Does post-caesarean dyspareunia reflect sexual malfunction, pelvic floor and perineal dysfunction?

The aim was to define post-caesarean dyspareunia as a sexual and pelvic-perineal symptom. Post-caesarean (80 elective, 104 emergency) and 100 vaginally delivered primiparae had domiciliary interviews at 10 months postpartum. A total of 50 (28% and 27%) post-caesarean and 46 (46%) vaginally delivered, reported dyspareunia. Severely impaired general sexual health occurred in 82 (24% elective, 25% emergency, 35% vaginally delivered) as category 3 (dyspareunia with sexual symptoms) and 27 (10% elective, 7% emergency, 12% vaginally delivered) as category 4 (reduced frequency <6). The risk of dyspareunia (RR 1.14, CI 0.73, 1.77) or impaired general sexual health (RR 0.93, CI 0.32, 2.74) was similar among those with or without perineal trauma. Both caesarean and perineal scars were associated with sexual malfunction. Primiparae with new incontinence had a lower risk of dyspareunia than impaired general sexual health. Awareness of the associations of post-caesarean dyspareunia and impaired general sexual health with incontinence would facilitate appropriate obstetric decision-making. Further research is indicated. © 2011 Informa UK, Ltd.

Physiotherapy for persistent postnatal stress urinary incontinence : a randomized controlled trial

OBJECTIVE: The aim of this study was to compare the effectiveness of multimodal supervised physiotherapy programs with the absence of treatment among women with persistent postnatal stress urinary incontinence. METHODS: This was a single-blind randomized controlled trial. Sixty-four women with stress urinary incontinence were randomly assigned to 8 weeks of either multimodal pelvic floor rehabilitation (n = 21), multimodal pelvic floor rehabilitation with abdominal muscle training (n = 23), or control non–pelvic floor rehabilitation (n = 20). The primary outcome measure consisted of a modified 20-minute pad test. The secondary outcome measures included a Visual Analog Scale describing the perceived burden of incontinence, the Urogenital Distress Inventory, the Incontinence Impact Questionnaire, and pelvic floor muscle function measurements. RESULTS: Two patients dropped out, leaving 62 for analysis. At follow-up, more than 70% of the women in the treatment groups (14/20 in the pelvic floor and 17/23 in the pelvic floor plus abdominal group) were continent on pad testing compared with 0% of women in the control group. Scores on the pad test, Visual Analog Scale, Urogenital Distress Inventory, and Incontinence Impact Questionnaire improved significantly in both treatment groups (all P < .002), whereas no changes were observed in the control group. Pelvic floor muscle function, however, did not improve significantly in either active group. CONCLUSION: Multimodal supervised pelvic floor physiotherapy is an effective treatment for persistent postnatal stress urinary incontinence.

Physiotherapy for persistent postnatal stress urinary incontinence : a randomized controlled trial

OBJECTIVE: The aim of this study was to compare the effectiveness of multimodal supervised physiotherapy programs with the absence of treatment among women with persistent postnatal stress urinary incontinence. METHODS: This was a single-blind randomized controlled trial. Sixty-four women with stress urinary incontinence were randomly assigned to 8 weeks of either multimodal pelvic floor rehabilitation (n = 21), multimodal pelvic floor rehabilitation with abdominal muscle training (n = 23), or control non–pelvic floor rehabilitation (n = 20). The primary outcome measure consisted of a modified 20-minute pad test. The secondary outcome measures included a Visual Analog Scale describing the perceived burden of incontinence, the Urogenital Distress Inventory, the Incontinence Impact Questionnaire, and pelvic floor muscle function measurements. RESULTS: Two patients dropped out, leaving 62 for analysis. At follow-up, more than 70% of the women in the treatment groups (14/20 in the pelvic floor and 17/23 in the pelvic floor plus abdominal group) were continent on pad testing compared with 0% of women in the control group. Scores on the pad test, Visual Analog Scale, Urogenital Distress Inventory, and Incontinence Impact Questionnaire improved significantly in both treatment groups (all P < .002), whereas no changes were observed in the control group. Pelvic floor muscle function, however, did not improve significantly in either active group. CONCLUSION: Multimodal supervised pelvic floor physiotherapy is an effective treatment for persistent postnatal stress urinary incontinence.

Pelvic-Floor Rehabilitation, Part 1 : Comparison of Two Surface Electrode Placements During Stimulation of the Pelvic-Floor Musculature in Women Who Are Continent Using Bipolar Interferential Currents

Background and Purpose. Electrical stimulation of the pelvic floor is used as an adjunct in the conservative treatment of urinary incontinence. No consensus exists, however, regarding electrode placements for optimal stimulation of the pelvic-floor musculature. The purpose of this study was to compare two different bipolar electrode placements, one suggested by Laycock and Green (L2) the other by Dumoulin (D2), during electrical stimulation with interferential currents of the pelvic-floor musculature in continent women, using a two-group crossover design. Subjects. Ten continent female volunteers, ranging in age from 20 to 39 years (X̅=27.3, SD=5.6), were randomly assigned to one of two study groups. Methods. Each study group received neuromuscular electrical stimulation (NMES) of the pelvic-floor musculature using both electrode placements, the order of application being reversed for each group. Force of contraction was measured as pressure (in centimeters of water [cm H2O]) exerted on a vaginal pressure probe attached to a manometer. Data were analyzed using a two-way, mixed-model analysis of variance. Results. No difference in pressure was observed between the two electrode placements. Differences in current amplitude were observed, with the D2 electrode placement requiring less current amplitude to produce a maximum recorded pressure on the manometer. Subjective assessment by the subjects revealed a preference for the D2 electrode placement (7 of 10 subjects). Conclusion and Discussion. The lower current amplitudes required with the D2 placement to obtain recordings comparable to those obtained with the L2 technique suggest a more comfortable stimulation of the pelvic-floor muscles. The lower current amplitudes required also suggest that greater increases in pressure might be obtained with the D2 placement by increasing the current amplitude while remaining within the comfort threshold. These results will help to define treatment guidelines for a planned clinical study investigating the effects of NMES and exercise in the treatment of urinary stress incontinence in women postpartum.

Changes in urethral sphincter size following rehabilitation in older women with stress urinary incontinence

Introduction and hypothesis The purpose of this study was to evaluate the effects of a pelvic floor muscle (PFM) rehabilitation program on the striated urethral sphincter in women over 60 years with stress urinary incontinence (SUI). We hypothesized that the PFM rehabilitation program would also exercise the striated urethral sphincter and that this would be demonstrated by hypertrophy of the sphincter on magnetic resonance imaging (MRI). Methods Women with at least weekly episodes of SUI were recruited. Participants were evaluated before and after a 12-week group PFM rehabilitation intervention with T2-weighted fast-spin-echo MRI sequences recorded in the axial plane at rest to assess urethral sphincter size. Data on SUI symptoms and their bother were also collected. No control group was included. Results Seventeen women participated in the study. The striated urethral sphincter increased significantly in thickness (21 %, p < 0.001), cross-sectional area (20 %, p = 0.003), and volume (12 %, p = 0.003) following the intervention. The reported number of incontinence episodes and their bother also decreased significantly. Conclusions This study appears to demonstrate that PFM training for SUI also trains the striated urethral sphincter and that improvement in incontinence signs and symptoms is associated with sphincter hypertrophy in older women with SUI. These findings support previous ultrasound (US) data showing an increase in urethral cross-sectional area following PFM training and extend the previous findings by more specifically assessing the area of hypertrophy and by demonstrating that older women present the same changes as younger women when assessed using MRI data.

Differences in pelvic floor morphology between continent, stress urinary incontinent, and mixed urinary incontinent elderly women : an MRI study

Aims To compare magnetic resonance imaging (MRI) of the pelvic floor musculature (PFM), bladder neck and urethral sphincter morphology under three conditions (rest, PFM maximal voluntary contraction (MVC), and straining) in older women with symptoms of stress (SUI) or mixed urinary incontinence (MUI) or without incontinence. Methods This 2008–2012 exploratory observational cohort study was conducted with community-dwelling women aged 60 and over. Sixty six women (22 per group), mean age of 67.7 ± 5.2 years, participated in the study. A 3 T MRI examination was conducted under three conditions: rest, PFM MVC, and straining. ANOVA or Kruskal–Wallis tests (data not normally distributed) were conducted, with Bonferroni correction, to compare anatomical measurements between groups. Results Women with MUI symptoms had a lower PFM resting position (M-Line P = 0.010 and PC/H-line angle P = 0.026) and lower pelvic organ support (urethrovesical junction height P = 0.013) than both continent and SUI women. Women with SUI symptoms were more likely to exhibit bladder neck funneling and a larger posterior urethrovesical angle at rest than both continent and MUI women (P = 0.026 and P = 0.008, respectively). There were no significant differences between groups on PFM MVC or straining. Conclusions Women with SUI and MUI symptoms present different morphological defects at rest. These observations emphasize the need to tailor UI interventions to specific pelvic floor defects and UI type in older women.

Pelvic-Floor Rehabilitation, Part 1 : Comparison of Two Surface Electrode Placements During Stimulation of the Pelvic-Floor Musculature in Women Who Are Continent Using Bipolar Interferential Currents

Background and Purpose. Electrical stimulation of the pelvic floor is used as an adjunct in the conservative treatment of urinary incontinence. No consensus exists, however, regarding electrode placements for optimal stimulation of the pelvic-floor musculature. The purpose of this study was to compare two different bipolar electrode placements, one suggested by Laycock and Green (L2) the other by Dumoulin (D2), during electrical stimulation with interferential currents of the pelvic-floor musculature in continent women, using a two-group crossover design. Subjects. Ten continent female volunteers, ranging in age from 20 to 39 years (X̅=27.3, SD=5.6), were randomly assigned to one of two study groups. Methods. Each study group received neuromuscular electrical stimulation (NMES) of the pelvic-floor musculature using both electrode placements, the order of application being reversed for each group. Force of contraction was measured as pressure (in centimeters of water [cm H2O]) exerted on a vaginal pressure probe attached to a manometer. Data were analyzed using a two-way, mixed-model analysis of variance. Results. No difference in pressure was observed between the two electrode placements. Differences in current amplitude were observed, with the D2 electrode placement requiring less current amplitude to produce a maximum recorded pressure on the manometer. Subjective assessment by the subjects revealed a preference for the D2 electrode placement (7 of 10 subjects). Conclusion and Discussion. The lower current amplitudes required with the D2 placement to obtain recordings comparable to those obtained with the L2 technique suggest a more comfortable stimulation of the pelvic-floor muscles. The lower current amplitudes required also suggest that greater increases in pressure might be obtained with the D2 placement by increasing the current amplitude while remaining within the comfort threshold. These results will help to define treatment guidelines for a planned clinical study investigating the effects of NMES and exercise in the treatment of urinary stress incontinence in women postpartum.

Changes in urethral sphincter size following rehabilitation in older women with stress urinary incontinence

Introduction and hypothesis The purpose of this study was to evaluate the effects of a pelvic floor muscle (PFM) rehabilitation program on the striated urethral sphincter in women over 60 years with stress urinary incontinence (SUI). We hypothesized that the PFM rehabilitation program would also exercise the striated urethral sphincter and that this would be demonstrated by hypertrophy of the sphincter on magnetic resonance imaging (MRI). Methods Women with at least weekly episodes of SUI were recruited. Participants were evaluated before and after a 12-week group PFM rehabilitation intervention with T2-weighted fast-spin-echo MRI sequences recorded in the axial plane at rest to assess urethral sphincter size. Data on SUI symptoms and their bother were also collected. No control group was included. Results Seventeen women participated in the study. The striated urethral sphincter increased significantly in thickness (21 %, p < 0.001), cross-sectional area (20 %, p = 0.003), and volume (12 %, p = 0.003) following the intervention. The reported number of incontinence episodes and their bother also decreased significantly. Conclusions This study appears to demonstrate that PFM training for SUI also trains the striated urethral sphincter and that improvement in incontinence signs and symptoms is associated with sphincter hypertrophy in older women with SUI. These findings support previous ultrasound (US) data showing an increase in urethral cross-sectional area following PFM training and extend the previous findings by more specifically assessing the area of hypertrophy and by demonstrating that older women present the same changes as younger women when assessed using MRI data.

Differences in pelvic floor morphology between continent, stress urinary incontinent, and mixed urinary incontinent elderly women : an MRI study

Aims To compare magnetic resonance imaging (MRI) of the pelvic floor musculature (PFM), bladder neck and urethral sphincter morphology under three conditions (rest, PFM maximal voluntary contraction (MVC), and straining) in older women with symptoms of stress (SUI) or mixed urinary incontinence (MUI) or without incontinence. Methods This 2008–2012 exploratory observational cohort study was conducted with community-dwelling women aged 60 and over. Sixty six women (22 per group), mean age of 67.7 ± 5.2 years, participated in the study. A 3 T MRI examination was conducted under three conditions: rest, PFM MVC, and straining. ANOVA or Kruskal–Wallis tests (data not normally distributed) were conducted, with Bonferroni correction, to compare anatomical measurements between groups. Results Women with MUI symptoms had a lower PFM resting position (M-Line P = 0.010 and PC/H-line angle P = 0.026) and lower pelvic organ support (urethrovesical junction height P = 0.013) than both continent and SUI women. Women with SUI symptoms were more likely to exhibit bladder neck funneling and a larger posterior urethrovesical angle at rest than both continent and MUI women (P = 0.026 and P = 0.008, respectively). There were no significant differences between groups on PFM MVC or straining. Conclusions Women with SUI and MUI symptoms present different morphological defects at rest. These observations emphasize the need to tailor UI interventions to specific pelvic floor defects and UI type in older women.

Protocolo de Treino dos Músculos do Pavimento Pélvico em Mulheres com Incontinência Urinária de Esforço: Revisão Sistemática

Introdução: Os exercícios de fortalecimento dos músculos do pavimento pélvico (EFMPP) são considerados a primeira intervenção no tratamento da incontinência urinária de esforço (IUE), porém os EFMPP são distintos, não existindo evidência sobre os parâmetros de treino. Objetivo: Identificar o protocolo e/ ou os parâmetros de treino dos músculos do pavimento pélvico (MPP) mais eficaz no tratamento da IUE feminina. Método: A pesquisa bibliográfica foi realizada entre janeiro de 1992 a março de 2014 nas bases de dados PubMed, Cochrane Library, PEDro, web of Science e LILACS. Os artigos incluídos eram de língua inglesa, estudos experimentais, no qual comparavam EFMPP com o tratamento placebo, usual ou sem tratamento, com idade compreendida entre os 18 e os 65 anos e diagnóstico de IUE. Os critérios de exclusão abrangeram o diagnóstico de IUE desencadeada por fatores externos ao trato urinário inferior, grávidas, puérperas, prolapso ≥ 2 e outros tipos de IU. A avaliação da qualidade metodológica for realizada através da escala PEDro. Resultados: Sete artigos de elevada qualidade metodológica foram incluídos na presente revisão. A amostra foi constituída por 331 mulheres, com idade média de 44,4 anos, duração média das perdas urinárias de 64 meses e a gravidade da IUE variou entre ligeira a severa. Os programas de EFMPP eram distintos em relação aos parâmetros de treino dos MPP, sendo que alguns estudos incluíram o treino abdominal, supervisão e técnicas adjuvantes. A taxa de curada da quantidade de perda urinária variou entre 28,6 a 80%, enquanto a força dos MPP variou de 15,6% a 161,7%. Conclusão: Na presente revisão sistemática, os EFMPP combinados com palpação digital, biofeedback e cones vaginais parecem ser mais eficazes na redução da quantidade de perda urinária, comparado com os EFMPP isolados ou sem tratamento. Esta revisão permitiu igualmente identificar as 12 semanas de duração da intervenção, 10 repetições por série e diferentes posições, sendo os parâmetros de treino mais consistentes na redução dos sintomas.

Étude comparative de la morphologie du plancher pelvien des femmes âgées continentes et avec incontinence urinaire

But: Cette étude a pour but de comparer : a)la morphologie du plancher pelvien (PP), du col vésical et du sphincter urogénital strié (SUS) par IRM et b) la fonction du PP par palpation digitale (PERFECT scheme) chez les femmes âgées continentes ou avec incontinence urinaire à l’effort (IUE) et mixte (IUM). Méthode: Les femmes ont appris à contracter correctement leur PP et la fonction de leur PP a été évaluée. Une séance d’IRM dynamique 3T a suivi. Résultats: 66 femmes ont participé à l’étude. Les groupes étaient similaires en âge, IMC, nombre d’accouchements vaginaux et d’hystérectomie. La validité et la fidélité des différentes mesures anatomiques utilisées ont été confirmées au début de cette étude. Afin de contrôler l’effet potentiel de la taille du bassin sur les autres paramètres, les femmes ont été appariées par la longueur de leur inlet pelvien. Les femmes avec IUM ont un PP plus bas et un support des organes pelviens plus faible, selon leurs ligne M, angle LPC/Ligne H et hauteur de la jonction urétro-vésicale (UV). Les femmes avec IUE ont un PP similaire à celui des continentes, mais présentent plus d’ouverture du col vésical et un angle UV postérieur plus large au repos que les autres groupes. Il n’y a aucune différence de morphologie du SUS entre les groupes. De plus, selon les résultats du PERFECT scheme, les femmes avec IU ont une force du PP plus faible que les continentes. Les femmes avec IUM montrent aussi une faible élévation des muscles du PP à la contraction. Les femmes avec IUE ont, quant à elle, un problème de coordination à la toux. Conclusion: Les déficits causant l’IUE et l’IUM sont différents, mais supportent tous le rationnel des exercices du PP pour le traitement de l’IUE et l’IUM. Ces résultats supportent le besoin de traitements de rééducation spécifiques aux déficits de chacun des types d’IU.

Prevalência de incontinência urinária e disfunção muscular do assoalho pélvico em primíparas dois anos após parto cesárea: Estudo transversal

CONTEXT AND OBJECTIVE: There is uncertainty in the literature regarding the theory that obstetric events and pelvic floor injuries give rise to lower risk of subsequent urinary incontinence among women delivering via cesarean section than among women delivering vaginally. The objective of this study was to assess the two-year postpartum prevalence of urinary incontinence and pelvic floor muscle dysfunction and the factors responsible for them. DESIGN AND SETTING: Cross-sectional study, conducted in a public university. METHODS: 220 women who had undergone elective cesarean section or vaginal childbirth two years earlier were selected. Their urinary incontinence symptoms were investigated, and their pelvic floor muscle dysfunction was assessed using digital palpation and a perineometer. RESULTS: The two-year urinary incontinence prevalences following vaginal childbirth and cesarean section were 17% and 18.9%, respectively. The only risk factor for pelvic floor muscle dysfunction was weight gain during pregnancy. Body mass index less than 25 kg/m2 and normal pelvic floor muscle function protected against urinary incontinence. Gestational urinary incontinence increased the risk of two-year postpartum urinary incontinence. CONCLUSION: Gestational urinary incontinence was a crucial precursor of postpartum urinary incontinence. Weight gain during pregnancy increased the subsequent risk of pelvic floor muscle dysfunction, and elective cesarean section did not prevent urinary incontinence.

Análise funcional da musculatura do assoalho pélvico pós-parto em mulheres primigestas

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Reprodutividade da avaliação funcional do assoalho pélvico em mulheres multíparas continentes

Pós-graduação em Bases Gerais da Cirurgia - FMB

Avaliação da força muscular do assoalho pélvico em mulheres nulíparas continentes: influência das diferentes posições corporais

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)