Online Group-based Pelvic Floor Muscle Training for Urinary Incontinence in Older Women: a Pilot Study.

INTRODUCTION AND HYPOTHESIS: Urinary incontinence (UI) is prevalent among older women, but conservative treatment rates remain low due to limited accessibility, despite evidence supporting pelvic floor muscle training (PFMT) efficacy. Group-based approaches, including online options, could offer cost-effective alternatives. Recent evidence supports the feasibility of online group-based PFMT for treating UI in older women. This pilot study now evaluated the clinical effects of this program on the number of leakage episodes per day, additional UI-specific outcomes, and other symptoms and indicators. METHODS: Community-dwelling women aged 65 and over, with stress or mixed UI, were recruited. Eligibility was assessed through in-person evaluations conducted by pelvic floor physiotherapists, who instructed participants on pelvic floor muscle contraction using digital palpation. Participants engaged in a 12-week group-based PFMT program with weekly 1-h sessions. Data were collected at three time points: recruitment (PRE1), before the first session (PRE2), and after the program (POST). Participants recorded UI symptoms using 7-day bladder diaries and standardized questionnaires on UI symptoms, quality of life (QoL), UI self-efficacy, and perceived costs. After the program (POST), participants provided feedback on their impression of improvement and satisfaction. RESULTS: Participants reported a significant reduction in their number of leakage episodes per day. Standardized questionnaire scores also supported the positive effects of the program on UI symptoms and QoL, self-efficacy in avoiding leakage and performing PFMT exercises, and monthly costs for continence products. Older women expressed high satisfaction with symptom improvement and the program. CONCLUSIONS: Online group-based PFMT improved UI symptoms, QoL, UI self-efficacy, and perceived UI costs among older women. Pragmatic randomized controlled trials are necessary for further validation.

Gynecological Cancer Survivors' Experiences of Dyspareunia and Factors Influencing Care-Seeking Behavior: A Qualitative Study.

Pain during sexual intercourse, also called dyspareunia, affects most women after treatment for gynecological cancer. Previous work adopted a biomedical approach to depict dyspareunia in this population, which provided a narrow perspective of this condition. Taking into account women's experiences of dyspareunia and the factors influencing their care-seeking behaviors would provide insight to improve care in the context of gynecological cancer. The aim of this study was to describe gynecological cancer survivors' experiences of dyspareunia and factors influencing care-seeking behavior. A qualitative study was performed with 28 gynecological cancer survivors with dyspareunia. Individual telephone interviews were conducted based on the Common-Sense Model of Self-Regulation. Interviews were recorded and transcribed for analysis using the interpretative description framework. Concerning their experience, participants reported the oncological treatments as the primary cause of dyspareunia. Loss of libido, lower vaginal lubrication, and smaller vaginal cavity were described as being linked with dyspareunia. Women explained how dyspareunia and these changes had led them to engage less in, and even interrupt, sexual activity. They expressed that they were distressed, felt less of a woman, and experienced low control and/or self-efficacy. Regarding the factors influencing women's care-seeking behaviors, participants emphasized that they were provided with insufficient information and support. Balancing priorities, denial or reluctance, misbeliefs, resignation and acceptance, and negative emotions were reported as barriers, whereas acknowledgement of sexual dysfunction, desire for improvement, awareness of treatment possibilities, willingness to undertake treatment and treatment acceptability were reported as facilitators to seeking care. Findings suggest that dyspareunia is a complex and impactful condition after gynecological cancer. While this study highlights the importance of alleviating the burden of sexual dysfunction in cancer survivors, it identified factors that should be considered in the provision of services to improve care.

Are hypopressive and other exercise programs effective for the treatment of pelvic organ prolapse?

INTRODUCTION AND HYPOTHESIS: Pelvic floor muscle training (PFMT) is effective for the treatment of pelvic organ prolapse (POP), but other exercise programs have also been promoted and used. The aim of this review was to evaluate the effect of hypopressive and other exercise programs besides PFMT for POP. METHODS: A literature search was conducted on Ovid Medline, EMBASE, CINAHL, Cochrane, PEDro, and Scopus databases from January 1996 to 30 December 2021. Only randomized controlled trials (RCTs) were included. The keywords were combinations of "pelvic organ prolapse" or "urogenital prolapse," and "exercise therapy," "hypopressive exercise," "Kegel," "pelvic floor muscle training," "pelvic floor muscle exercises," "Pilates," "treatment," "yoga," "Tai Chi." Methodological quality was assessed using the PEDro rating scale (0-10). RESULTS: Seven RCTs containing hypopressive exercise, yoga or breathing and hip muscle exercises in an inverted position were retrieved and analyzed. PEDro score ranged from 4 to 7. There was no additional effect of adding hypopressive exercise to PFMT, and PFMT was more effective than hypopressive exercise alone. The studies that included the term "yoga" included regular PFMT and thus can be classified as PFMT. Hip exercises in an inverted position added to PFMT vs PFMT alone showed better improvement in some secondary outcomes but not in the primary outcome, POP stage. CONCLUSIONS: There are few RCTs assessing the effects of other exercise programs besides PFMT in the treatment of POP. To date, there is no evidence that other exercise programs are more effective than PFMT for POP.

Acceptability of multimodal pelvic floor physical therapy to treat dyspareunia after gynecological malignancies: a qualitative study of women's views and experiences.

INTRODUCTION AND HYPOTHESIS: Multimodal pelvic floor physical therapy (PFPT) is recommended after gynecological malignancies to treat dyspareunia. However, data to strongly support its implementation in the cancer care continuum are lacking. The aim of this study was to explore the views and experiences of gynecological cancer survivors with dyspareunia regarding the acceptability of multimodal PFPT. METHODS: This qualitative study was conducted with the participants (n = 28) of a study investigating a 12-week multimodal PFPT treatment. Individual semi-structured telephone interviews served to collect qualitative data pertaining to women's views and experiences of the treatment they received. Interviews were recorded and transcribed for analysis using the interpretative description framework. RESULTS: Our cohort described the appropriateness of the treatment in terms of modalities, physical therapist, care delivery, and intensity (Theme 1). While the intensity was reported as demanding by a few, all participants stressed that it was relevant to see significant improvements (Theme 2). In addition to the treatment characteristics and women's beliefs and attitudes, noticing the treatment effects motivated their participation (Theme 2). Women expressed being highly satisfied with the treatment based on their positive experiences and the balance between their efforts and the results they obtained (Theme 3). As a result, they all recommended this treatment (Theme 3). CONCLUSIONS: This is the first study to examine the acceptability of multimodal PFPT in the context of gynecological malignancies. This treatment was found acceptable and can be offered to gynecological cancer survivors.

Strenuous physical activity, exercise, and pelvic organ prolapse: a narrative scoping review.

INTRODUCTION AND HYPOTHESIS: High-intensity physical activity and exercise have been listed as possible risk factors for pelvic organ prolapse (POP). The aim of the present study is to conduct a literature review on the prevalence and incidence of POP in women who engage in regular physical activity. In addition, we review the effects of a single exercise or a single session of exercise on pelvic floor support. Finally, the effect of exercises on POP in the early postpartum period is reviewed. METHODS: This is a narrative scoping review. We searched PubMed and Ovid Medline, the Physiotherapy Evidence Database (PEDro), and the Cochrane Database of Systematic Reviews up to May 2022 with the following MeSH terms: "physical activity" AND "exercise" AND "pelvic floor" AND "pelvic organ prolapse". RESULTS: Eight prevalence studies were retrieved. Prevalence rates of symptomatic POP varied between 0 (small study within different sports) and 23% (Olympic weightlifters and power lifters). Parity was the only factor associated with POP in most studies. Three studies evaluated the pelvic floor after a single exercise or one session of exercise and found increased vaginal descent or increased POP symptoms. One prospective cohort study reported the development of POP after 6 weeks of military parashot training, and one randomized trial reported increased POP symptoms after transverse abdominal training. There is scant knowledge on exercise and POP in the postpartum period. CONCLUSIONS: Prevalence of POP in sports varies widely. Experimental and prospective studies indicate that strenuous exercise increased POP symptoms and reduced pelvic floor support.

International urogynecology consultation chapter 3 committee 2; conservative treatment of patient with pelvic organ prolapse: Pelvic floor muscle training.

INTRODUCTION AND HYPOTHESIS: This manuscript from Chapter 3 of the International Urogynecology Consultation (IUC) on Pelvic Organ Prolapse (POP) describes the current evidence and suggests future directions for research on the effect of pelvic floor muscle training (PFMT) in prevention and treatment of POP. METHODS: An international group of four physical therapists, four urogynecologists and one midwife/basic science researcher performed a search of the literature using pre-specified search terms on randomized controlled trials (RCTs) in Ovid Medline, EMBASE, CINAHL, Cochrane, PEDro and Scopus databases for publications between 1996 and 2021. Full publications or expanded abstracts in English or in other languages with abstracts in English were included. The PEDro rating scale (0-10) was used to evaluate study quality. Included RCTs were reviewed to summarize the evidence in six key sections: (1) evidence for PFMT in prevention of POP in the general female population; (2) evidence for early intervention of PFMT in the peripartum period for prevention and treatment of POP; (3) evidence for PFMT in treatment of POP in the general female population; (4) evidence for perioperative PFMT; (5) evidence for PFMT on associated conditions in women with POP; (6) evidence for the long-term effect of PFMT on POP. Full publications in English or in other languages with abstracts in English and expanded abstracts presented at international condition specific societies were included. Internal validity was examined by the PEDro rating scale (0-10). RESULTS: After exclusion of duplicates and irrelevant trials, we classified and included 2 preventive trials, 4 trials in the post-partum period, 11 treatment trials of PFMT for POP in the general female population in comparison with no treatment or lifestyle interventions, 10 on PFMT as an adjunct treatment to POP surgery and 9 long-term treatment trials. Only three treatment studies compared PFMT with the use of a pessary. The RCTs scored between 4 and 8 on the PEDro scale. No primary prevention studies were found, and there is sparse and inconsistent evidence for early intervention in the postpartum period. There is good evidence/recommendations from 11 RCTs that PFMT is effective in reducing POP symptoms and/or improving POP stage (by one stage) in women with POP-Q stage I, II and III in the general female population, but no evidence from 9/10 RCTs that adding PFMT pre- and post -surgery for POP is effective. There are few long-term follow-up studies, and results are inconsistent. There are no serious adverse effects or complications reported related to PFMT. CONCLUSIONS: There are few studies on prevention and in the postpartum period, and the effect is inconclusive. There is high-level evidence from 11 RCTs to recommend PFMT as first-line treatment for POP in the general female population. PFMT pre- and post-POP surgery does not seem to have any additional effect on POP. PFMT is effective and safe but needs thorough instruction and supervision to be effective.

Multimodal physical therapy versus topical lidocaine for provoked vestibulodynia: a multicenter, randomized trial.

BACKGROUND: Provoked vestibulodynia is the most common subtype of chronic vulvar pain. This highly prevalent and debilitating condition is characterized by acute recurrent pain located at the entry of the vagina in response to pressure application or attempted vaginal penetration. Although physical therapy is advocated as a first-line treatment for provoked vestibulodynia, evidence supporting its efficacy is scarce. OBJECTIVE: The purpose of this study was to establish the efficacy of multimodal physical therapy compared with topical lidocaine, a frequently used first-line treatment. STUDY DESIGN: We conducted a multicenter, parallel-group, randomized clinical trial in women diagnosed as having provoked vestibulodynia recruited from the community and 4 Canadian university hospitals. Women were randomly assigned (1:1) to receive either weekly sessions of physical therapy or overnight topical lidocaine (5% ointment) for 10 weeks. Randomization was stratified by center using random permuted blocks from a computer-generated list managed by an independent individual. Physical therapy entailed education, pelvic floor muscle exercises with biofeedback, manual therapy, and dilation. Assessments were conducted at baseline, posttreatment, and 6-month follow-up. Outcome assessors, investigators, and data analysts were masked to allocation. The primary outcome was pain intensity during intercourse evaluated with the numeric rating scale (0-10). Secondary outcomes included pain quality (McGill-Melzack Pain Questionnaire), sexual function (Female Sexual Function Index), sexual distress (Female Sexual Distress Scale), satisfaction (numeric rating scale of 0-10), and participants' impression of change (Patient Global Impression of Change). Intention-to-treat analyses were conducted using piecewise linear-growth models. RESULTS: Among 212 women who were recruited and randomized, 201 (95%) completed the posttreatment assessment and 195 (92%) completed the 6-month follow-up. Multimodal physical therapy was more effective than lidocaine for reducing pain intensity during intercourse (between-group pre-post slope difference, P<.001; mean group postdifference, 1.8; 95% confidence interval, 1.2-2.3), and results were maintained at 6-month follow-up (mean group difference, 1.8; 95% confidence interval, 1.2-2.5). The physical therapy group also performed better than the lidocaine group in all secondary outcomes (pain quality, sexual function, sexual distress, satisfaction, and participants' impression of change) at posttreatment and 6-month follow-up. Moreover, the changes observed after physical therapy were shown to be clinically meaningful. Regarding participants' impression of change, 79% of women in the physical therapy group reported being very much or much improved compared with 39% in the lidocaine group (P<.001). CONCLUSION: The findings provide strong evidence that physical therapy is effective for pain, sexual function, and sexual distress and support its recommendation as the first-line treatment of choice for provoked vestibulodynia.

A Prospective Single-Arm Study Evaluating the Effects of a Multimodal Physical Therapy Intervention on Psychosexual Outcomes in Women With Dyspareunia After Gynecologic Cancer.

BACKGROUND: Dyspareunia affects most women after treatment for gynecologic malignancies. However, to date, evidence-based interventions remain limited and no study has examined the effects of multimodal physical therapy on psychosexual outcomes in these patients. AIM: To assess the effects of multimodal physical therapy on psychosexual outcomes including sexual distress, body image concerns, pain anxiety, pain catastrophizing, pain self-efficacy and depressive symptoms in women with dyspareunia after treatment for gynecologic malignancies. METHODS: Thirty-one gynecologic cancer survivors with dyspareunia enrolled in this prospective single-arm interventional study. The participants undertook 12 weekly sessions of physical therapy incorporating education, pelvic floor muscle exercises with biofeedback, manual therapy and home exercises. Outcome measures were evaluated pre- and post-treatment. Paired t-tests were conducted to investigate the changes from pre-treatment (P-value Ë‚ 0.05) while effect sizes (Cohen's d) were calculated to measure the magnitude of the change. MAIN OUTCOME MEASURES: Sexual distress (Female Sexual Distress Scale-Revised), body image concerns (Body Image Scale), pain anxiety (Pain Anxiety Symptoms Scale), pain catastrophizing (Pain Catastrophizing Scale), pain self-efficacy (Painful Intercourse Self-Efficacy Scale) and depressive symptoms (Beck Depression Inventory-II). RESULTS: Significant changes were found from pre- to post-treatment for all psychosexual outcomes. Women reported reductions in sexual distress (P Ë‚ 0.001, d = 1.108), body image concerns (P Ë‚ 0.001, d = 0.829), pain anxiety (P Ë‚ 0.001, d = 0.980), pain catastrophizing (P Ë‚ 0.001, d = 0.968) and depression symptoms (P = 0.002, d = 0.636) with an increase in pain self-efficacy (P Ë‚ 0.001, d ≥ 0.938) following the intervention. CLINICAL IMPLICATIONS: The results suggest that multimodal physical therapy significantly improves sexual distress, body image concerns, pain anxiety, pain catastrophizing, pain self-efficacy and depressive symptoms in our sample of women with dyspareunia after treatment for gynecologic malignancies. The medium to large effect sizes obtained with the high proportion of women presenting meaningful changes according to the known minimal clinically important difference or clinical cut-off underlines the significance of these effects. STRENGTHS & LIMITATIONS: The current study used validated questionnaires to assess the psychosexual outcomes of a well-designed physical therapy intervention using multiple modalities to address the multifaceted aspect of dyspareunia in cancer survivors. This study did not include a control group, which may limit drawing definitive conclusions. CONCLUSION: Findings showed that multimodal physical therapy yielded significant improvements in psychosexual outcomes in gynecologic cancer survivors with dyspareunia. A randomized controlled trial is indicated to confirm these results. Cyr M-P, Dumoulin C, Bessette P, et al. A Prospective Single-Arm Study Evaluating the Effects of a Multimodal Physical Therapy Intervention on Psychosexual Outcomes in Women With Dyspareunia After Gynecologic Cancer. J Sex Med 2021;18:946-954.

Pelvic floor morphometrical and functional changes immediately after pelvic floor muscle training and at 1-year follow-up, in older incontinent women.

AIMS: To compare the effects of group-based and individual physiotherapy for stress or mixed urinary incontinence (UI) on pelvic floor morphometry, pelvic floor muscle (PFM) function, and related self-efficacy, immediately after treatment and at 1 year. METHODS: This is a planned secondary analysis of the group rehabilitation or individual physiotherapy study, an assessor-blinded, randomized, noninferiority trial. Eligible participants included 362 community-dwelling older women with symptoms of stress/mixed UI. After learning how to contract PFMs, participants completed 12 weeks of PFM training, either individually (one-on-one) or as part of a group (eight women). Pelvic floor transperineal ultrasound volumes (morphometry), PFM intravaginal dynamometric data (function), and self-efficacy in performing PFM exercises were acquired at baseline, posttreatment, and at 1 year. RESULTS: Groups were comparable at all time points. Immediately posttreatment, both groups demonstrated significant changes in pelvic floor morphometry during coughs, and in PFM function during contractions and coughs. Participants also reported improved self-efficacy in performing PFM exercises. Results were sustained at 1 year. When participants coughed, pelvic floor structures were better supported (reflected by less caudal movement of the puborectalis sling and a smaller opening of the levator hiatus) in a pattern consistent with the "knack" strategy. Furthermore, both interventions resulted in stronger, faster, more coordinated, and more endurant PFMs. CONCLUSION: In older women with stress or mixed UI, both individual and group-based PFM training resulted in comparable improvements in overall PFM function, pelvic floor morphometry during coughs, and related self-efficacy in performing PFM exercises, which were sustained at 1 year.

Feasibility, acceptability and effects of multimodal pelvic floor physical therapy for gynecological cancer survivors suffering from painful sexual intercourse: A multicenter prospective interventional study.

OBJECTIVES: Painful sexual intercourse (dyspareunia) is a distressing condition affecting a large proportion of gynecological cancer survivors, yet treatments remain limited and poorly studied. This multicenter prospective interventional study examined the feasibility, acceptability and effects of multimodal pelvic floor physical therapy in gynecological cancer survivors with dyspareunia. METHODS: Thirty-one endometrial and cervical cancer survivors with dyspareunia participated in 12 weekly 60-min physical therapy sessions combining education, manual therapy, pelvic floor muscle exercises using biofeedback and home exercises, which included the use of a dilator. The adherence rate to home exercises (≥80%), the attendance rate at physical therapy sessions (≥80% of participants attending ≥10 sessions) and the dropout rate (˂15%) served as feasibility and acceptability outcomes and benchmarks. Pain intensity, pain quality, sexual function, pelvic floor dysfunction symptoms and quality of life were measured at baseline and post-treatment. Treatment satisfaction and participants' perceived improvement were also assessed. RESULTS: The adherence rate was 88% (SD 10), 29/31 (94%) women attended ≥10 treatment sessions, and the dropout rate was 3%. Moreover, women experienced significant improvements in all outcomes after the intervention (p ≤ 0.044). They also reported being highly satisfied with the treatment (9.3/10 (SD 1.2)), and 90% of them were very much or much improved. CONCLUSIONS: Our findings support the feasibility and acceptability of multimodal pelvic floor physical therapy for gynecological cancer survivors with dyspareunia. The intervention also led to significant improvements in pain, sexual function, pelvic floor dysfunction symptoms and quality of life. A randomized controlled trial is needed to confirm these results.

Efficiency and Cost: E-Recruitment Is a Promising Method in Gynecological Trials.

BACKGROUND: Recruitment of participants is crucial to the success of any trial as it can have a major impact on study costs, the duration of the study itself, and, more critically, trial failure. Given that vulvodynia particularly affects young women, the use of social media and e-recruitment could prove efficient for enrollment. AIM: To compare the efficiency, effectiveness, and cost-effectiveness of three different recruitment methods. METHODS: The comparison data were collected as part of a bicentric randomized controlled trial evaluating the efficacy of physiotherapy in comparison with topical lidocaine in 212 women suffering from provoked vestibulodynia. The recruitment methods included: (i) conventional methods (eg, posters, leaflets, business cards, newspaper ads); (ii) health professional referrals, and (iii) e-recruitment (eg, Facebook ads and web initiatives). Women interested in participating were screened by telephone for eligibility criteria and were assessed by a gynecologist to confirm their diagnosis. Once included, structured interviews were undertaken to describe their baseline characteristics. MAIN OUTCOME MEASURES: The outcomes of this study were the recruitment efficiency (the number of patients screened/enrolled), recruitment effectiveness (the number of participants enrolled), cost-effectiveness (cost per enrolled participant), and retention rate, and baseline characteristics of participants were monitored for each method. RESULTS: The conventional methods (n = 101, 48%) were more effective as they allowed for greater enrollment of participants, followed by e-recruitment (n = 60, 28%) and health professional referrals (n = 33, 16%) (P < 0.007). Recruitment efficiency was found to be similar for e-recruitment and referrals (60/122 and 33/67, 49%, P = 0.055) but lower for conventional methods (101/314, 32%, P < 0.011). Nonsignificant differences were found between the three groups for baseline characteristics (P ≥ 0.189) and retention rate (91%, P ≥ 0.588). The average cost per enrolled participant was fairly similar for e-recruitment ($117) and conventional methods ($110) and lower for referrals ($60). CLINICAL IMPLICATIONS: Our results suggest that having a variety of recruitment methods is beneficial in promoting clinical trial recruitment without affecting participant characteristics and retention rates. STRENGTH & LIMITATIONS: Although recruitment methods were used concomitantly, this study gives an excellent insight into the advantages and limitations of recruitment methods owing to a large sample size. CONCLUSION: The study findings revealed that e-recruitment is a valuable recruitment method because of its comparable efficiency and cost-effectiveness to health professional referrals and conventional methods, respectively. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, number NCT01455350. Benoit-Piau J, Dumoulin C, Carroll MS, et al. Efficiency and Cost: E-Recruitment Is a Promising Method in Gynecological Trials. J Sex Med 2020;17:1304-1311.

What do we really know about the role of caffeine on urinary tract symptoms? A scoping review on caffeine consumption and lower urinary tract symptoms in adults.

AIMS: The purpose of this scoping review was to map out the existing literature on caffeine intake and lower urinary tract symptoms (LUTS) in adults. METHODS: In this scoping review, we searched for all studies available until June 2019 in MEDLINE, Embase, CINAHL, Cochrane Central Register, PsycINFO, LILACS, LiSSa, Web of Science, and Joanna Briggs Institute electronic databases, in addition to a hand search of the bibliographies of all relevant articles and a gray literature search. Both intervention studies on the effects of caffeine reduction in adults with LUTS and observational studies on the association between caffeine intake and LUTS-related outcomes in adults were included and assessed for methodological quality by two independent reviewers. RESULTS: Fourteen intervention and 12 observational studies were included. Overall, there was a decrease in urgency episodes (level of evidence 2, grade of recommendation B) and nocturnal enuresis episodes (4, C) with caffeine reduction. Observational studies reported an unclear association between caffeine intake and LUTS-related outcomes. Most importantly, this present review highlighted high heterogeneity in the studied populations, caffeine measures, and reported outcomes. There was also unknown or high risk of bias in most identified studies. CONCLUSIONS: Caffeine reduction appears to reduce LUTS. Future studies on caffeine reduction interventions should target populations with urgency and urge urinary incontinence, which show the most promising results, and include valid and reliable measures of caffeine intake and LUTS. Finally, future studies should also use reporting guidelines to ensure lower risk of bias.

Pelvic Floor Muscle Morphometry and Function in Women With Primary and Secondary Provoked Vestibulodynia.

INTRODUCTION: Provoked vestibulodynia (PVD) can be categorized as primary PVD affecting women from their first sexual intercourse or secondary PVD, which appears after a period of pain-free intercourse. There is growing evidence that these subgroups may be distinct entities presenting different pathophysiological mechanisms. Although there are documented pelvic floor muscle alterations in provoked vestibulodynia, no study has yet evaluated whether the pelvic floor muscle morphometry or function differed between women with primary and secondary provoked vestibulodynia. AIM: To assess and compare pelvic floor muscle morphometry and function in women with primary and secondary provoked vestibulodynia. METHODS: A total of 212 women with provoked vestibulodynia (primary = 75 and secondary = 137) participated in the study after completing a gynecologic exam to confirm their diagnosis. MAIN OUTCOME MEASURE: Pelvic floor muscle morphometry was evaluated at rest and during maximal contraction using 3D/4D transperineal ultrasound and pelvic floor muscle function (tone, strength, speed of contraction, endurance) was assessed with a dynamometric speculum. RESULTS: Pelvic floor muscle morphometry at rest and during contraction was not statistically different between women with primary and secondary provoked vestibulodynia (P > .327 adjusted for the duration of symptoms; P > .137 unadjusted t-tests). Regarding pelvic floor muscle function assessed with the dynamometric speculum, no differences were found in tone, strength, speed of contraction, endurance between the 2 groups (P > .144 adjusted for duration of symptoms; P > .118 unadjusted t-tests). CLINICAL IMPLICATIONS: Women with primary and secondary PVD do not differ on pelvic floor muscle morphometric or dynamometric characteristics, suggesting that physical therapy modalities should be offered to both subgroups of PVD. STRENGTHS & LIMITATIONS: The current study used a large and mixed clinical and community sample providing more representative findings. Moreover, the analyses were adjusted for relevant variables such as duration of symptoms. Although the inclusion of nulliparous women below 45 years of age ensured the homogeneity of the sample, it may limit the external validity. CONCLUSION: These findings suggest that primary and secondary subgroups of provoked vestibulodynia cannot be differentiated by morphometric or dynamometric characteristics. Pelvic floor muscles alterations in provoked vestibulodynia are therefore not influenced by the onset of the symptoms. Fontaine F, Dumoulin C, Bergeron S, et al. Pelvic floor muscle morphometry and function in women with primary and secondary provoked vestibulodynia. J Sex Med 2018;15:1149-1157.

Test-retest reliability of clitoral blood flow measurements using color Doppler ultrasonography at rest and after a pelvic floor contraction task in healthy adult women.

AIMS: Test-retest reliability assessment of the dorsal clitoral artery's blood flow at rest and after muscle activation has never been documented. If this outcome measure is to be used in conditions impeding vascularity, it requires a psychometric evaluation. The aim of this study was to assess the inter-session test-retest reliability of clitoral blood flow in healthy women using color Doppler ultrasonography at rest and after a pelvic floor muscle (PFM) contraction task. METHODS: Two assessment sessions were conducted using a clinical ultrasound system. Clitoral blood flow measurements were repeated at rest and after a PFM contraction task. Measurements of the peak systolic velocity (PSV), time-averaged maximum velocity (TAMX), end-diastolic velocity (EDV), pulsatility index (PI), and resistance index (RI) were taken. The test-retest reliability was assessed using paired t-test, intraclass correlation coefficient (ICC), and Bland-Altman plots. RESULTS: For reliability at rest, ICC values were 0.95 for PSV, 0.87 for TAMX, and 0.67 for both PI and RI. The variability between measurements, as per Bland-Altman plots, was small for PSV, TAMX, and RI and acceptable for PI. For reliability after the PFM contractions task, ICC values were 0.85 for PSV, 0.77 for TAMX, 0.79 for PI, and 0.81 for RI. The variability between measurements was small for PSV and RI and acceptable for TAMX and PI. EDV parameter did not perform as well in both conditions. CONCLUSIONS: Assessment of the clitoral blood flow with color Doppler ultrasound is reliable at rest and after a PFM contraction task.

The association between lower urinary tract symptoms and falls: Forming a theoretical model for a research agenda.

BACKGROUND: There is a well-recognised association between falls and lower urinary tract symptoms (LUTS) in older adults, with estimates of odd ratios for falls in the presence of LUTS ranging between 1.5 and 2.3. Falls and LUTS are both highly prevalent among older people and both are markers of frailty, with significant associated morbidity, mortality, and healthcare resource cost. This association is not well examined or explained in the literature. AIMS: We aimed to outline current knowledge of the association between falls and lower urinary tract symptoms and suggest a research program to further investigate this. MATERIALS AND METHODS: A consensus conference of experts in the field was convened to review the current literature and brainstorm potential future investigative avenues. RESULTS AND DISCUSSION: Despite the recognition of this association, there has been little research to examine its potential causes, and no intervention trial has established if reducing LUTS or urinary incontinence can reduce the risk of falls. The commonly held assumption that urgency causes falls through rushing to the toilet is likely incorrect. Falls and LUTS are both symptoms of frailty and have many common causes. Gait, balance, and continence are all processes requiring cognitive input, and the concept of dual tasking may be a further link. CONCLUSION: The significant association between lower urinary tract symptoms and falls is currently unexplained, and further research into the potential causes of this association is needed.

Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women.

BACKGROUND: Pelvic floor muscle training (PFMT) is the most commonly used physical therapy treatment for women with stress urinary incontinence (SUI). It is sometimes also recommended for mixed urinary incontinence (MUI) and, less commonly, urgency urinary incontinence (UUI).This is an update of a Cochrane Review first published in 2001 and last updated in 2014. OBJECTIVES: To assess the effects of PFMT for women with urinary incontinence (UI) in comparison to no treatment, placebo or sham treatments, or other inactive control treatments; and summarise the findings of relevant economic evaluations. SEARCH METHODS: We searched the Cochrane Incontinence Specialised Register (searched 12 February 2018), which contains trials identified from CENTRAL, MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, WHO ICTRP, handsearching of journals and conference proceedings, and the reference lists of relevant articles. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials in women with SUI, UUI or MUI (based on symptoms, signs or urodynamics). One arm of the trial included PFMT. Another arm was a no treatment, placebo, sham or other inactive control treatment arm. DATA COLLECTION AND ANALYSIS: At least two review authors independently assessed trials for eligibility and risk of bias. We extracted and cross-checked data. A third review author resolved disagreements. We processed data as described in the Cochrane Handbook for Systematic Reviews of Interventions. We subgrouped trials by diagnosis of UI. We undertook formal meta-analysis when appropriate. MAIN RESULTS: The review included 31 trials (10 of which were new for this update) involving 1817 women from 14 countries. Overall, trials were of small-to-moderate size, with follow-ups generally less than 12 months and many were at moderate risk of bias. There was considerable variation in the intervention's content and duration, study populations and outcome measures. There was only one study of women with MUI and only one study with UUI alone, with no data on cure, cure or improvement, or number of episodes of UI for these subgroups.Symptomatic cure of UI at the end of treatment: compared with no treatment or inactive control treatments, women with SUI who were in the PFMT groups were eight times more likely to report cure (56% versus 6%; risk ratio (RR) 8.38, 95% confidence interval (CI) 3.68 to 19.07; 4 trials, 165 women; high-quality evidence). For women with any type of UI, PFMT groups were five times more likely to report cure (35% versus 6%; RR 5.34, 95% CI 2.78 to 10.26; 3 trials, 290 women; moderate-quality evidence).Symptomatic cure or improvement of UI at the end of treatment: compared with no treatment or inactive control treatments, women with SUI who were in the PFMT groups were six times more likely to report cure or improvement (74% versus 11%; RR 6.33, 95% CI 3.88 to 10.33; 3 trials, 242 women; moderate-quality evidence). For women with any type of UI, PFMT groups were two times more likely to report cure or improvement than women in the control groups (67% versus 29%; RR 2.39, 95% CI 1.64 to 3.47; 2 trials, 166 women; moderate-quality evidence).UI-specific symptoms and quality of life (QoL) at the end of treatment: compared with no treatment or inactive control treatments, women with SUI who were in the PFMT group were more likely to report significant improvement in UI symptoms (7 trials, 376 women; moderate-quality evidence), and to report significant improvement in UI QoL (6 trials, 348 women; low-quality evidence). For any type of UI, women in the PFMT group were more likely to report significant improvement in UI symptoms (1 trial, 121 women; moderate-quality evidence) and to report significant improvement in UI QoL (4 trials, 258 women; moderate-quality evidence). Finally, for women with mixed UI treated with PFMT, there was one small trial (12 women) reporting better QoL.Leakage episodes in 24 hours at the end of treatment: PFMT reduced leakage episodes by one in women with SUI (mean difference (MD) 1.23 lower, 95% CI 1.78 lower to 0.68 lower; 7 trials, 432 women; moderate-quality evidence) and in women with all types of UI (MD 1.00 lower, 95% CI 1.37 lower to 0.64 lower; 4 trials, 349 women; moderate-quality evidence).Leakage on short clinic-based pad tests at the end of treatment: women with SUI in the PFMT groups lost significantly less urine in short (up to one hour) pad tests. The comparison showed considerable heterogeneity but the findings still favoured PFMT when using a random-effects model (MD 9.71 g lower, 95% CI 18.92 lower to 0.50 lower; 4 trials, 185 women; moderate-quality evidence). For women with all types of UI, PFMT groups also reported less urine loss on short pad tests than controls (MD 3.72 g lower, 95% CI 5.46 lower to 1.98 lower; 2 trials, 146 women; moderate-quality evidence).Women in the PFMT group were also more satisfied with treatment and their sexual outcomes were better. Adverse events were rare and, in the two trials that did report any, they were minor. The findings of the review were largely supported by the 'Summary of findings' tables, but most of the evidence was downgraded to moderate on methodological grounds. The exception was 'participant-perceived cure' in women with SUI, which was rated as high quality. AUTHORS' CONCLUSIONS: Based on the data available, we can be confident that PFMT can cure or improve symptoms of SUI and all other types of UI. It may reduce the number of leakage episodes, the quantity of leakage on the short pad tests in the clinic and symptoms on UI-specific symptom questionnaires. The authors of the one economic evaluation identified for the Brief Economic Commentary reported that the cost-effectiveness of PFMT looks promising. The findings of the review suggest that PFMT could be included in first-line conservative management programmes for women with UI. The long-term effectiveness and cost-effectiveness of PFMT needs to be further researched.

Test-retest reliability of internal pudendal artery blood flow using color Doppler ultrasound in healthy women.

INTRODUCTION AND HYPOTHESIS: The internal pudendal artery (IPA) is one of the main arteries supplying the pelvic floor muscles (PFMs) and vulvo-vaginal tissues. Its assessment with color Doppler ultrasound has been documented previously, but the reliability of IPA measurements has never been assessed. This study evaluates the test-retest reliability of IPA blood flow parameters measured by color Doppler ultrasound under two conditions: at rest and after a PFM contraction task. METHODS: Twenty healthy women participated in this study. One observer performed two measurement sessions using a clinical ultrasound system with a curved-array probe on the participant's gluteal area. IPA measurements were repeated: at rest and after a PFM contraction task. Peak systolic velocity (PSV), time-averaged maximum velocity (TAMX), end-diastolic velocity (EDV), pulsatility index (PI), and resistance index (RI) were measured. Test-retest reliability was assessed using a paired t test, intraclass correlation coefficient (ICC), and Bland and Altman plots. RESULTS: There was no significant difference for all IPA blood flow measurements between the two repeated sessions. At rest, reliability was excellent for PSV and TAMX and the variability between measurements, as per Bland and Altman plots, was small. After PFM contractions, reliability was excellent for PSV and TAMX and fair to good for PI. The variability between measurements was small for PSV and acceptable for TAMX and PI. EDV and RI parameters did not perform as well. CONCLUSION: The assessment of IPA blood flow with color Doppler ultrasound to evaluate vascular change in women is reliable.

Pelvic floor morphometry and function in women with and without puborectalis avulsion in the early postpartum period.

BACKGROUND: Pelvic floor muscles are subject to considerable stretching during vaginal birth. In 13-36% of women, stretching results in avulsion injury whereby the puborectalis muscle disconnects from its insertion points on the pubis bone. Until now, few studies have investigated the effect of this lesion on pelvic floor muscles in the early postpartum period. OBJECTIVE: The primary aim of this study was to compare pelvic floor muscle morphometry and function in primiparous women with and without puborectalis avulsion in the early postpartum period. Our secondary objective was to compare the 2 groups for pelvic floor disorders and impact on quality of life. STUDY DESIGN: In all, 52 primiparous women diagnosed with (n = 22) or without (n = 30) puborectalis avulsion injury were assessed at 3 months postpartum. Pelvic floor muscle morphometry was evaluated with 3-/4-dimensional transperineal ultrasound at rest, maximal contraction, and Valsalva maneuver. Different parameters were measured in the midsagittal and axial planes: bladder neck position, levator plate angle, anorectal angle, and levator hiatus dimensions. The dynamometric speculum was used to assess pelvic floor muscle function including: passive properties (passive forces and stiffness) during dynamic stretches, maximal strength, speed of contraction, and endurance. Pelvic floor disorder-related symptoms (eg, urinary incontinence, vaginal and bowel symptoms) and impact on quality of life were evaluated with the International Consultation on Incontinence Questionnaire and the Pelvic Floor Impact Questionnaire-Short Form. Pelvic Organ Prolapse Quantification was also assessed. RESULTS: In comparison to women without avulsion, women with avulsion presented an enlarged hiatus area at rest, maximal contraction, and Valsalva maneuver (P ≤ .013) and all other ultrasound parameters were found to be significantly altered during maximal contraction (P ≤ .014). They showed lower passive forces at maximal and 20-mm vaginal apertures as well as lower stiffness at 20-mm aperture (P ≤ .048). Significantly lower strength, speed of contraction, and endurance were also found in women with avulsion (P ≤ .005). They also presented more urinary incontinence symptoms (P = .040) whereas vaginal and bowel symptoms were found to be similar in the 2 groups. Pelvic Organ Prolapse Quantification revealed greater anterior compartment descent in women with avulsion (P ≤ .010). The impact of pelvic floor disorders on quality of life was found to be significantly higher in women with avulsion (P = .038). CONCLUSION: This study confirms that pelvic floor muscle morphometry and function are impaired in primiparous women with puborectalis avulsion in the early postpartum period. Moreover, it highlights specific muscle parameters that are altered such as passive properties, strength, speed of contraction, and endurance.

An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for the conservative and nonpharmacological management of female pelvic floor dysfunction.

Introduction and hypothesis There has been an increasing need for the terminology on the conservative management of female pelvic floor dysfunction to be collated in a clinically based consensus report. Methods This Report combines the input of members and elected nominees of the Standardization and Terminology Committees of two International Organizations, the International Urogynecological Association (IUGA) and the International Continence Society (ICS), assisted at intervals by many external referees. An extensive process of nine rounds of internal and external review was developed to exhaustively examine each definition, with decision-making by collective opinion (consensus). Before opening up for comments on the webpages of ICS and IUGA, five experts from physiotherapy, neurology, urology, urogynecology, and nursing were invited to comment on the paper. Results A Terminology Report on the conservative management of female pelvic floor dysfunction, encompassing over 200 separate definitions, has been developed. It is clinically based, with the most common symptoms, signs, assessments, diagnoses, and treatments defined. Clarity and ease of use have been key aims to make it interpretable by practitioners and trainees in all the different specialty groups involved in female pelvic floor dysfunction. Ongoing review is not only anticipated, but will be required to keep the document updated and as widely acceptable as possible. Conclusion A consensus-based terminology report for the conservative management of female pelvic floor dysfunction has been produced, aimed at being a significant aid to clinical practice and a stimulus for research.

Pelvic floor morphometry: a predictor of success of pelvic floor muscle training for women with stress and mixed urinary incontinence.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to determine if pelvic floor muscle (PFM) morphometry at baseline, as measured by MRI, can predict response to PFM training in women with stress or mixed urinary incontinence (UI). METHODS: This study was a prospective quasi-experimental pre-test, post-test cohort study of women with UI, aged 60 years and older. All participants completed a baseline assessment of UI severity and impact, using the 72-h bladder diary and the Incontinence Impact Questionnaire. They underwent a pelvic MRI examination to assess the PFM anatomy. Women then participated in a 12-week PFM training program. Finally, they attended a post intervention assessment of UI severity and impact. The association between morphometry and PFM training response was assessed by univariate analysis, multivariate analysis, and receiver operating characteristic (ROC) curve analysis. RESULTS: The urethro-vesical junction height at rest, as measured by MRI before treatment, was associated with response to PFM training both on univariate (p ≤ 0.005) and multivariate analyses (p = 0.007). The area under the ROC curve was 0.82 (95% confidence interval [CI]: 0.67-0.96). Using a cut-off point of 11.4 mm, participants' response to PFM training was predicted with a sensitivity of 77% and a specificity of 83%. Incontinent women with a urethro-vesical junction height above this threshold were 35% more likely to respond to PFM training (OR 1.35; 95% CI: 1.08-1.67). CONCLUSION: In older women with UI, a urethro-vesical junction height at rest of at least 11.4 mm appears to be predictive of PFM training response.