful for predicting the risk of pelvic organ prolapse in BEEC.     

Pelvic floor muscle function in a general female population in relation with age and parity and the relation between voluntary and involuntary contractions of the pelvic floor musculature

Introduction and hypothesis  

The objective of this study is to describe pelvic floor muscle function (PFMF) in relation to age and parity in a general female population and to test whether strength/endurance measurements represent all functions of the pelvic floor musculature.     

A randomized controlled trial of antenatal pelvic floor exercises to prevent and treat urinary incontinence

Introduction and hypothesis  

The aim of the study was to evaluate the effect of antenatal pelvic floor muscle exercise (PFME) in the prevention and treatment of urinary incontinence during pregnancy and postpartum period.     

Measurement of transurethral bladder neck displacement during tension-free vaginal tape procedure

Introduction and hypothesis  

The rigid catheter guide is used during the tension-free vaginal tape (TVT) procedure to direct the bladder neck away from the retropubic passage of the sling arm. Our aim was to measure, using transperineal ultrasound, the amount of bladder neck displacement by the rigid catheter guide during TVT placement.     

Dynamic magnetic resonance imaging of the pelvic floor in children and adolescents with vesical and anorectal malformations

Background

Magnetic resonance imaging (MRI) of the pelvic floor allows better assessment of pelvic pathology and has a potential as an adjunct for therapy planning. In complex congenital malformations of the pelvic floor and continence organs, it plays a major role in assessing urinary and fecal incontinence or constipation, especially when performed as a dynamic investigation such as MRI defecography.

Patients and Methods

Twenty-three patients (3-21 years old) with urinary and/or fecal incontinence or constipation attributable to congenital malformations of the pelvic region presented at our institution. The diagnoses were anorectal malformations (18), bladder exstrophy (2), and cloacal exstrophy (3). All patients underwent static and dynamic MRI of the pelvic floor with rest, squeeze, and evacuation in supine position.

Results

Morphology and function of the pelvic floor and pelvic organs could be demonstrated in each case. The reason for urinary incontinence, fecal incontinence, or constipation could be defined, and an individual therapeutic management concept was made based upon the data obtained by the investigation.

Conclusions

The advantages of this method, in comparison to others, are direct visualization of the pelvic floor muscles and continence organs and their anatomical relationship during different functional actions. Pelvic floor dysfunction is often the reason for fecal and urinary incontinence and can be detected by MRI. Especially in children, minimizing radiation exposure is of major concern. Disadvantages are the costs and long investigation time.     

The relationship between uterine leiomyomata and pelvic floor symptoms

Introduction and hypothesis

To compare pelvic floor symptoms in women with a leiomyomatous uterus ≤12 weeks and those >12 weeks in size and to evaluate the resolution of these symptoms after surgical intervention.

Methods

The PFDI-20, PFIQ-7 and 3-day voiding diaries were administered prospectively to all subjects. Demographics and questionnaire responses were compared using a t test, Chi-squared test or Mann–Whitney U test as indicated.

Results

One hundred and forty-five women completed the questionnaires and were included for analysis. There were 58 women with uterine size ≤12 weeks (group I) and 87 women with size >12 weeks (group II). Participants in group I reported more straining to defecate (p?=?0.042), while group II reported increased feeling of incomplete bladder emptying (p?=?0.007) and difficulty emptying their bladder (p?=?0.008). Review of ultrasound images revealed no difference in pelvic floor symptoms when stratified by leiomyoma location. At 1-year follow-up, 69 women (48 %) responded, and 40 (58 %) had undergone surgical intervention. Surgery was shown to improve symptoms for all questions reviewed at 1-year follow-up.

Conclusions

A leiomyomatous uterus >12 weeks is associated with the symptom of incomplete bladder emptying, but does not appear to have an effect on other pelvic floor symptoms compared with women with a smaller leiomyomatous uterus. Surgical intervention for leiomyomata improves pelvic floor symptoms.     

Detection of abdominal wall adhesions using visceral slide

Background  

Abdominal surgery, peritonitis, and pelvic inflammatory disease often give rise to intra-abdominal adhesions. They may lead to chronic pain, infertility, bowel obstruction, etc. Development in surgical strategies in the last decade has resulted in an increase in laparoscopic procedures and, as a consequence, a steep rise in reported bowel lesions. Accordingly, noninvasive diagnostic tools are desirable to identify adhesions before abdominal surgery. This study was designed to validate transabdominal ultrasonography (TAU) and magnetic resonance imaging (cine MRI) for detection of abdominal wall adhesions.     

Resection rectopexy—laparoscopic neuromapping reveals neurogenic pathways to the lower segment of the rectum: preliminary results

Purpose

Nerve sparing in functional pelvic floor surgery is strongly recommended as intraoperative damage to the autonomic nerves may predispose to persistent or worsened anorectal and urogenital function. The aim of this study was to investigate the intraoperative neural topography above the pelvic floor in patients undergoing laparoscopic resection rectopexy in combination with electrophysiologic neuromapping.

Methods

Ten consecutive female patients underwent laparoscopic resection rectopexy for rectal prolapse. Intraoperative identification of pelvic autonomic nerves was carried out with a novel intraoperative neuromonitoring system based on electric stimulation under simultaneous electromyography of the internal anal sphincter and manometry of the bladder. Neuromonitoring results were compared to patients' preoperative anorectal and urogenital function and their functional results at the 3-month follow-up.

Results

Laparoscopy in combination with electrophysiologic neuromapping revealed neurogenic pathways to the lower segment of the rectum during surgical mobilization. In all procedures, intraoperative neuromonitoring finally confirmed functional nerve integrity to the internal anal sphincter and the bladder. Patients with preoperatively diagnosed fecal incontinence were continent at the 3-month follow-up. The Wexner score improved in median from preoperative 4 (range 1–18) to 1 (range 0–3) at follow-up (p?=?0.012). Cleveland Clinical Constipation Score improved in median from 10 (range 5–17) to 3 (range 1–7; p?=?0.005). In none of the investigated patients a new onset of urinary dysfunction did occur. No change in sexual function was observed.

Conclusions

Laparoscopy in combination with electrophysiologic neuromapping during nerve-sparing resection rectopexy identified and preserved neurogenic pathways heading to the lower segment of the rectum above the level of the pelvic floor.     

Evaluation of urinary incontinence in pregnancy and postpartum in Curitiba Mothers Program: a prospective study

Introduction and hypothesis  

The objective of this study was to evaluate the prevalence of urinary incontinence (UI), the pelvic floor, and the quality of life during pregnancy and in the postpartum.     

Mechanical properties of pelvic soft tissue of young women and impact of aging

Introduction and hypothesis

The female pelvic floor is a complex network of ligaments and muscles whose mechanical properties have not been completely understood. The goal of this study is to understand the biomechanical properties of the pelvic floor tissues of young women and the impact of aging.

Methods

Biomechanical uniaxial tension tests were performed on pelvic floor tissues (ligaments and organs) of six young female cadavers (average 29 years old). Results have been analyzed in order to define the characteristics of the mechanical properties of young pelvic soft tissues. Results have been compared with those in the literature in order to understand the similarities and discrepancies between young and old patients.

Results

Damageable, nonlinear elastic biomechanical behavior is observed. The variation in stiffness among the pelvic floor organs could be shown. Ligaments and the vaginal wall are the most rigid organs, whereas the rectum and bladder tend to be less rigid (approximately two times less rigid for small deformations and three times less rigid for large deformations). This study shows that ligaments and the vaginal wall of young women have similar mechanical behavior while those of older women differ. Furthermore, young women’s tissues differ slightly from older women’s tissues.

Conclusions

Results show that aging and possibly diverse “trauma” have an impact on modifying the mechanical behavior of pelvic floor tissues. Over time pelvic floor ligaments and vaginal tissues will differentiate and acquire different mechanical behavior, as seen within the literature in older cadavers.     

What is normal bladder neck anatomy?

Introduction and hypothesis

Functional anatomy of the bladder neck and proximal urethra has been studied extensively because of the belief that it is important for urinary continence. The aim of this study was to explore the limits of normality for pelvic floor ultrasound parameters of bladder neck and urethral mobility associated with stress urinary incontinence (SUI) and urodynamic stress incontinence (USI).

Methods

A retrospective study was conducted on 589 women seen for urodynamic testing in a tertiary urogynaecology clinic. All women were assessed following a protocol including interview, clinical examination, flowmetry, urodynamic testing and 4D pelvic floor ultrasound. Volume data sets were analysed offline to assess for bladder neck descent (BND), urethral rotation and the retrovesical angle (RVA) on maximal Valsalva.

Results

After excluding women with previous incontinence or prolapse surgery, 429 datasets were available. SI was significantly associated with the RVA (p?=?0.033) and BND (p?=?0.036); USI was associated with urethral rotation (p?=?0.021) and BND (p?<?0.001). On multivariate logistic regression analysis, controlling for confounders including age, BMI, parity, previous hysterectomy and maximal urethral pressure, the association between SUI and BND remained significant (OR [per 10 mm]?=?1.23; 95 % CI: 1.01 to 1.51; p?=?0.043), as did the association between USI and BND (OR [per 10 mm]?=?1.58; 95 % CI: 1.3 to 1.91; p?<?0.001). ROC statistics for BND suggested a cut-off of 25 mm in describing the limit of normality.

Conclusions

Measures of functional bladder neck anatomy are weakly associated with SUI and USI (with association between BND and USI being the strongest). It is suggested that a BND of 25 mm or higher be defined as abnormal (“hypermobile”) on the basis of its association with USI.

     

MRI suggests increased tonicity of the levator ani in women with interstitial cystitis/bladder pain syndrome

Introduction and hypothesis

In interstitial cystitis/bladder pain syndrome (IC/BPS), pelvic floor dysfunction may contribute significantly to pelvic pain. To determine if pelvic floor hypertonicity manifests alterations on magnetic resonance imaging (MRI) in patients with IC/BPS, we retrospectively compared pelvic measurements between patients and controls.

Methods

Fifteen women with IC/BPS and 15 age-matched controls underwent pelvic MRI. Two blinded radiologists measured the pelvic musculature, including the H- and M lines, vaginal length, urethral length and cross-sectional area, levator width and length, and posterior puborectalis angle. MRI measures and clinical factors, such as age, parity, and duration of symptoms, were compared using a paired, two-tailed t test.

Results

There were no significant differences in age, parity, or symptom duration between groups. Patients with IC/BPS exhibited shorter levator muscles (right: 5.0?±?0.7 vs. 5.6?±?0.8, left: 5.0?±?0.8 vs. 5.7?±?0.8 cm, P?<?0.002) and a wider posterior puborectalis angle (35.0?±?8.6 vs. 26.7?±?7.9°, P?<?0.01) compared with controls. The H line was shorter in patients with IC/BPS (7.8?±?0.8 vs. 8.6?±?0.9 cm, P?<?0.02), while M line did not differ. Total urethral length was similar, but vaginal cuff and bladder neck distances to the H line were longer in patients with IC/BPS (5.7?±?0.6 vs. 5.1?±?0.9 cm, P?<?0.02; 1.9?±?0.4 vs. 1.4?±?0.2 cm, P?<?0.001, respectively).

Conclusions

Patients with IC/BPS have pelvic floor hypertonicity on MRI, which manifests as shortened levator, increased posterior puborectalis angles, and decreased puborectal distances. We identified evidence of pelvic floor hypertonicity in patients with IC/BPS, which may contribute to or amplify pelvic pain. Future studies are necessary to determine the MRI utility in understanding pelvic floor hypertonicity in patients with IC/BPS.

     

Pelvic floor muscle function before and after first childbirth

Introduction and hypothesis  

Pregnancy and vaginal delivery are considered to be the main risk factors for development of pelvic floor dysfunction. We hypothesize that; 1) pelvic floor muscle (PFM) strength and endurance is significantly reduced by first delivery in general, and 2) changes in PFM strength and endurance are influenced by mode of delivery.