Pelvic floor muscle dysfunction at 3D transperineal ultrasound in maternal exposure to gestational diabetes mellitus: A prospective cohort study during pregnancy.

AIM: This study aimed to assess, for the first time, the dynamic morphometry of pelvic floor muscles (PFM) using three-dimensional transperineal ultrasound (3D-TPUS) and its progression at two-time points of gestation between women with and without gestational diabetes mellitus (GDM), and whether the PFM dysfunction is connected to GDM. METHODS: The study comprised 83 consecutive pregnant women with (n = 38) and without (n = 45) GDM screened at 24-30 and 38-40 weeks of gestation. 3D-TPUS and a mobility test were used to quantify PFM dynamic morphometry during maximum contraction and the Valsalva maneuver. RESULTS: When compared to the control group, GDM women had no significant variations in all levator hiatal dimensions at 24-30 weeks of gestation. Meanwhile, women with GDM experienced an increase in levator hiatal area (LHa) (p < 0.000) during PFM contraction and enlargement in LHa (p < 0.001) during Valsalva maneuver (p = 0.010) at 38-40 weeks of gestation. As a result, the mobility index among GDM women had a lower value (p = 0.000). The dynamic morphometry development of PFM in GDM women at two stages during pregnancy revealed a substantial decrease (p = 0.000) in all LHa dimensions of contraction, distension, and mobility. CONCLUSIONS: Using 3D-TPUS, we found that GDM women had a specific pattern of PFM functional changes in the third trimester of pregnancy. These initial findings revealed alterations in PFM functionality, such as decreased contractility, distensibility, or mobility. This dysfunctional PFM could contribute to the long-term development of pelvic floor dysfunction years after a GDM pregnancy.

Impact of gestational diabetes on pelvic floor: A prospective cohort study with three-dimensional ultrasound during two-time points in pregnancy.

AIM: To evaluate the pelvic floor (PF) biometry using three-dimensional ultrasound (US) at two-time points of gestational in pregnant women with gestational diabetes mellitus (GDM). METHODS: A prospective cohort study conducted at the Perinatal Diabetes Research Center including 44 pregnant women with GDM and 66 pregnant women without GDM at 24 to 28 weeks of gestation. Three-dimensional transperineal US was performed at 24 to 28 and 34 to 38 weeks of gestation in the lithotomy position at rest. The axial plane of the minimal Levator hiatal dimensions was used to determine Levator ani muscle and Hiatal area (HA) biometry at 24 to 28 and 34 to 38 weeks of gestation. RESULTS: Of the 110 pregnant women, 100 (90.9%) completed the follow-up at 34 to 38 weeks of gestation. The evaluation by US showed a negative biometric change between the two-time points, during pregnancy in women with GDM; in the HA (ß coefficient: estimative of effect in biometric progression according to GDM diagnosis, using the non-GDM group as reference = -6.76; P = .020), anteroposterior diameter (ß = -5.07; P = .019), and Levator ani thickness (ß = -12.34; P = .005). CONCLUSIONS: Pregnant women with GDM had a significantly lower than expected percentage of changes in biometry of Levator ani thickness and HA from 24 to 28 to 34 to 38 weeks of gestation when compared with the group of pregnant women without GDM. GDM alters the morphology of PF structures assessed by three-dimension US. This reported complication may be implicated in adverse birth outcomes and may play a role in the development of PF dysfunction.

Negative impact of gestational diabetes mellitus on progress of pelvic floor muscle electromyography activity: Cohort study.

BACKGROUND AND OBJECTIVE: Pelvic floor muscles are involved in postural stability, in maintenance intra-abdominal pressure, and on mechanical support for pelvic organ. Gestational Diabetes Mellitus' (GDM) pregnancies complicated by fetal macrosomia, large placenta and polyhydramnios contribute for abrupt and intense increase in maternal intra-abdominal pressure. Our objective was analyze the impact of GDM on pelvic floor muscle (PFM) electromyography (EMG) activity progress from 24-30 to 36-38 weeks of gestation. We conducted a prospective cohort study. PFM EMG was performed in nulliparous or primiparous women with one previous elective cesarean delivery and with or not GDM diagnosed by the American Diabetes Association criteria. A careful explanation of the muscle anatomy and functionality of the PFM was given before EMG assessment. The outcome measures were PFM recruitment and progress from 24-30 to 36-38 weeks of gestation analyzed by the normalized root mean square (RMS) during rest-activity, fast and hold pelvic floor muscle contraction. RESULTS: Fifty-two pregnant women were assigned to 2 groups: the GDM (n = 26) and normoglycemic (NG) (n = 26). The demographic and obstetric data showed homogeneity between the groups. PFM activity progress was decreased in rest-activity (P = 0.042) and hold contraction (P = 0.044) at 36-38 weeks of gestation in the GDM group relative to that in the NG group. CONCLUSION: GDM group showed a progressive decrease in EMG-PFM activity during rest-activity and hold contractions from 24-30 to 36-38 weeks of gestation.

Submaximal pelvic floor muscle contractions: similar bladder-neck elevation, longer duration, less intra-abdominal pressure.

INTRODUCTION AND HYPOTHESIS: An adequate pelvic floor muscle contraction (PFMC) elevates the bladder neck (BN) and stabilizes it during increased intra-abdominal pressure (IAP). A maximal PFMC may increase the IAP and thereby prevent BN elevation. The aim of this study was to assess BN elevation during submaximal and maximal PFMC and their achievable duration. METHODS: We recruited 68 women with stress urinary incontinence and 14 vaginally nulliparous continent controls who were able to perform a PFMC on vaginal palpation. Women were upright and performed a maximal PFMC as long as possible, followed by a submaximal PFMC, controlled by vaginal electromyogram (EMG). BN position was measured with perineal ultrasound, IAP and urethral pressure with a microtip catheter, and breathing with a circular thorax sensor. RESULTS: A submaximal PFMC elevated the bladder neck 4 mm in continent and incontinent women (p = 0.655) and 4.5 vs. 5 mm during maximal PFMC (0.528). Submaximal PFMC was maintained significantly longer than a maximal PFMC (33 vs 12 s) with no difference between groups. A maximal PFMC resulted in BN descent in 29% of continent and 28% of incontinent women, which was not observed during submaximal PFMC. Breathing was normal in 70% of continent and 71% of incontinent women during submaximal PFMC but stopped completely in 21 and 50%, respectively, during maximal PFMC (p = 0.011). IAP increase was significantly greater with maximal PFMC in both groups (24 vs. 9.6 cmH2O and 17 vs. 9 cmH2O, respectively). CONCLUSION: Submaximal PFMC are sufficient to elevate the bladder neck, can be maintained longer, and breathing was not influenced.

Valsalva versus straining: There is a distinct difference in resulting bladder neck and puborectalis muscle position.

AIMS: To assess the effects of the Valsalva manoeuvre versus straining on bladder neck (BN) and puborectalis muscle (PR) position, BN stiffness and pelvic floor muscle (PFM) activation in urinary incontinent women and healthy continent controls. METHODS: We recruited 17 continent and 85 incontinent women. A Microtip transducer measured urethral and vesical/abdominal pressures. A surface EMG electrode attached to a sponge was placed vaginally at the pelvic floor level. BN and PR movements were assessed with perineal ultrasound. Stiffness was calculated as the increase in vesical pressure per descent of BN and PR during manoeuvres. Women were standing and asked to perform a Valsalva against a closed mouth and glottis and thereafter to relax the PFM and strain as if defecating. To demonstrate a difference of 5 mm in PR descent between Valsalva and straining with a power of 80% and α = 0.05, 24 women were necessary. RESULTS: During Valsalva, 71% of continent and 76% of incontinent women demonstrated PFM activation, whereas during straining significantly fewer women activated the PFM (29% and 32%, respectively). During straining, BN and PR muscle descent was significantly greater and stiffness was lower than during Valsalva in both incontinent and continent women. CONCLUSION: Valsalva and straining are different tasks with different PFM activation patterns. The PF is stiffer with Valsalva resulting in better BN support whereas straining leads to more PR and BN descent. These terms should not be used interchangeably and women have to be instructed carefully to allow appropriate interpretation of data.

Bladder-neck effective, integrative pelvic floor rehabilitation program: follow-up investigation.

OBJECTIVES: To evaluate the effectiveness of a pelvic floor rehabilitation program consisting of pelvic floor (PF) and transverse abdominal muscle (TrA) pre-contraction, coordination training and sustained submaximal contractions employing a validated pelvic floor questionnaire. STUDY DESIGN: Fifty-five consecutive women with stress urinary incontinence (n=9), overactive bladder (n=9) or mixed symptoms (n=37) were invited to participate. The German version of the Australian pelvic floor questionnaire was completed by all women before and after treatment, and additional validated improvement and satisfaction scales assessed patient-centered outcome. Individual treatment programs were selected according to the dysfunction evaluated by vaginal palpation and perineal ultrasound. Bladder-neck effective pelvic floor contraction was ensured using perineal ultrasound. Co-contraction of TrA was incorporated. Active integration of the pelvic floor contraction into daily life and individual incontinence triggering activities was practiced (duration, submaximal contraction, maintenance, pre-contraction before breathing, getting up and urgency). RESULTS: Of 46 women with stress urinary incontinence symptoms, 67% and of 46 women with OAB symptoms 78% were improved or cured. Bladder, bowel and sexual function domain scales improved significantly after 1-6 sessions (median 2). Pre-contraction of PF and TrA was routinely performed by 39 of 55 women (71%) resulting in less incontinence. CONCLUSION: The bladder-neck effective, integrative pelvic floor rehabilitation program is highly effective for SUI and OAB. Although PF strengthening with maximal contractions was omitted, these results are comparable with strength programs in the literature. Due to the integration of submaximal PF contractions into daily life and individual incontinence situations, life-long strength training might be unnecessary, and this has to be studied further.

Effect of abdominal and pelvic floor tasks on muscle activity, abdominal pressure and bladder neck.

INTRODUCTION AND HYPOTHESIS: Although the bladder neck is elevated during a pelvic floor muscle (PFM) contraction, it descends during straining. This study aimed to investigate the relationship between bladder neck displacement, electromyography (EMG) activity of the pelvic floor and abdominal muscles and intra-abdominal pressure (IAP) during different pelvic floor and abdominal contractions. METHODS: Nine women without PFM dysfunction performed maximal, gentle and moderate PFM contractions, maximal and gentle transversus abdominis (TrA) contractions, bracing, Valsalva and head lift. Bladder neck position was assessed with perineal ultrasound. PFM and abdominal muscle activities were recorded with a vaginal probe and fine-wire electrodes, respectively. IAP was recorded with a rectal balloon. RESULTS: Bladder neck elevation only occurred during PFM and TrA contractions. PFM EMG and IAP increased during all tasks from 0.5 (gentle TrA) to 45.7 cmH2O (maximal Valsalva). CONCLUSION: Bladder neck elevation was only observed when the activity of PFM EMG was high relative to the IAP increase.