Co-activation of the abdominal and pelvic floor muscles during voluntary exercises

The response of the abdominal muscles to voluntary contraction of the pelvic floor (PF) muscles was investigated in women with no history of symptoms of stress urinary incontinence to determine whether there is co-activation of the muscles surrounding the abdominal cavity during exercises for the PF muscles. Electromyographic (EMG) activity of each of the abdominal muscles was recorded with fine-wire electrodes in seven parous females. Subjects contracted the PF muscles maximally in three lumbar spine positions while lying supine. In all subjects. the EMG activity of the abdominal muscles was increased above the baseline level during contractions of the PF muscles in at least one of the spinal positions. The amplitude of the increase in EMG activity of obliquus externus abdominis was greatest when the spine was positioned in flexion and the increase in activity of transversus abdominis was greater than that of rectus abdominis and obliquus externus abdominis when the spine was positioned in extension. In an additional pilot experiment. EMG recordings were made from the pubococcygeus and the abdominal muscles with fine-wire electrodes in two subjects during the performance of three different sub-maximal isometric abdominal muscle maneuvers. Both subjects showed an increase in EMG activity of the pubococcygeus with each abdominal muscle contraction. The results of these experiments indicate that abdominal muscle activity is a normal response to PF exercise in subjects with no symptoms of PF muscle dysfunction and provide preliminary evidence that specific abdominal exercises activate the PF muscles. Neurourol. Urodynam. 20:31-42, 2001. (C) 2001 Wiley-Liss, Inc.

Normal values for pelvic organ descent in health nulligravid young caucasian women

Translabial ultrasound is increasingly being used for the assessment of women presenting with pelvic floor dysfunction and incontinence (1,2). However, there is little information on normal values for bladder neck descent, with the two available studies disagreeing widely (3,4). No data has so far been published on mobility of the central and posterior compartment which can now also be assessed by ultrasound (5). This study presents normal values for urethral, bladder, cervical and rectal mobility in a cohort of young, stress continent, nulliparous nonpregnant women. Methods 118 nonpregnant nulliparous Caucasian women between 18 and 23 years of age were recruited for an ongoing twin study of pelvic floor function. Translabial ultrasound assessment of pelvic organ mobility was undertaken supine and after bladder emptying (6,7). The best of at least three effective Valsalva manoeuvres was used for evaluation, with no attempts at standardization of Valsalva pressure. Parameters of anterior compartment mobility were obtained by the use of on-screen calipers; cervical and rectal descent were evaluated on printouts. All examinations were carried out under direct supervision of the first author or by personnel trained by him for at least 100 consecutive assessments. Results The median age of participants in this study was 20 (range 18- 23). Mean body mass index was 23 (range 16.9- 36.7). Of 118 women, 2 were completely unable to perform a Valsalva manoeuvre despite repeated efforts at teaching and were excluded from analysis, as were ten women who complained of urinary stress incontinence, leaving 106 datasets. Average measurements for the parameters ‘retrovesical angle at rest’ (RVA-R) and on Valsalva (RVA-S), urethral rotation, bladder neck mobility, cysto-cele descent, cervical descent and descent of the rectal ampulla are given in Table 1.

Active and passive behaviors of soft tissues: Pelvic floor muscles

: A new active-contraction visco-elastic numerical model of the pelvic floor (skeletal) muscle is presented. Our model includes all elements that represent the muscle constitutive behavior, contraction and relaxation. In contrast with the previous models, the activation function can be null. The complete equations are shown and exactly linearized. Small verification and validation tests are performed and the pelvis is modeled using the data from the intra-abdominal pressure tests

Severe stress urinary incontinence: pelvic floor muscle training program

International guidelines recommend a first line therapy in the treatment of female stress urinary incontinence (SUI), the pelvic floor muscle (PFM) training. This case report assesses the effects of the PFM training program in treating women with severe SUI. The urodynamic parameters allow diagnosed intrinsic sphincter deficiency and urethral hypermobility. The subjective and objective parameters were assessed at the beginning and after six-month of PFM training program. This case report confirms the efficiency of the intensive training program in severe SUI. The medical implications of the PFM training as first treatment option reflect favourable individual results and additionally contribute to the selection of the non-invasive treatment, the reduction of the incidence collateral effects, low costs and that does not prevent future treatment options.

Head-Up Tilt Testing with Different Nitroglycerin Dosages: Experience in Elderly Patients with Unexplained Syncope

AIMS: Protocols using sublingual nitrates have been increasingly used to improve diagnostic accuracy of head-up tilt testing (HUT). Nevertheless, exaggerated responses to nitrates have been frequently described, particularly in elderly patients. The aim of this article is to evaluate, in an elderly population with unexplained syncope, whether the impact of sublingual nitroglycerin (NTG) used as a provocative agent is dose-dependent. METHODS AND RESULTS: One hundred and twenty consecutive elderly patients submitted to HUT using NTG after an asymptomatic drug-free phase were studied. Patients were divided into three groups according to the NTG dosage: 500, 375 and 250 microg. The test was considered positive when there was reproduction of symptoms with bradycardia and/or arterial hypotension. A gradual decrease in the blood pressure after NTG was considered an exaggerated response to nitrates. There were no differences in the clinical characteristics of the different subgroups. A positive test was obtained in 50% of the patients in each group. The rate of exaggerated responses was identical in all groups and ranged between 15 and 17%. CONCLUSION: In an elderly population with syncope of unknown origin submitted to HUT, the response to NTG is not dose-dependent, and no difference was found in the rate of exaggerated responses to nitrates with different NTG dosages.

O Treino de Ortostatismo (Tilt Training) Aumenta a Reserva Vasoconstritora em Doentes com Síncope Reflexa Neurocardiogénica

A síncope neurocardiogénica (SNc) é uma entidade clínica comum, resultante de uma resposta autonómica reflexa excessiva durante o stress ortostático. As diferentes opções terapêuticas são controversas e de eficácia limitada. O treino de ortostatismo (TTr) tem-se mostrado uma alternativa prometedora no tratamento destes doentes (D). No entanto, permanece por esclarecer o seu mecanismo de acção e o impacto clínico numa população com SNc recorrente. Objectivo: Caracterizar a resposta hemodinâmica e autonómica durante um programa de TTr em doentes com SNc refratária às medidas convencionais. População e métodos: Foram estudados 28D (50% do sexo masculino, 41±14 anos), sem evidência de cardiopatia, com SNc documentada em teste de ortostatismo passivo. O TTr incluiu 9 sessões hospitalares (3x/semana, 30 minutos) com monitorizac¸ão contínua de pressão arterial e frequência cardíaca (60◦ - 6 sessões - 70◦ - 3 sessões), complementadas com treino diário no domicílio e elevação da cabeceira a 10◦ durante o sono. O volume sistólico, o débito cardíaco, a resistência vascular periférica, a sensibilidade do barorreflexo e a variabilidade da frequência cardíaca foram calculados. Todos os doentes foram reavaliados no fim do 1.◦ mês e no final de cada 6 meses num período máximo de 36 meses (follow-up 24±12 meses). Resultados: Ao longo das sessões de TTr verificou-se um aumento significativo e consistente da resistência total periférica (1485±225 vs. 1591±187 dyne*s/cm−5, p < 0,05) associado a uma diminuição do seu desvio-padrão (206±60 vs. 150±42, p < 0,05). Durante o período de follow-up, houve recorrência de síncope em 5D (19%), com redução significativa do número de síncopes (4,0±3,2/D nos 12 meses pre-TTr vs. 1,4±0,8/D pos-TTr, p < 0,05). Conclusão: Em doentes com SNc refratária, o TTr mostrou ser uma opção terapêutica eficaz, com benefício a longo prazo. A melhor tolerância ao ortostatismo parece resultar do aumento da reserva vasoconstritora e da sua menor variabilidade.

Tilt Training Increases Vasoconstrictor Reserve in Patients with Neurocardiogenic Syncope

Neurocardiogenic syncope (NCS) is a common clinical entity resulting from an excessive reflex autonomic response, particularly during orthostatism. Treatment options are controversial and of limited effectiveness. Tilt training (TT) is a promising option to treat these patients. However, its mechanism of action and clinical impact remain unclear. OBJECTIVE: To characterize hemodynamic and autonomic responses during a TT program in patients with NCS refractory to conventional measures. METHODS: We studied 28 patients (50% male, mean age 41±14 years) without structural heart disease, with NCS documented by tilt testing. The TT program included 9 tilt sessions (3 times a week, 30 min) (60° - 6 sessions, 70° - 3 sessions), under ECG and blood pressure monitoring combined with home orthostatic self-training and 10° head-up during sleep. Systolic volume, cardiac output, total peripheral resistance, baroreflex sensitivity and heart-rate variability were computed. Patients were reassessed at 1 month and every 6 months for a maximum of 36 months (24±12 months). RESULTS: Over the course of the TT program there was a significant increase in total peripheral resistance (1485±225 vs. 1591±187 dyn·s·cm(-5), p<0.05), with a decrease in standard deviation (206±60 vs. 150±42, p<0.05). During follow-up, syncope recurred in five patients (19%), with a significant reduction in the number of episodes (4.0±3.2/patient in the 12 months before TT vs. 1.4±0.8/patient post-TT, p<0.05). CONCLUSION: In refractory NCS, TT may be an effective therapeutic option, with long-term benefits. These results appear to be due to an increase in vasoconstrictor reserve combined with a reduction in its variance.

A Rare Abdomino-Pelvic Tumor: Paraganglioma

Paragangliomas are rare tumors, with a reported incidence of 2–8 per million. They are chromaffin cell tumors that develop from the neural crest cells and may be divided in tumors derived from the parasympathetic or sympathetic ganglia. We report a case a of a 32-year-old nulliparous woman, referred to our Infertility Clinic. Abdomino-pelvic ultrasound identified a large abdominopelvic tumor, without ovarian origin (both ovaries were identified and had normal morphology). Magnetic Resonance Imaging suggested a right adnexal multicystic, vascularized mass close to iliac vessels and questioning an ovarian origin. At exploratory laparotomy, a 10 cm encapsulated and vascularized mass was found beginning just below right renal artery and extending to the level of the broad ligament. This mass was totally excised and histopathology was consistent with Paraganglioma.

Impact of Syncope on Quality of Life: Validation of a Measure in Patients Undergoing Tilt Testing

INTRODUCTION AND OBJECTIVES: Recurrent syncope has a significant impact on quality of life. The development of measurement scales to assess this impact that are easy to use in clinical settings is crucial. The objective of the present study is a preliminary validation of the Impact of Syncope on Quality of Life questionnaire for the Portuguese population. METHODS: The instrument underwent a process of translation, validation, analysis of cultural appropriateness and cognitive debriefing. A population of 39 patients with a history of recurrent syncope (>1 year) who underwent tilt testing, aged 52.1 ± 16.4 years (21-83), 43.5% male, most in active employment (n=18) or retired (n=13), constituted a convenience sample. The resulting Portuguese version is similar to the original, with 12 items in a single aggregate score, and underwent statistical validation, with assessment of reliability, validity and stability over time. RESULTS: With regard to reliability, the internal consistency of the scale is 0.9. Assessment of convergent and discriminant validity showed statistically significant results (p<0.01). Regarding stability over time, a test-retest of this instrument at six months after tilt testing with 22 patients of the sample who had not undergone any clinical intervention found no statistically significant changes in quality of life. CONCLUSIONS: The results indicate that this instrument is of value for assessing quality of life in patients with recurrent syncope in Portugal.

Pelvic lymphoscintigraphy: contribution to the preoperative staging of rectal cancer

PURPOSE: Preservation of the anal sphincter in surgery for cancer of the distal rectum in an attempt to avoid colostomy has been a main concern of colorectal surgeons. Various proposed procedures contradict oncological principles, especially with respect to pelvic lymphadenectomy. Therefore, prior knowledge of pelvic lymph node involvement is an important factor in choosing the operative technique, i.e., radical or conservative resection. Introduction of ultrasound, computerized tomography, and magnetic resonance have made preoperative study of the area possible. Nevertheless, these resources offer information of an anatomical nature only. Lymphoscintigraphy enables the morphological and functional evaluation of the pelvic area and contributes toward complementing the data obtained with the other imaging techniques. The objective of this prospective study is twofold: to standardize the lymphoscintigraphy technique and to use it to differentiate patients with rectal cancer from those with other coloproctologic diseases. CASUISTIC AND METHODS: Sixty patients with various coloproctologic diseases were studied prospectively. Ages ranged from 21 to 96 years (average, 51 and median, 55 years). Twenty-six patients were male and 34 were female. Thirty patients had carcinoma of the distal rectum as diagnosed by proctologic and anatomic-pathologic examinations, 20 patients had hemorrhoids, 5 had chagasic megacolon, 2 had diverticular disease, 2 had neoplasm of the right colon, and 1 had ulcerative colitis as diagnosed by proctologic exam and/or enema. The lymphoscintigraphy method consisted of injecting 0.25 mL of a dextran solution marked with radioactive technetium-99m into the right and left sides of the perianal region and obtaining images with a gamma camera. The results were analyzed statistically with a confidence level of 95% (P < .05) using the following statistical techniques: arithmetic and medium average, Fisher exact test, chi-square test corrected for continuity according to Yates, and distribution tables for the number of patients. RESULTS: In rectal cancer, the tracer progresses unilaterally or is absent; in other patients, the progress of the tracer is bilateral and symmetrical, although its progress may be slow. Statistical tests showed with high significance that the agreement index between the clinical diagnosis and the result of the lymphoscintigraphic exam was 93%. CONCLUSIONS: Lymphoscintigraphy is a standardized, painless, and harmless test that can be performed in all cases; it differentiates patients with rectal cancer from those with other coloproctological diseases.

A case study of product usability of a pelvic device used by children with neuromotor impairments

On assistive technology targeted for people with activity limitations and participation, usability issues becomes an essential tool to ensure that the product has the appropriate ergonomics characteristics, in other words, ensure that it fits the specific user´s needs. The aim of this study was to analyze the usability of an adaptive seating device for children with neuromotor impairments, by using kinematic indicators of the reaching movement. The study sample consisted of 13 children with associated neurologic conditions. The tests were developed by using a wooden bench height adjustable, integrated with the adaptive seating device under study, and a system to capture three-dimensional image, called Qualisys Track Manager. The following reaching kinematics variables were measured: maximum reaching velocity, movement duration, index of curvature, and unit movements. It was found that the use of the adaptive seating device had a positive impact on upper limb function in children with neuromotor impairments. It was also noticed an improvement in the reaching movement kinematics, which was statistical significant for the index of curvature and unit movements. As main conclusions, it is possible to point out some positive effects that the product under study seems to have on users' movements, such as the improved movement quality of the upper limb, which could mean a better postural adjustments and higher trunk postural control. By identifying new measures of usability in terms of effectiveness and efficiency for the analyzeddevice, the results obtained may serve also as performance indicators, providing new data that may help to improve the product and eventually modifying it, in order to turn it more compatible with the needs of the considered target population.

Diagnostic value of the tilt-table test for the assessment of syncope in children and adolescents

OBJECTIVE - To assess the diagnostic value, the characteristics, and feasibility of tilt-table testing in children and adolescents. METHODS - From August 1991 to June 1997, we retrospectively assessed 94 patients under the age of 18 years who had a history of recurring syncope and presyncope of unknown origin and who were referred for tilt-table testing. These patients were divided into 2 groups: group I (children) - 36 patients with ages ranging from 3 to 12 (mean of 9.19±2.31) years; group II (adolescents) - 58 patients with ages ranging from 13 to 18 (mean of 16.05±1.40) years. We compared the positivity rate, the type of hemodynamic response, and the time period required for the test to become positive in the 2 groups. RESULTS - The positivity rates were 41.6 % and 50% for groups I and II, respectively. The pattern of positive hemodynamic response that predominated in both groups was the mixed response. The mean time period required for the test to become positive was shorter in group I (11.0±7.23 min) than in group II (18.44±7.83 min). No patient experienced technical difficulty or complications. CONCLUSION - No difference was observed in regard to feasibility, positivity rate, and pattern of positive response for the tilt-table test in children and adolescents. Pediatric patients had earlier positive responses.

Comparison between tilt-table testing results performed during different periods of the day

OBJECTIVE: To evaluate the influences of circadian variations on tilt-table testing (TTT) results by comparing the positivity rate of the test performed during the morning with that of the test performed in the afternoon and to evaluate the reproducibility of the results in different periods of the day. METHODS: One hundred twenty-three patients with recurrent unexplained syncope or near-syncope referred for TTT were randomized into 2 groups. In group I, 68 patients, TTT was performed first in the afternoon and then in the morning. In group II, 55 patients, the test was performed first in the morning and then in the afternoon. RESULTS: The TTT protocol was the prolonged passive test, without drug sensitization. Twenty-nine (23.5%) patients had a positive result in at least one of the periods. The positivity rate for each period was similar: 20 (16.2%) patients in the afternoon and 19 (15.4%) in the morning (p=1.000). Total reproducibility (positive/positive and negative/negative) was observed in 49 (89%) patients in group I and in 55 (81%) in group II. Reproducibility of the results was obtained in 94 (90.4%) patients with first negative tests but in 10 (34%) patients with first positive tests. CONCLUSION: TTT could be performed during any period of the day, and even in the 2 periods to enhance positivity. Considering the low reproducibility rate of the positive tests, serial TTT to evaluate therapeutic efficacy should be performed during the same period of the day.