Voluntary Control Over Pelvic Floor Muscles in Women With and Without Vaginistic Reactions

The ability to voluntarily contract and relax the pelvic floor muscles may differentiate between women with and without vaginistic reactions. This was investigated using intravaginal surface electromyographic (EMG) recordings of the pelvic floor muscles and EMG measurements of the surrounding muscle groups, during muscle exercises. Sixty-seven physician- or self-referred women with vaginismus and 43 control subjects participated. They performed six short flick contractions and three 10-second holding contractions. No difference in baseline was found between groups, indicating a comparable level of relaxation. There was no difference between groups in the performance of the exercises. As the women with vaginistic reactions do not have less voluntary control, treatment should not be based solely on an increase in control.     

Evaluation of Pelvic Floor Muscle Strength Using Four Different Techniques

The aim of the study was to evaluate whether four different techniques were able to correctly measure pelvic floor muscle strength only. Sixteen volunteers performed a set of muscle contractions using the pelvic floor muscles (PFM) only, the abdominal muscles with and without PFM, gluteal muscles with and without PFM, adductor muscles with and without PFM and Valsalva maneuver with and without PFM. Pelvic floor muscle strength was evaluated by digital palpation, intravaginal EMG, pressure perineometry and perineal ultrasound. A “non-pelvic muscle induced” reading was defined as a significant increase even though the pelvic floor muscles were not contracted. Results were as follows: isolated abdominal muscle contraction: non-pelvic muscle induced readings in 3/8 women with EMG and in 3/8 with pressure perineometry; isolated gluteal muscle contraction: non-pelvic muscle induced readings in 1/2 women with EMG perineometry; isolated adductor muscle contraction: non-pelvic muscle induced readings in 6/11 women with EMG perineometry and in 2/11 women with pressure perineometry; Valsalva maneuver: non-pelvic muscle induced readings in 4/9 women with EMG perineometry and 9/9 women with pressure perineometry. It was concluded that EMG and pressure perineometry do not selectively depict pelvic floor muscle activity.     

Pelvic Floor and Abdominal Muscle Interaction: EMG Activity and Intra-abdominal Pressure

Pelvic floor muscle exercises prescribed for the treatment of incontinence commonly emphasize concurrent relaxation of the abdominal muscles. The purpose of this study was to investigate the interaction between individual muscles of the abdominal wall and the pelvic floor using surface and intramuscular electromyography, and the effect of their action on intra-abdominal pressure. Four subjects were tested in the supine and standing positions. The results indicated that the transversus abdominis (TA) and the obliquus internus (OI) were recruited during all pelvic floor muscle contractions. It was not possible for these subjects to contract the pelvic floor effectively while maintaining relaxation of the deep abdominal muscles. A mean intra-abdominal pressure rise of 10 mmHg (supine) was recorded during a maximum pelvic floor muscle contraction. These results suggest that advice to keep the abdominal wall relaxed when performing pelvic floor exercises is inappropriate and may adversely affect the performance of such exercises.     

The Use of Perineal Ultrasound to Quantify Levator Activity and Teach Pelvic Floor Muscle Exercises

Perineal ultrasound was used to detect and quantify levator activity by measuring the displacement of the internal urethral meatus against the inferoposterior margin of the symphysis pubis. Women who had previously been instructed in pelvic floor muscle exercises were more likely to contract the levator muscle when asked to do so than were those without previous instruction (P<0.0001). Of the 56 women who were unable to contract the pelvic floor on request, 32 (57%) eventually succeeded with visual ultrasound biofeedback. Pelvic floor muscle assessment and teaching can be used as an adjunct to the ultrasound assessment of urogynecologic patients, requiring at most 5 minutes. It allows quantification of lavator activity and can provide visual biofeedback, which is easily understood and readily accepted by women.     

Conservative Treatment of Stress Urinary Incontinence in Women: Who will Benefit?

The aim of the study was to find out which factors can predict the outcome of conservative treatment of urinary stress incontinence in women. One hundred and four women with stress urinary incontinence were evaluated by recall, and by clinical and urodynamic investigation and were given pelvic floor muscle exercises with or without the use of biphasic low-frequency electrostimulation and visual biofeedback. Two groups could be distinguished. The first consisted of 37 patients in whom conservative therapy proved successful; the second consisted of 67 patients in whom incontinence continued. The study investigated whether there was a significant difference in patients’ characteristics between the two groups. The number of conservative treatment sessions was not different between the two groups. The presence of a high body mass index, previous pelvic surgery, strong levator muscles and urethral hypermobility appeared to be poor prognostic features. More research is required to evaluate which patients can benefit from conservative treatment and which criteria can predict the outcome of pelvic floor physiotherapy in women with stress incontinence. This way, patients selection is possible and excessive costs can be saved.     

The Role of the Levator Ani Muscle in Evacuation, Sexual Performance and Pelvic Floor Disorders

This paper reviews the role of the levator ani muscle (LAM) in evacuation, sexual performance and pelvic floor disorders. The LAM fixes the vesical neck, anorectal junction and vaginal fornices to the side wall of the pelvis by means of the suspensory sling and hiatal ligament. On contraction it shares in the mechanism of evacuation (urination, defecation). During the sexual act vaginal distension by the erect penis evokes the vaginolevator and vaginopuborectalis reflexes, with a resulting LAM contraction. The LAM also contracts upon stimulation of the clitoris or cervix uteri, an action mediated through clitoromotor and cervicomotor reflexes. LAM contraction leads to upper vagina ballooning, which acts as receptacle for semen collection, to uterine elevation and straightening and to elongation and narrowing of the vagina. These actions enhance the sexual response and prepare the uterus and vagina for the reproductive process. During ejaculation LAM contraction facilitates semen ejection. Levator subluxation and sagging leads to levator dysfunction syndrome, which may present as pudendal canal syndrome.     

Management of the Very Weak Pelvic Floor. Is there a Point?

Conservative treatment in the form of pelvic muscle exercises is effective in the treatment of stress urinary incontinence. There are no studies specifically looking at women who have extremely weak pelvic muscles and their response to conservative treatment. This study looks at the effectiveness of pelvic muscle therapy in women with very weak pelvic muscles. Out of 965 women attending the bladder clinic at Kirwan Hospital, 219 were assessed to have weak pelvic muscles by digital palpation. All patients were subjected to a detailed urogynecological questionnaire, a frequency/volume chart, and clinical assessment. All patients were then given detailed verbal and written instructions on good bladder habits, including posture, dietetic habits and pelvic muscle exercises. Of the 219 women, 163 were able to complete their treatment and presented for review. Out of 163 women 118 (72%) reported a subjective improvement; 89 (54%) demonstrated an objective improvement in pelvic muscle strength. Correspondence and offprint requests to: Assoc. Prof. Rane, Department of Urogynecology, 100 Angus Smith Drive, Douglas, Townsville, 4812, Queensland, Australia.     

Sexual Function in Women with and without Urinary Incontinence and/or Pelvic Organ Prolapse

The sexual function of women with and without urinary incontinence and/or pelvic organ prolapse (UI/POP) was compared using a condition-specific validated questionnaire, the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ). Eighty-three women with UI/POP and 56 without agreed to participate. PISQ scores were significantly lower among women with UI/POP than in those without (P = 0.003). No differences in the stages of sexual excitement were noted between groups. The frequency of intercourse was less with UI/POP than without (P = 0.04). Women with UI/POP restricted sexual activity for fear of losing urine more frequently than did those without (P= 0.005). No differences were reported in patients’ or partners’ sexual satisfaction. This study found that women with UI/POP have poorer sexual functioning than those without, as measured by the PISQ, and report less frequent sexual activity. In addition, women with UI/POP are more likely to restrict sexual activity for fear of incontinence, although they report similar levels of satisfaction with their sexual relationships as do women without UI/POP.     

Prevalence of Urinary Incontinence During Pregnancy and Postpartum

The purpose of the study was to investigate the prevalence of urinary incontinence during pregnancy and the postpartum, and to examine postpartum pelvic floor muscle strength. Eight weeks postpartum the prevalence of urinary incontinence and pelvic floor muscle strength was registered. All women in a Norwegian community, delivering at the local hospital during a 1-year period, were included in the study. The final study group consisted of 144 women (72%). Data concerning the prevalence of urinary incontinence was collected by a structured interview and clinical assessment (pad test) 8 weeks postpartum. Pelvic floor muscle strength was also measured. The prevalence of urinary incontinence during pregnancy was 42%. Eight weeks after delivery the prevalence of self-reported urinary incontinence was 38%. There was a difference between self-reported symptoms and urinary incontinence as assessed by the pad test. Symptoms of fecal incontinence postpartum were reported by 6 women (4.2%). The prevalence of urinary incontinence was found to be nearly the same 8 weeks postpartum as during pregnancy. This documents the need for a strategy to prevent and treat urinary incontinence during these periods.     

Virtual Reality of the Lower Urinary Tract in Women

Advances in computerized and imaging technology permit both students and doctors to depict the anatomy of the human pelvis more realistically than with previous methods. Further refinements outline fine pelvic structures, such as the nerve plexus, which may as a result be spared during major pelvic surgery, thus preserving the function of the bladder neck and urethra. Dynamic computerized tomography or magnetic resonance imaging, coupled with three-dimensional depiction of the lower urinary tract and its adjacent structures, enable visualization of the whole lower urinary tract and the pelvic floor musculature in both continent and incontinent women. In patients with a reconstructed lower urinary tract computer-assisted image processing shows the postoperatively altered topographical anatomy. This may be clinically useful for interpretation of unexpected findings with conventional imaging modalities, postoperative morbidity, and surgical planning of a lower abdominal reoperation. Examples of our own work regarding the innervation of female pelvic organs, dynamic depiction of the bladder and pelvic floor musculature during straining in normal and incontinent women, and the situation of female patients after undergoing an anterior pelvic exenteration with subsequent orthotopic neobladder procedure, are given. In addition, the data of these patients have been compiled for virtual reality endoscopy, which is useful for patient consent and for teaching residents, students and nurses.     

Effects of Epidural Analgesia on Pelvic Floor Function after Spontaneous Delivery: A Longitudinal Retrospective Study

The aim of the study was to assess the effects of epidural analgesia on pelvic floor function. Eighty-two primiparous women (group 1, consisting of 41 given an epidural, and group 2 of 41 not given an epidural) were investigated during pregnancy and at 2 and 10 months after delivery by a questionnaire, clinical examination, and assessment of bladder neck behavior, urethral sphincter function and intravaginal/intra-anal pressures. The prevalence of stress urinary incontinence was similar in both groups at 2 months (24% vs. 17%, P = 0.6) and 10 months (22% vs. 7%, P = 0.1), as was the prevalence of decreased sexual vaginal response at 10 months (27% vs. 10%, P = 0.08). Bladder neck behavior, urethral sphincter function and intravaginal and intra-anal pressures showed no significant differences between the two groups. Ten months after spontaneous delivery, there were no significant differences in the prevalence of stress urinary incontinence and decreased sexual vaginal response, or in bladder neck behavior, urethral sphincter function and pelvic floor muscle strength between women who had or had not had epidural analgesia. RID="*" ID="*"^*This author participated equally to this publication. Correspondence and offprint requests to: Dr Sylvain Meyer, Urogynecology Unit, Department of Gynecology and Obstetrics, CHUV, 1011 Lausanne, Switzerland. Tel: +(41) 21.803.23.29; Fax: +(41) 21.804.23.17; E-mail: Sylvain.Meyer@chuv.hospvd.ch     

Treatment of Female Urinary Incontinence with EMG-Controlled Biofeedback Home Training

The aim of the study was to evaluate the efficacy of pelvic floor training with EMG-controlled home biofeedback in the treatment of stress and mixed incontinence in women. Subjects were recruited from the urodynamic outpatient clinic and performed pelvic muscle training with an EMG-controlled biofeedback device for 20 minutes daily for 6 months. The number of pads used per day, the number of incontinence and urgency episodes, voiding frequency, maximum urethral closure pressure, functional urethral length and pressure/transmission ratio during stress were assessed before and after treatment. Thirty-three patients (13 with stress and 20 with mixed incontinence) completed the study. There was a significant decrease in the number of pads used per day, the number of incontinence and urgency episodes, and the voiding frequency. Twenty-eight patients (85%) reported that they were cured or improved. Urodynamic parameters did not change significantly. It was concluded that home pelvic floor training with EMG-controlled biofeedback is efficient in 85% of patients in alleviating the symptoms of genuine stress and mixed incontinence without causing side effects.     

Vault Prolapse I: Dynamic Supports of the Vagina

The relative contributions of muscle forces and vaginal suspensory ligaments to the anatomical support of the vagina have been long disputed. The aim of this study was to gain further insights into the role of striated muscle forces. Fifty consecutive patients presenting to a pelvic floor clinic were tested with perineal ultrasound, lateral X-rays at rest and on straining, 10 ml of radio-opaque dye having been injected into bladder, vagina, rectum and, in 12 patients, into the levator plate also. The relevance of muscle forces to the three anatomical levels of support, the cardinal/uterosacral ligament complex (level 1), the rectovaginal fascia (level 2) and the perineal body (level 3), was analyzed. Biopsies of the suspensory ligaments were performed per vaginam. During effort, the upper part of the vagina was stretched backwards and downwards against the perineal body. Compression of level 2 on standing lateral X-ray appeared to be related to the angle of the upper vagina to the horizontal at rest. In 23 patients in whom the angle was 45° or more to the horizontal, only 2 demonstrated significant angulation of the upper vagina and therefore compression of level 2 on straining. In contast, all 27 patients with an angle less than 45° to the horizontal demonstrated both vaginal angulation and compression. Histology demonstrated smooth muscle and nerves in the suspensory ligaments, indicating an active contractile role for these structures. Analysis of the directional forces suggests that inability ot angulate the vagina sufficiently may predispose to herniations of the walls of the vagina owing to the twin influences of gravity and downward muscle forces exerted by the levator muscles.     

Conservative Treatment of Stress Incontinence with Geisha Balls

In a pilot study 6 women with stress urinary incontinence were treated with Geisha balls while performing pelvic floor muscle exercises at home half an hour a day for 12 weeks. Subjectively 4 patients were cured and 2 had improved. Before the treatment the 24-hour pad test was a mean 48 g and after the treatment a mean 10 g. There were no adverse effects.     

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.     

The Pain Cycle: Implications for the Diagnosis and Treatment of Pelvic Pain Syndromes

The aim of the study was to report our results of sacral nerve stimulation in patients with pelvic pain after failed conservative treatment. From 1992 to August 1998 we treated 111 patients (40 males, 71 females, ages 46 ± 16 years) with chronic pelvic pain. All patients with causal treatment were excluded from this study. Pelvic floor training, transcutaneous electrical nerve stimulation (TENS) and intrarectal or intravaginal electrostimulation were applied and sacral nerve stimulation was used for therapy-resistant pain. The outcome of conservative treatment and sacral nerve stimulation (VAS <3/10; >50% pain relief) was related to symptoms of voiding dysfunction and dyschezia, and urodynamic proof of dysfunctional voiding, not to the pain localization or treatment modality. Outcome was inversely related to neuropathic pain. When conservative treatment failed, a test stimulation of the S3 root was effective in 16/26 patients, and 11 patients were implanted successfully with a follow-up of 36 ± 8 months. So far no late failures have been seen. A longer test stimulation is needed in patients with pelvic pain because of a higher incidence of initial false positive tests. Our conclusion is that sacral nerve stimulation is effective in the treatment of therapy-resistant pelvic pain syndromes linked to pelvic floor dysfunction.     

Anal Incontinence After Obstetric Third- /Fourth-Degree Laceration. One-Year Follow-up After Pelvic Floor Exercises

The study was a 1-year follow-up of 48 women with obstetric third- /fourth-degree perineal laceration. After primary surgical repair the symptomatic patients were treated with pelvic floor exercises with or without transanal electrical stimulation. Various methods for assessing anal sphincter function were also evaluated. One month postpartum 10 women (21%) complained of anal incontinence, 8 for flatus only; 1 patient was reoperated on. After 1 year none complained of fecal incontinence, and 3 (7%) complained of flatus incontinence. We found relatively few women with anal incontinence after third- /fourth-degree laceration. The pelvic floor training program was effective, but electrical stimulation was abandoned because of anal pain. Grade IIIb lesion, dilution of the sphincter at anal ultrasonography, and sphincter weakness at palpation were significantly related to symptoms of anal incontinence. For routine follow-up after third- /fourth-degree laceration, palpation of the anal sphincter and pelvic floor seems sufficient as first-line assessment.     

The Anatomic and Functional Variability of Rectoceles in Women

Fluoroscopic parameters of the rectum in women with pelvic organ prolapse were studied. Ninety-eight consecutive women undergoing reconstructive pelvic surgery completed a urogynecologic history with physical examination and pelvic floor fluoroscopy. The presence of rectocele and contrast trapping was determined on each fluoroscopic study. Each frame of the study was measured to determine the rectal width. Seventy-eight per cent of the women had fluoroscopically demonstrated rectoceles. Their maximum and minimum rectal widths were larger than those of women without rectoceles. Contrast-retaining rectoceles were larger than non-contrast retaining rectoceles. Fluoroscopic evidence of contrast retention did not relate to patient symptoms. There was no difference in the grade of posterior wall prolapse in women with and without rectoceles. Rectoceles have anatomic and functional variability. Fluoroscopy may be a valuable adjunct to the physical examination in assisting gynecologic surgeons to refine their surgical approach for rectocele repair.     

The Standardization of Terminology for Researchers in Female Pelvic Floor Disorders

The lack of standardized terminology in pelvic floor disorders (pelvic organ prolapse, urinary incontinence, and fecal incontinence) is a major obstacle to performing and interpreting research. The National Institutes of Health convened the Terminology Workshop for Researchers in Female Pelvic Floor Disorders to: (1) agree on standard terms for defining conditions and outcomes; (2) make recommendations for minimum data collection for research; and (3) identify high priority issues for future research. Pelvic organ prolapse was defined by physical examination staging using the International Continence Society system. Stress urinary incontinence was defined by symptoms and testing; ‘cure’ was defined as no stress incontinence symptoms, negative testing, and no new problems due to intervention. Overactive bladder was defined as urinary frequency and urgency, with and without urge incontinence. Detrusor instability was defined by cystometry. For all urinary symptoms, defining ‘improvement’ after intervention was identified as a high priority. For fecal incontinence, more research is needed before recommendations can be made. A standard terminology for research on pelvic floor disorders is presented and areas of high priority for future research are identified.