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.

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.

The Effect Of Pelvic Floor Muscle Training Alone Or In Combination With Electrostimulation In The Treatment Of Sexual Dysfunction In Women With Multiple Sclerosis.

Sexual dysfunction (SD) affects up to 80% of multiple sclerosis (MS) patients and pelvic floor muscles (PFMs) play an important role in the sexual function of these patients. The objective of this paper is to evaluate the impact of a rehabilitation program to treat lower urinary tract symptoms on SD of women with MS. Thirty MS women were randomly allocated to one of three groups: pelvic floor muscle training (PFMT) with electromyographic (EMG) biofeedback and sham neuromuscular electrostimulation (NMES) (Group I), PFMT with EMG biofeedback and intravaginal NMES (Group II), and PFMT with EMG biofeedback and transcutaneous tibial nerve stimulation (TTNS) (Group III). Assessments, before and after the treatment, included: PFM function, PFM tone, flexibility of the vaginal opening and ability to relax the PFMs, and the Female Sexual Function Index (FSFI) questionnaire. After treatment, all groups showed improvements in all domains of the PERFECT scheme. PFM tone and flexibility of the vaginal opening was lower after the intervention only for Group II. All groups improved in arousal, lubrication, satisfaction and total score domains of the FSFI questionnaire. This study indicates that PFMT alone or in combination with intravaginal NMES or TTNS contributes to the improvement of SD.

Effect of intravaginal electrical stimulation on pelvic floor muscle strength

The aim of this study was to evaluate the effect of intravaginal electrical stimulation (IES) on pelvic floor muscle (PFM) strength in patients with mixed urinary incontinence (MUI). Between January 2001 and February 2002, 40 MUI women (mean age: 48 years) were studied. Urge incontinence was the predominant symptom; 92.5% also presented mild stress urinary incontinence (SUI). Selection criteria were clinical history and urodynamics. Pre-treatment urodynamic study showed no statistical differences between the groups. Ten percent of the women in each group had involuntary detrusor contractions. Patients were randomly distributed, in a double-blind study, into two groups. Group G 1 (n=20), effective IES, and group G2 (n=20), sham IES, with follow-up at 1 month. The following parameters were studied: (1) clinical questionnaire, (2) examiner's evaluation of perineal muscle strength, (3) objective evaluation of perineal muscle by perineometry, (4) vaginal weight test, and (5) urodynamic study. The IES protocol consisted of three 20-min sessions per week over a 7-week period using a Dualpex Uro 996 at 4 Hz. There was no statistically significant difference in the demographic data of both groups. The number of micturitions per 24 h after treatment was reduced significantly in both groups. Urge incontinence, present in all patients before treatment, was reduced to 15% in G1 and 31.5% in G2 post-treatment. The subjective evaluation of PFM strength demonstrated a significant improvement in G1. Objective evaluation of PFM force by perineometer showed a significant improvement in maximum peak contraction post-treatment in both groups. In the vaginal weight test, there was a significant increase in average number of cone retentions post-treatment in both groups. With regard to satisfaction level, after treatment, 80% of the patients in G1 and 65% of the patients in G2 were satisfied. There was no statistically significant difference between the groups. There was a significant improvement in PFM strength from both effective and sham electrostimulation, questioning the effectiveness of electrostimulation as a monotherapy in treating MUI.

Pelvic-Floor Rehabilitation, Part 2 : Pelvic-Floor Reeducation With Interferential Currents and Exercise in the Treatment of Genuine Stress Incontinence in Postpartum Women : A Cohort Study

Background and Purpose. This descriptive cohort study investigated a physical therapy program of pelvic-floor neuromuscular electrostimulation (NMES) combined with exercises, with the aim of developing a simple, inexpensive, and conservative treatment for postpartum genuine stress incontinence (GSI). Subjects. Eight female subjects with urodynamically established GSI persisting more than 3 months after delivery participated in the study. The subjects ranged in age from 24 to 37 years (X̅=32, SD=4.2). Methods. This was a descriptive multiple-subject cohort study. Each subject received a total of nine treatment sessions during 3 consecutive weeks, consisting of two 15-minute sessions of NMES followed by a 15-minute pelvic-floor muscle exercise program. Patients also practiced daily pelvic-floor exercises during the 3-week treatment period. The treatment intervention was measured using three separate variables. Maximum muscle contractions (pretraining, during training, and posttraining) were measured indirectly as pressure, using perineometry. Urine loss pretraining and posttraining was measured by means of a Pad test. Self-reported frequency of incontinence was recorded daily throughout the period of the study, using a diary. Data were analyzed using a one-way repeated measures analysis of variance (ANOVA), a Wilcoxon signed-ranks test, and a Friedman two-way ANOVA by ranks. Results. The results indicated that maximum pressure generated by pelvic-floor contractions was greater and both the quantity of urine loss and the frequency of incontinence were lower following the implementation of the physical therapy program. Five subjects became continent, and three others improved. A follow-up survey 1 year later confirmed the consistency of these results. Conclusion and Discussion. The results suggest that the proposed physical therapy program may influence postpartum GSI. Further studies are needed to validate this simple, inexpensive, and conservative physical therapy protocol.

Pelvic-Floor Rehabilitation, Part 2 : Pelvic-Floor Reeducation With Interferential Currents and Exercise in the Treatment of Genuine Stress Incontinence in Postpartum Women : A Cohort Study

Background and Purpose. This descriptive cohort study investigated a physical therapy program of pelvic-floor neuromuscular electrostimulation (NMES) combined with exercises, with the aim of developing a simple, inexpensive, and conservative treatment for postpartum genuine stress incontinence (GSI). Subjects. Eight female subjects with urodynamically established GSI persisting more than 3 months after delivery participated in the study. The subjects ranged in age from 24 to 37 years (X̅=32, SD=4.2). Methods. This was a descriptive multiple-subject cohort study. Each subject received a total of nine treatment sessions during 3 consecutive weeks, consisting of two 15-minute sessions of NMES followed by a 15-minute pelvic-floor muscle exercise program. Patients also practiced daily pelvic-floor exercises during the 3-week treatment period. The treatment intervention was measured using three separate variables. Maximum muscle contractions (pretraining, during training, and posttraining) were measured indirectly as pressure, using perineometry. Urine loss pretraining and posttraining was measured by means of a Pad test. Self-reported frequency of incontinence was recorded daily throughout the period of the study, using a diary. Data were analyzed using a one-way repeated measures analysis of variance (ANOVA), a Wilcoxon signed-ranks test, and a Friedman two-way ANOVA by ranks. Results. The results indicated that maximum pressure generated by pelvic-floor contractions was greater and both the quantity of urine loss and the frequency of incontinence were lower following the implementation of the physical therapy program. Five subjects became continent, and three others improved. A follow-up survey 1 year later confirmed the consistency of these results. Conclusion and Discussion. The results suggest that the proposed physical therapy program may influence postpartum GSI. Further studies are needed to validate this simple, inexpensive, and conservative physical therapy protocol.

Analysis of pelvic floor musculature function during pregnancy and postpartum: a cohort study

Aim. To compare the measurements of women`s pelvic floor musculature strength (PFMS) during pregnancy and postpartum period. Background. Pregnancy and childbirth can have an influence on the muscles and pelvic floor and can cause morbidities of women`s genito-urinary tract. Design. A prospective cohort study. Methods. There were included 226 primigravidae women, attended by community health services in the city of Itapecerica da Serra, Sao Paulo, Brazil. The participants were followed in four stages: (1) within 12 weeks of pregnancy; (2) between 36-40 weeks of pregnancy; (3) within 48 hours after childbirth; (4) 42-60 days after childbirth. Data were collected from February 2007-August 2008. The pelvic floor musculature strength was evaluated by perineometry and digital vaginal palpation in stages 1, 2 and 4. The final sample included 110 women who completed all four stages of the study. Results. The pelvic floor musculature strength of the women did not change significantly during pregnancy or after delivery (anova: p = 0 center dot 78). In all three examined stages, a low-intensity pelvic floor musculature strength was prevalent (in mmHg: stage 1 = 15 center dot 9; stage 2 = 15 center dot 2, stage 4 = 14 center dot 7), with scores from 0-3 on the Oxford scale. The pelvic floor musculature strength did not differ in relation to maternal age, skin colour, conjugal status, dyspareunia, stool characteristics, type of delivery, or conditions of the perineum. An interaction between maternal nutritional state and newborn`s weight may affect the pelvic floor musculature strength (manova: p = 0 center dot 04). Conclusion. Pregnancy and childbirth did not reduce significantly pelvic floor musculature strength. The perineometry and digital vaginal palpation used to assess the pelvic floor musculature strength were well accepted by the women. Relevance to clinical practice. In clinical practice, digital vaginal palpation is effective for supporting the diagnosis of urinary, intestinal and sexual dysfunctions. Perineometry use is particularly important together with the performance of perineal exercises with biofeedback in the treatment these disorders.

Contraction of the pelvic floor muscles during abdominal maneuvers

Objective: To determine whether voluntary abdominal muscle contraction is associated with pelvic floor muscle activity. Design: Pelvic floor muscle activity was recorded during contractions of the abdominal muscles at 3 different intensities in supine and standing positions. Setting: Research laboratory. Participants: Six women and 1 man with no histories of lower back pain. Interventions: Not applicable. Main Outcome Measures: Electromyographic activity of the pelvic floor muscles was recorded with surface electrodes inserted into the anus and vagina. These recordings were corroborated by measurements of anal and vaginal pressures. Gastric pressure was recorded in 2 subjects. Results: Pelvic floor muscle electromyography increased with contraction of the abdominal muscles. With strong abdominal contraction, pelvic floor muscle activity did not differ from that recorded during a maximal pelvic floor muscle effort. The pressure recordings confirmed these data. The increase in pressure recorded in the anus and vagina preceded the pressure in the abdomen. Conclusions: In healthy subjects, voluntary activity in the abdominal muscles results in increased pelvic floor muscle activity. The increase in pelvic floor pressure before the increase in the abdomen pressure indicates that this response is preprogrammed. Dysfunction of the pelvic floor muscles can result in urinary and fecal incontinence. Abdominal muscle training to rehabilitate those muscles may be useful in treating these conditions.

Long-Term Effect of Early Postoperative Pelvic Floor Biofeedback on Continence in Men Undergoing Radical Prostatectomy: A Prospective, Randomized, Controlled Trial

Purpose: The impact of pelvic floor muscle training on the recovery of urinary continence after radical prostatectomy is still controversial. We tested the effectiveness of biofeedback-pelvic floor muscle training in improving urinary incontinence in the 12 months following radical prostatectomy. Materials and Methods: A total of 73 patients who underwent radical prostatectomy were randomized to a treatment group (36) receiving biofeedback-pelvic floor muscle training once a week for 3 months as well as home exercises or a control group (37). Patients were evaluated 1, 3, 6 and 12 months postoperatively. Continence was defined as the use of 1 pad or less daily and incontinence severity was measured by the 24-hour pad test. Incontinence symptoms and quality of life were assessed with the International Continence Society male Short Form questionnaire and the Incontinence Impact Questionnaire. Pelvic floor muscle strength was evaluated with the Oxford score. Results: A total of 54 patients (26 pelvic floor muscle training and 28 controls) completed the trial. Duration of incontinence was shorter in the treatment group. At postoperative month 12, 25 (96.15%) patients in the treatment group and 21 (75.0%) in the control group were continent (p = 0.028). The absolute risk reduction was 21.2% (95% CI 3.45-38.81) and the relative risk of recovering continence was 1.28 (95% CI 1.02-1.69). The number needed to treat was 5 (95% CI 2.6-28.6). Overall there were significant changes in both groups in terms of incontinence symptoms, lower urinary tract symptoms, quality of life and pelvic floor muscle strength (p <0.0001). Conclusions: Early biofeedback-pelvic floor muscle training not only hastens the recovery of urinary continence after radical prostatectomy but allows for significant improvements in the severity of incontinence, voiding symptoms and pelvic floor muscle strength 12 months postoperatively.

Influence of visual feedback on pelvic floor muscle strength

Objective: The objective of this study is to evaluate the visual feedback influence on pelvic floor muscle contraction. Study design: Seventeen nulliparous, urinary-continent women participated in this study. Pelvic floor muscle strength with and without the use of visual feedback was measured with a dynamometric speculum in two directions (anteroposterior and left-right). To compare the mean strength values with and without the use of visual feedback, the t test was applied. Results: There was no significant difference between the pelvic floor muscle anteroposterior strength values with and without the use of visual feedback (p = 0.30), and no significant difference for the left-right strength (p = 0.37). Conclusion: There was no difference between the pelvic floor muscle strength values with and without the use of visual feedback. (C) 2010 Elsevier Ireland Ltd. All rights reserved.

Thiele massage as a therapeutic option for women with chronic pelvic pain caused by tenderness of pelvic floor muscles

Aims and objectives Musculoskeletal system has been found to be involved in genesis and perpetuation of chronic pelvic pain (CPP) and has strong evidences that up to 80% of women with CPP present dysfunction of the musculoskeletal system. In this study, we report a series of women with CPP caused by tenderness of pelvic floor muscles successfully treated with Thiele massage. Methods Were included in this study six women with CPP caused by tenderness of the levator ani muscle that underwent transvaginal massage using the Thiele technique, over a period of 5 minutes repeated once a week for 4 weeks. After 1 month, the women returned for follow-up. Results The median tenderness score for the six women evaluated was 3 at the first evaluation and 0 after 1 month of follow-up (P < 0.01). The mean Visual Analogue Scale and McGill Pain Index scores were 8.1 and 34, respectively, at the first evaluation, and 1.5 and 16.6 at follow-up (P < 0.01). Conclusion Thiele massage appears to be very helpful for women with CPP caused by tenderness of the levator ani muscle. However, these results are preliminary and a larger number of women are necessary to obtain more conclusive results.

Comparison of pelvic floor muscle strength between women undergoing vaginal delivery, cesarean section, and nulliparae using a perineometer and digital palpation

Objectives. To compare pelvic floor muscle (PFM) strength between women undergoing vaginal delivery, cesarean section, and nulliparae, investigating the factors associated with PFM strength, and observing the correlation between vaginal digital palpation and use of a perineometer. Methods. A cross-sectional study was conducted, including 31 women following vaginal delivery, 30 women following cesarean section, and 30 nulliparous women. PFM strength was measured by vaginal digital palpation and use of a perineometer. Multiple linear regression analysis with adjustment for covariables was used to compare the mean PFM strength and identify its associated factors. Results. The mean PFM strength of women undergoing vaginal delivery and cesarean section was 25.6 +/- 14.5 cmH(2)O and 39.6 +/- 22.0 cmH(2)O (p < 0.01, adjusted for covariables), respectively. A correlation was observed between measurements of PFM strength obtained by vaginal digital palpation and use of a perineometer (tau = 0.82; p < 0.01). The non-white race/ethnicity was negatively associated with PFM strength (coefficient: -10.2424; p = 0.02). Conclusions. A lower PFM strength was observed in women with a history of vaginal delivery compared to those undergoing cesarean section. Non-white race/ethnicity negatively affected PFM strength. Our data suggest that vaginal digital palpation may be used in clinical practice because of its expressive correlation with use of a perineometer.

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