Pelvic floor muscle (PFM) dysfunctions are reported to be involved in provoked vestibulodynia (PVD). Although heightened PFM tone has been suggested, the relative contribution of active and passive ...components of tone remains misunderstood. Likewise, alterations in PFM contractility have been scarcely studied.
To compare PFM tone, including the relative contribution of its active and passive components, and muscular contractility in women with PVD and asymptomatic controls.
Fifty-six asymptomatic women and 56 women with PVD participated in the study. The PVD diagnosis was confirmed by a gynecologist based on a standardized examination.
PFM function was evaluated using a dynamometric speculum combined with surface electromyography (EMG). PFM general tone was evaluated in static conditions at different vaginal apertures and during repeated dynamic cyclic stretching. The active contribution of tone was characterized using the ratio between EMG in a static position and during stretching and the proportion of women presenting PFM activation during stretching. Contribution of the passive component was evaluated using resting forces, stiffness, and hysteresis in women sustaining a negligible EMG signal during stretching. PFM contractility, such as strength, speed of contraction, coordination, and endurance, also was assessed during voluntary isometric efforts.
Greater PFM resting forces and stiffness were found in women with PVD compared with controls, indicating an increased general tone. An increased active component also was found in women with PVD because they presented a superior EMG ratio, and a larger proportion of them presented PFM activation during stretching. Higher passive properties also were found in women with PVD. Women with PVD also showed decreased strength, speed of contraction, coordination, and endurance compared with controls.
Findings provide further evidence of the contribution of PFM alterations in the etiology of PVD. These alterations should be assessed to provide patient-centered targeted treatment options.
The use of a validated tool investigating PFM alterations constitutes a strength of this study. However, the study design does not allow the determination of the sequence of events in which these muscle alterations occurred-before or after the onset of PVD.
Findings support the involvement of active and passive components of PFM tone and an altered PFM contractility in women with PVD. Morin M, Binik YM, Bourbonnais D, et al. Heightened Pelvic Floor Muscle Tone and Altered Contractility in Women With Provoked Vestibulodynia. J Sex Med 2017;14:592-600.
Hypertonicity of the pelvic floor (PFH) is a disabling condition with urological, gynecological and gastrointestinal symptoms, sexual problems and chronic pelvic pain, impacting quality of life. ...Pelvic floor physical therapy (PFPT) is a first-line intervention, yet no systematic review on the efficacy of PFPT for the treatment of PFH has been conducted.
To systematically appraise the current literature on efficacy of PFPT modalities related to PFH.
PubMed, Embase, Emcare, Web of Science, and Cochrane databases were searched from inception until February 2020. A manual search from reference lists of included articles was performed. Ongoing trials were reviewed using clinicaltrial.gov. Randomized controlled trials (RCTs), prospective - and retrospective cohorts and case-study analyses were included.
Outcome measures were pelvic floor muscle tone and function, pain reports, sexual function, pelvic floor symptom scores, quality of life and patients’ perceived effect.
The literature search resulted in 10 eligible studies including 4 RCTs, 5 prospective studies, and 1 case study published between 2000 and 2019. Most studies had a high risk of bias associated with the lack of a comparison group, insufficient sample sizes and non-standardized interventions. Six studies were of low and 4 of medium quality. All studies were narratively reviewed. Three of 4 RCTs found positive effects of PFPT compared to controls on five out of 6 outcome measures. The prospective studies found significant improvements in all outcome measures that were assessed. PFPT seems to be efficacious in patients with chronic prostatitis, chronic pelvic pain syndrome, vulvodynia, and dyspareunia. Smallest effects were seen in patients with interstitial cystitis and painful bladder syndrome.
The findings of this systematic review suggest that PFPT can be beneficial in patients with PFH. Further high-quality RCTs should be performed to confirm the effectiveness of PFPT in the treatment of PFH.
van Reijn-Baggen DA, Han-Geurts IJM, Voorham-van der Zalm PJ, et al. Pelvic Floor Physical Therapy for Pelvic Floor Hypertonicity: A Systematic Review of Treatment Efficacy. Sex Med Rev 2022;10:209–230.
Objectives
To assess the extents of pelvic floor descent both during the maximal straining phase and the defecation phase in healthy volunteers and in patients with pelvic floor disorders, studied ...with MR defecography (MRD), and to define specific threshold values for pelvic floor descent during the defecation phase.
Material and methods
Twenty-two patients (mean age 51 ± 19.4) with obstructed defecation and 20 healthy volunteers (mean age 33.4 ± 11.5) underwent 3.0T MRD in supine position using midsagittal T2-weighted images. Two radiologists performed measurements in reference to PCL-lines in straining and during defecation. In order to identify cutoff values of pelvic floor measurements for diagnosis of pathologic pelvic floor descent anterior, middle, and posterior compartments (AC, MC, PC), receiver-operating characteristic (ROC) curves were plotted.
Results
Pelvic floor descent of all three compartments was significantly larger during defecation than at straining in patients and healthy volunteers (
p
< 0.002). When grading pelvic floor descent in the straining phase, only two healthy volunteers showed moderate PC descent (10%), which is considered pathologic. However, when applying the grading system during defecation, PC descent was overestimated with 50% of the healthy volunteers (10 of 20) showing moderate PC descent. The AUC for PC measurements during defecation was 0.77 (
p
= 0.003) and suggests a cutoff value of 45 mm below the PCL to identify patients with pathologic PC descent. With the adapted cutoff, only 15% of healthy volunteers show pathologic PC descent during defecation.
Conclusion
MRD measurements during straining and defecation can be used to differentiate patients with pelvic floor dysfunction from healthy volunteers. However, different cutoff values should be used during straining and during defecation to define normal or pathologic PC descent.
Pelvic floor spasm as a cause of voiding dysfunction Kuo, Tricia L.C; Ng, L.G; Chapple, Christopher R
Current opinion in urology,
2015-July, 2015-Jul, 2015-07-00, 20150701, Letnik:
25, Številka:
4
Journal Article
PURPOSE OF REVIEWPelvic floor disorders can present with lower urinary tract symptoms, bowel, sexual dysfunction, and/or pain. Symptoms of pelvic muscle spasm (nonrelaxing pelvic floor or ...hypertonicity) vary and can be difficult to recognize. This makes diagnosis and management of these disorders challenging. In this article, we review the current evidence on pelvic floor spasm and its association with voiding dysfunction.
RECENT FINDINGSTo distinguish between the different causes of voiding dysfunction, a video urodynamics study and/or electromyography is often required. Conservative measures include patient education, behavioral modifications, lifestyle changes, and pelvic floor rehabilitation/physical therapy. Disease-specific pelvic pain and pain from pelvic floor spasm needs to be differentiated and treated specifically. Trigger point massage and injections relieves pain in some patients. Botulinum toxin A, sacral neuromodulation, and acupuncture has been reported in the management of patients with refractory symptoms.
SUMMARYPelvic floor spasm and associated voiding problems are heterogeneous in their pathogenesis and are therefore often underrecognized and undertreated; it is therefore essential that a therapeutic strategy needs to be personalized to the individual patientʼs requirements. Therefore, careful evaluation and assessment of individuals using a multidisciplinary team approach including a trained physical therapist/nurse clinician is essential in the management of these patients.
Women with pelvic floor disorders (PFDs) typically undergo surgery involving transvaginal mesh implants; however, transvaginal mesh surgery is associated with many adverse events including ...post-surgical pain. Assessment of pain as a symptom is necessary using patient-reported outcome measures (PROMs). This scoping review aimed to describe and compare existing PROMs previously used to measure pain in women with PFDs. A scoping search of Ovid MEDLINE, EMBASE, CINAHL Plus, Ovid PsycInfo, and grey literature was conducted. Studies published in English describing the development, implementation, and application of PFD-associated pain PROMs among adult women before and after pelvic floor surgery were included. From each article, a descriptive summary organised by study first author, publication year, country, setting, aim, study characteristics, and results were extracted. From 2,604 articles identified, 54 studies were included, describing 44 PROMs. Most studies described at least 2 to 3 instruments. The Pelvic Floor Distress Inventory-20 was most commonly described by 12 studies followed by the Patient Global Impression of Improvement scale. Of the 44 PROMs, 27 were condition-specific, of which 9 included items on pain; 17 generic PROMs, 4 of which contained items on pain; and 6 pain-specific PROMs. PROMs identified in our review measured pain not related to PFDs or pelvic floor surgery and quantified the pain experienced. These PROMs did not measure all areas of pain including region, sensation, impact, and triggers. The findings of this review will assist with developing a new pain-specific PROM in this population.
Women with pelvic floor disorders often undergo surgery involving transvaginal mesh, from which they experience debilitating pain. Pain is a major issue impacting women’s lives. Patient-reported outcome measures can be used to assess the pain; however, it is unclear whether existing instruments are relevant.
•Many women with pelvic floor disorders experience pain after pelvic floor surgery.•Pain reduces women’s quality of life.•Pain has previously been measured with quality of life questionnaires.•Existing questionnaires do not measure pain as a symptom of surgical adverse events.•A new pain-specific questionnaire is needed for women with pelvic floor disorders.
Aims
To discuss the advantages and limitation of the different pelvic floor muscle (PFM) dynamometers available, both in research and industry, and to present the extent of variation between them in ...terms of structure, functioning, psychometric properties, and assessment procedures.
Methods
We identified relevant studies from four databases (MEDLINE, Compendex, Web of Science, and Derwent Innovations Index) up to December 2020 using terms related to dynamometry and PFM. In addition, we conducted a hand search of the bibliographies of all relevant reports. Peer‐reviewed papers, conference proceedings, patents and user's manuals for commercial dynamometers were included and assessed by two independent reviewers.
Results
One hundred and one records were included and 23 PFM dynamometers from 15 research groups were identified. From these, 20 were considered as clinical dynamometers (meant for research settings) and three as personal dynamometers (developed by the industry). Overall, significant heterogeneity was found in their structure and functioning, which limits development of normative data for PFM force in women. Further research is needed to assess the psychometric properties of PFM dynamometers and to standardize assessment procedures.
Conclusion
This review points up to the heterogeneity of existing dynamometers and methods of assessing PFM function. It highlights the need to better document their design and assessment protocol methods. Additionally, this review recommends standards for new dynamometers to allow the establishment of normalized data.
Risks of pelvic organ prolapse and urinary incontinence increase after the first vaginal delivery. During the early postpartum period, a time of active regeneration and healing of the pelvic floor, ...women may be particularly vulnerable to greater pelvic floor loading.
This prospective cohort study aimed to determine whether objectively measured moderate to vigorous physical activity in the early postpartum period predicts pelvic floor support and symptoms 1 year after the first vaginal birth.
We enrolled nulliparous women in the third trimester, later excluding those who had a cesarean or preterm delivery. Participants wore triaxial wrist accelerometers at 2 to 3 weeks and 5 to 6 weeks postpartum for ≥4 days. Primary outcomes, assessed 1 year postpartum, included (1) pelvic floor support on Pelvic Organ Prolapse Quantification examination, dichotomized as maximal vaginal descent of <0 cm (better support) vs ≥0 cm (worse support); and (2) pelvic floor symptom burden, considered positive with report of ≥1 bothersome symptom in ≥2 of 6 domains, assessed using the Epidemiology of Prolapse and Incontinence Questionnaire. The primary predictor was average daily moderate to vigorous physical activity. Because we could not eliminate women with pelvic floor changes before pregnancy, we modeled prevalence, rather than risk, ratios for each outcome using modified Poisson regression.
Of 825 participants eligible after delivery, 611 completed accelerometry and 1-year follow-up; 562 completed in-person visits, and 609 completed questionnaires. The mean age was 28.9 years (standard deviation, 5.01). The mean for moderate to vigorous physical activity measured in minutes per day was 57.3 (standard deviation, 25.4) and 68.1 (standard deviation, 28.9) at 2 to 3 weeks and 5 to 6 weeks, respectively. One year postpartum, 53 of 562 participants (9.4%) demonstrated worse vaginal support and 330 of 609 participants (54.2%) met criteria for pelvic floor symptom burden. In addition, 324 (53.1%), 284 (46.6%), 144 (23.6%), and 25 (4.1%) reported secondary outcomes of stress urinary incontinence, overactive bladder, anal incontinence, and constipation, respectively, and 264 (43.4%), 250 (41.0%), and 89 (14.6%) reported no, mild, or moderate to severe urinary incontinence, respectively.
The relationship between moderate to vigorous physical activity and outcomes was not linear. On the basis of plots, we grouped quintiles of moderate to vigorous physical activity into 3 categories: first and second quintiles combined, third and fourth quintiles combined, and fifth quintile. In final multivariable models, compared with women in moderate to vigorous physical activity quintiles 3 and 4, those in the lower 2 (prevalence ratio, 0.55; 95% confidence interval, 0.31–1.00) and upper quintile (prevalence ratio, 0.70; 95% confidence interval, 0.35–1.38)) trended toward lower prevalence of worse support. However, we observed the reverse for symptom burden: compared with women in quintiles 3 and 4, those in the lower 2 (prevalence ratio, 1.20; 95% confidence interval, 1.02–1.41) and upper quintile prevalence ratio 1.34 (95% confidence interval, 1.11–1.61) demonstrated higher prevalence of symptom burden.
Moderate to vigorous physical activity did not predict any of the secondary outcomes. The presence of a delivery factor with potential to increase risk for levator ani muscle injury did not modify the effect of moderate to vigorous physical activity on outcomes.
Except for support, which was worse in women with moderately high levels of activity, early postpartum moderate to vigorous physical activity was either protective or had no effect on other parameters of pelvic floor health. Few women performed substantial vigorous activity, and thus, these results do not apply to women performing strenuous exercise shortly after delivery.
Introduction and hypothesis
Vaginal delivery may lead to levator ani muscle (LAM) injury or avulsion. Episiotomy may reduce obstetric anal sphincter injury in operative vaginal delivery, but may ...increase the risk of LAM injury. Our aim was to assess whether lateral episiotomy in vacuum extraction (VE) in primiparous women causes LAM injury.
Methods
A prospective cohort study of 58 primiparous women with episiotomy nested within an ongoing multicenter randomized controlled trial of lateral episiotomy versus no episiotomy in VE (EVA trial) was carried out in Sweden. LAM injury was evaluated using 3D endovaginal ultrasound 6–12 months after delivery and Levator Ani Deficiency (LAD) score. Episiotomy scar properties were measured. Characteristics were described and compared using Chi-squared tests. We stipulated that if a lateral episiotomy cuts the LAM, ≥50% would have a LAM injury. Among those, ≥50% would be side specific. We compared the observed prevalence with a test of one proportion.
Results
Twelve (20.7%, 95% CI 10.9–32.9) of 58 women had a LAD (
p
< 0.001, compared with the stipulated 50%). Six (50.0%, 95% CI 21.1% to 78.9%) of 12 women had a LAD on the episiotomy side, including those with bilateral LAD (
p
= 1.00). Two (16.7%, 95% CI 2.1% to 48.4%) of 12 women had a LAD exclusively on the episiotomy side (
p
= 0.02).
Conclusions
There was no excessive risk of cutting the LAM while performing a lateral episiotomy. LAD was not seen in women with episiotomies shorter than 18 mm.
Please cite this paper as: Albrich S, Laterza R, Skala C, Salvatore S, Koelbl H, Naumann G. Impact of mode of delivery on levator morphology: a prospective observational study with three‐dimensional ...ultrasound early in the postpartum period. BJOG 2012;119:51–61.
Objective To evaluate morphology and integrity of the levator ani muscle (LAM) with three‐dimensional ultrasound early in the postpartum period.
Design Prospective cross‐sectional observational study.
Setting University hospital in Germany.
Population Women after vaginal delivery and caesarean section with no previous vaginal delivery.
Methods Three‐dimensional perineal ultrasound was performed between 48 and 72 hours postpartum. The axial plane at the level of minimal hiatal dimension and tomographic ultrasound imaging were used to determine LAM biometry and defect.
Main outcome measures Primary outcome was to compare hiatal dimensions and levator defect following vaginal delivery or caesarean section. For secondary outcomes, we evaluated the role of caesarean section in protecting levator integrity, and the possible involvement of the first stage of labour in LAM changes.
Results In all, 157 women participated: 81 (51.6%) following vaginal delivery (70 spontaneous and 11 operative deliveries) and 76 (48.4%) following caesarean section (55 elective and 21 emergency caesarean sections). All biometric indices of the levator were higher after vaginal delivery (P < 0.001), except for LAM thickness. LAM defects were found to be significantly associated with vaginal delivery, with relative risk 7.5 (P < 0.001). Following vaginal delivery, 32 (39.5%) levator defects were found: 27 (38.5%) after spontaneous delivery and five (45.4%) after operative delivery. Four (5.2%) women had a levator defect following emergency caesarean section.
Conclusion Vaginal delivery modifies and damages the LAM: the risk of levator defect after vaginal delivery is more than seven times higher than after caesarean section. Despite this, emergency caesarean section seems to have no complete preventive effect on LAM trauma.
PDF
