Treatment of urinary stress incontinence by intravaginal electrical stimulation and pelvic floor physiotherapy

Treatment of urinary stress incontinence (USI) by intravaginal electrical stimulation (IES) and pelvic floor physiotherapy represents an alternative to other therapies. The purpose of this work was to evaluate the effectiveness of this treatment inpatients with urinary incontinence. From January 1998 to May 2000, 30 women (mean age 54 years) were studied. All patients had USI and 70% urge incontinence; average follow-up was 7 months. Selection criteria were based on clinical history, objective evaluation of perineal musculature by perineometry, and urodynamics. The treatment protocol consisted of three sessions of IES per week for 14 weeks using INNOVA equipment. Physiotherapy was initiated in the fifth week of IES. A significant decrease in the number of micturitions and urgency was observed after treatment (P<0.01). The pad test showed a reduction in urinary leakage from 13.9 to 5.9 g after treatment (P<0.01). Objective evaluation of perineal muscle strength showed a significant improvement in all patients after treatment (P<0.01). A positive correlation was observed between maximum flow rate (Q(max)) and all three variables: urethral pressure profile at rest and on straining (stop test), and abdominal leak-point pressure (ALPP). A positive correlation was also observed between ALPP and the stop test. Over 100 different surgical and conservative treatments have been tried to manage USI. The majority of these procedures reveal that despite progress already made in this area, there is no ideal treatment. Satisfactory results can be achieved with this method, especially with patients who are reluctant to undergo surgery because of personal or clinical problems.

Treatments for invasive carcinoma of the cervix: What are their impacts on the pelvic floor functions?

Aims: Describe the impact of surgery, radiotherapy and chemoradiation in the pelvic floor functions in cervical cancer patients. Materials and Methods: A prospective study with women submitted to radical hysterectomy (RH) (n = 20),exclusive radiotherapy (RT) (n= 20)or chemoradiation (CT/RT)(n = 20)for invasive cervical cancer. Urinary, intestinal and sexual function, as well as vaginal length and pelvic floor musclecontraction were evaluated. Comparisons between groups were performed by Kruskal-Wallis and Chi-square tests (p < 0.05). Results: The groups were similar in stress urinary incontinence incidence (p = 0.56), urinary urgency (p = 0.44),urge incontinence (p = 0.54),nocturia(p = 0.53), incomplete bowel emptying (p = 0.76),bowel urgency(p = 0.12)and soilage(p = 0.43). The CT/ RT group presented a higher urinary frequency(p < 0.001)and diarrhea(p = 0.025). Patients in the RH group were more sexually active(p = 0.01) and experienced less dyspareunia (p = 0.021). Vaginal length was shorter in RT group (5.5 ± 1.9 cm) and CT/ RT(.3 ± 1.5 cm) than in the RH group (7.4 ± 1.1 cm) (p < 0.001). Pelvic floor muscle contraction was similar (p = 0.302). Conclusions: RT and CT/RT treatment for cervical carcinoma are more associated to sexual and intestinal dysfunctions.

Pelvic floor muscle strength evaluation in different body positions in nulliparous healthy women and its correlation with sexual activity

Objective: The aim of this study was to assess pelvic floor muscle (PFM) strength in different body positions in nulliparous healthy women and its correlation with sexual activity.Materials and Methods: Fifty healthy nulliparous women with mean age of 23 years were prospectively studied. Subjective evaluation of PFM was assessed by transvaginal digital palpation (TDP) of anterior and posterior areas regarding the vaginal introitus. A perineometer with inflatable vaginal probe was used to assess the PFM strength in four different positions: supine with extended lower limbs (P1); bent-knee supine (P2); sitting (P3); standing (P4).Results: Physical activity, 3 times per week, was reported by 58% of volunteers. Sexual activity was observed in 80% of women and 82% of them presented orgasm. The average body mass index (BMI) was 21.76 kg/m(2), considered as normal according World Health Organization (WHO). We observed that 68% of volunteers were conscious about the PFM contraction. TDP showed concordance of 76% when anterior and posterior areas were compared (p = 0.00014). There was not correlation between PFM strength and orgasm in subjective evaluation. The PFM strength was significantly higher in standing position when compared with the other positions (p < 0.000). No statistical difference was observed between orgasm and PFM strength when objective evaluations were performed.Conclusions: There was concordance between anterior and posterior areas in 76% of cases when subjective PFM strength was assessed. In objective evaluation, higher PFM strength was observed when volunteers were standing. No statistical correlation was observed between PFM strength and orgasm in nulliparous healthy women.

Reliability of pelvic floor muscle strength assessment in healthy continent women

Background: The aim of this study was to compare pelvic floor muscle (PFM) strength using transvaginal digital palpation in healthy continent women in different age groups, and to compare the inter- and intra-rater reliability of examiners performing anterior and posterior vaginal assessments.Methods: We prospectively studied 150 healthy multiparous women. They were distributed into four different groups, according to age range: G1 (n = 37), 30-40 years-old; G2 (n = 39), 41-50 years-old; G3 (n = 39), 51-60 years-old; and G4 (n = 35), older than 60 years-old. PFM strength was evaluated using transvaginal digital palpation in the anterior and posterior areas, by 3 different examiners, and graded using a 5-point Amaro's scale.Results: There was no statistical difference among the different age ranges, for each grade of PFM strength. There was good intra-rater concordance between anterior and posterior PFM assessment, being 64.7%, 63.3%, and 66.7% for examiners A, B, and C, respectively. The intra-rater concordance level was good for each examiner. However, the inter-rater reliability for two examiners varied from moderate to good.Conclusions: Age has no effect on PFM strength profiles, in multiparous continent women. There is good concordance between anterior and posterior vaginal PFM strength assessments, but only moderate to good inter-rater reliability of the measurements between two examiners.

Comparison of active and passive forces of the pelvic floor muscles in women with and without stress urinary incontinence

Background: The reduction of the pelvic floor muscles (PFM) strength is a major cause of stress urinary incontinence (SUI). Objective: To compare active and passive forces, and vaginal cavity aperture in continent and stress urinary incontinent women. Method: The study included a total of thirty-two women, sixteen continent women (group 1 - G1) and sixteen women with SUI (group 2 - G2). To evaluate PFM passive and active forces in anteroposterior (sagittal plane) and left-right directions (frontal plane) a stainless steel specular dynamometer was used. Results: The anteroposterior active strength for the continent women (mean +/- standard deviation) (0.3 +/- 0.2 N) was greater compared to the values found in the evaluation of incontinent women (0.1 +/- 0.1 N). The left-right active strength (G1=0.43 +/- 0.1 N; G2=0.40 +/- 0.1 N), the passive force (G1=1.1 +/- 0.2 N; G2=1.1 +/- 0.3 N) and the vaginal cavity aperture (G1=21 +/- 3 mm; G2=24 +/- 4 mm) did not differ between groups 1 and 2. Conclusion: The function evaluation of PFM showed that women with SUI had a lower anteroposterior active strength compared to continent women.

Is the Sexual Satisfaction of Postmenopausal Women Enhanced by Physical Exercise and Pelvic Floor Muscle Training?

Introduction. Physical exercise including pelvic floor muscle (PFM) training seems to improve the sexual function of women with urinary incontinence. This effect in postmenopausal women who are continent has not yet been determined. Aim. The aim of this study was to assess the effect of a 3-month physical exercise protocol (PEP) on the sexual function and mood of postmenopausal women. Methods. Thirty-two sedentary, continent, sexually active women who had undergone menopause no more than 5 years earlier and who had follicle stimulating hormone levels of at least 40 mIU/mL were enrolled into this longitudinal study. All women had the ability to contract their PFMs, as assessed by vaginal bimanual palpation. Muscle strength was graded according to the Oxford Modified Grading Scale (OMGS). A PEP was performed under the guidance of a physiotherapist (M. M. F.) twice weekly for 3 months and at home three times per week. All women completed the Sexual Quotient-Female Version (SQ-F) and the Hospital Anxiety and Depression Scale (HADS) before and after the PEP. Main Outcome Measures. SQ-F to assess sexual function, HASDS to assess mood, and OMGS to grade pelvic floor muscle strength. Results. Thirty-two women (24 married women, eight women in consensual unions) completed the PEP. Following the PEP, there was a significant increase in OMGS score (2.59 +/- 1.24 vs. 3.40 +/- 1.32, P < 0.0001) and a significant decrease in the number of women suffering from anxiety (P < 0.01), but there was no effect on sexual function. Conclusion. Implementation of our PEP seemed to reduce anxiety and improve pelvic floor muscular strength in sedentary and continent postmenopausal women. However, our PEP did not improve sexual function. Uncontrolled variables, such as participation in a long-term relationship and menopause status, may have affected our results. We suggest that a randomized controlled trial be performed to confirm our results. Lara LAS, Montenegro ML, Franco MM, Abreu DCC, Rosa e Silva ACJS, Ferreira CHJ. Is the sexual satisfaction of postmenopausal women enhanced by physical exercise and pelvic floor muscle training? J Sex Med 2012; 9: 218-223.

Early postoperative pelvic-floor biofeedback improves erectile function in men undergoing radical prostatectomy: a prospective, randomized, controlled trial

Erectile dysfunction (ED) and urinary incontinence are common complications following radical prostatectomy (RP). Although pelvic-floor biofeedback training (PFBT) may improve urinary continence following RP, its effects on the recovery of potency are unknown. Fifty-two patients selected for RP were prospectively randomized for a treatment group (n=26) receiving PFBT once a week for 3 months and home exercises or a control group (n=26), in which patients received verbal instructions to contract the pelvic floor. Erectile function (EF) was evaluated with the International Index of Erectile Function-5 (IIEF-5) before surgery and 1, 3, 6 and 12 months postoperatively. Patients were considered potent when they had a total IIEF-5 score >20. Continence status was assessed and defined as the use of no pads. Groups were comparable in terms of age, body mass index, diabetes, pathological tumor stage and neurovascular bundle preservation. A significant reduction in IIEF-5 scores was observed after surgery in both groups. In the treatment group, 8 (47.1%) patients recovered potency 12 months postoperatively, as opposed to 2 (12.5%) in the control group (P=0.032). The absolute risk reduction was 34.6% (95% confidence interval (CI): 3.8-64%) and the number needed to treat was 3 (95% CI: 1.5-17.2). A strong association between recovery of potency and urinary continence was observed, with continent patients having a 5.4 higher chance of being potent (P=0.04). Early PFBT appears to have a significant impact on the recovery of EF after RP. Urinary continence status was a good indicator of EF recovery, with continent patients having a higher chance of being potent.

Vaginal prolapse, pelvic floor function, and related symptoms 16 years after sex reassignment surgery in transsexuals

To evaluate the prevalence of prolapse and related bladder, bowel, and sexual problems in transsexual patients (TS) after sex reassignment surgery.

Continuous versus intermittent stochastic resonance whole body vibration and its effect on pelvic floor muscle activity

To determine the optimal stochastic whole body vibration (SR-WBV) load modality regarding pelvic floor muscle (PFM) activity in order to complete the SR-WBV training methodology for future PFM training with SR-WBV.

Pelvic floor stimulation: what are the good vibrations?

OBJECTIVE: The aim of this study was to determine if two different whole body vibration, sinusoidal vibration (SV) and stochastic resonance vibration (SRV), using various intensities lead to a reactive activation of pelvic floor muscles. STUDY DESIGN: We compared the pelvic floor muscle response of a healthy control group with that of a post partum group with weakened pelvic floor contraction. Activation effects of stochastic resonance vibration and sinusoidal vibration with six increasing vibration intensities were investigated using pelvic floor EMG and compared to activity during rest and maximum voluntary contraction. RESULTS: Both whole body vibration systems were able to activate pelvic floor muscles significantly depending on vibration intensity. Generally, the SRV achieved a significantly higher activation than maximum voluntary contraction, especially in women post partum and using a frequency of 6-12 Hz. CONCLUSION: SRV, compared to SV, leads to higher pelvic floor muscle activation in subjects with weakened pelvic floor muscles and achieves higher pelvic floor activation than maximum voluntary contraction alone. Neurourol. Urodynam. 28:405-410, 2009. (c) 2009 Wiley-Liss, Inc.

Intra-session test-retest reliability of pelvic floor muscle electromyography during running

INTRODUCTION AND HYPOTHESIS The prevalence of female stress urinary incontinence is high, and young adults are also affected, including athletes, especially those involved in "high-impact" sports. To date there have been almost no studies testing pelvic floor muscle (PFM) activity during dynamic functional whole body movements. The aim of this study was the description and reliability test of PFM activity and time variables during running. METHODS A prospective cross-sectional study including ten healthy female subjects was designed with the focus on the intra-session test-retest reliability of PFM activity and time variables during running derived from electromyography (EMG) and accelerometry. RESULTS Thirteen variables were identified based on ten steps of each subject: Six EMG variables showed good reliability (ICC 0.906-0.942) and seven time variables did not show good reliability (ICC 0.113-0.731). Time variables (e.g. time difference between heel strike and maximal acceleration of vaginal accelerator) showed low reliability. However, relevant PFM EMG variables during running (e.g., pre-activation, minimal and maximal activity) could be identified and showed good reliability. CONCLUSION Further adaptations regarding measurement methods should be tested to gain better control of the kinetics and kinematics of the EMG probe and accelerometers. To our knowledge this is the first study to test the reliability of PFM activity and time variables during dynamic functional whole body movements. More knowledge of PFM activity and time variables may help to provide a deeper insight into physical strain with high force impacts and important functional reflexive contraction patterns of PFM to maintain or to restore continence.

Pelvic floor muscle activation and strength components influencing female urinary continence and stress incontinence: A systematic review

AIMS A better understanding of pelvic floor muscle (PFM) activation and strength components is a prerequisite to get better insight in PFM contraction mechanisms and develop more specific PFM-training regimens for female stress urinary incontinence (SUI) patients. The aim of this systematic review (2012:CRD42012002547) was to evaluate and summarize existing studies investigating PFM activation and strength components influencing female continence and SUI. METHODS PubMed, EMBASE, and Cochrane databases were systematically searched for literature from January 1980 to November 2013 for cross-sectional studies comparing female SUI patients with healthy controls and intervention studies with SUI patients reporting on the association between PFM activation and strength components and urine loss. Trial characteristics, evaluated PFM components, their definitions, measurement methods, study outcomes, as well as quality measures, based on the Cochrane risk of bias tool, were independently extracted. The high heterogeneity of the retrieved data made pooling of results impossible and therefore restricted the analysis to a systematic review. RESULTS Cross-sectional studies showed group differences in favor of the continent women compared to SUI patients for PFM activation or PFM maximal strength, mean strength or sustained contraction. All intervention studies showed an improvement of PFM strength and decrease in urine loss in SUI patients after physical therapy. CONCLUSIONS Higher PFM activation and strength components influence female continence positively. This systematic review underscored the need for a standardized PFM components' terminology (similar to rehabilitation and training science), standardized test procedures and well matched diagnostic instruments. Neurourol. Urodynam. © 2014 Wiley Periodicals, Inc.

Pelvic floor muscle electromyography during different running speeds: an exploratory and reliability study.

PURPOSE Stress urinary incontinence (SUI) affects women of all ages including young athletes, especially those involved in high-impact sports. To date, hardly any studies are available testing pelvic floor muscles (PFM) during sports activities. The aim of this study was the description and reliability test of six PFM electromyography (EMG) variables during three different running speeds. The secondary objective was to evaluate whether there was a speed-dependent difference between the PFM activity variables. METHODS This trial was designed as an exploratory and reliability study including ten young healthy female subjects to characterize PFM pre-activity and reflex activity during running at 7, 9 and 11 km/h. Six variables for each running speed, averaged over ten steps per subject, were presented descriptively, tested regarding their reliability (Friedman, ICC, SEM, MD) and speed difference (Friedman). RESULTS PFM EMG variables varied between 67.6 and 106.1 %EMG, showed no systematic error and were low for SEM and MD using the single value model. Applying the average model over ten steps, ICC (3,k) were >0.75 and SEM and MD about 50 % lower than for the single value model. Activity was found to be highest in 11 km/h. CONCLUSION EMG variables showed excellent ICC and very low SEM and MD. Further studies should investigate inter-session reliability and PFM reactivity patterns of SUI patients using the average over ten steps for each variable as it showed very high ICC and very low SEM and MD. Subsequently, longer running distances and other high-impact sports disciplines could be studied.

Pelvic floor muscle displacement during voluntary and involuntary activation in continent and incontinent women: a systematic review.

INTRODUCTION Investigations of the dynamic function of female pelvic floor muscles (PFM) help us to understand the pathophysiology of stress urinary incontinence (SUI). Displacement measurements of PFM give insight into muscle activation and thus help to improve rehabilitation strategies. This systematic review (PROSPERO 2013: CRD42013006409) was performed to summarise the current evidence for PFM displacement during voluntary and involuntary activation in continent and incontinent women. METHODS MEDLINE, EMBASE, Cochrane and SPORTDiscus databases were searched using selected terminology reflecting the PICO approach. Screening of Google Scholar and congress abstracts added to further information. Original articles investigating PFM displacement were included if they reported on at least one of the aims of the review, e.g., method, test position, test activity, direction and quantification of displacement, as well as the comparison between continent and incontinent women. Titles and abstracts were screened by two reviewers. The papers included were reviewed by two individuals to ascertain whether they fulfilled the inclusion criteria and data were extracted on outcome parameters. RESULTS Forty-two predominantly observational studies fulfilled the inclusion criteria. A variety of measurement methods and calculations of displacement was presented. The sample was heterogeneous concerning age, parity and continence status. Test positions and test activities varied among the studies. CONCLUSIONS The findings summarise the present knowledge of PFM displacement, but still lack deeper comprehension of the SUI pathomechanism of involuntary, reflexive activation during functional activities. We therefore propose that future investigations focus on PFM dynamics during fast and stressful impact tasks.

Standardized pelvic floor exercises improve stress urinary incontinence in women with intrinsic sphincter deficiency.

OBJECTIVES Pelvic floor rehabilitation is the conservative therapy of choice for women with stress urinary incontinence (SUI). The success rate of surgical procedures in SUI patients with intrinsic sphincter deficiency (ISD) is low. The aim of this study was to analyse the effect of a standardized physiotherapy on patients with SUI and normotonic urethra and ISD. METHODS In this study, 64 patients with ISD and 69 patients with normotonic urethra were enrolled. Maximum urethral pressure (MUCP) >20 cm H2 O was considered as normotonic urethral pressure. Before and after physiotherapy MUCP was measured and cough testing was performed. Additionally, patient reported outcome was assessed using the King's Health Questionnaire (KHQ). For statistical analyses Excel 2010 (Microsoft Inc; Redmond, Washington) and SPSS 20 (SPSS Inc; Chicago, Illinois) for Windows were used. Power calculation was based on the primary endpoint incontinence impact and general health. For power calculation, GraphPad Statmate version 2.00 for Windows was used. RESULTS Sixty-four patients with ISD and 69 patients with normotonic urethra were included in the study. In SUI patients with normotonic and hypotonic urethra KHQ-scores regarding the primary endpoins "general health" and "incontinence impact" significantly improved following standardized physiotherapy. In both groups MUCP increased after physiotherapy. In SUI patients with ISD standardized physiotherapy resulted in a decreased incidence of a positive cough test. CONCLUSIONS Standardized physiotherapy should be offered to patients with SUI and ISD. Long-term results are subject to future studies. Neurourol. Urodynam. © 2015 Wiley Periodicals, Inc.