Exercise Position to Improve Synergy Between the Diaphragm and Pelvic Floor Muscles in Women With Pelvic Floor Dysfunction: A Cross Sectional Study.

OBJECTIVE: This study aimed to investigate the synergy between the diaphragm and pelvic floor muscles (PFM) according to different exercise positions in women with pelvic floor dysfunction. Our secondary aim was to determine the short-term effects of single-week pelvic floor muscle training (PFMT) program on diaphragmatic function. METHODS: The cross-sectional study included 64 women with pelvic floor dysfunction. The participants' diaphragm and abdominal muscle functions during voluntary PFM contraction and relaxation were assessed by surface electromyography and ultrasonography. The surface electromyography assessments were performed in supine (P1), crawling (P2) and sitting (P3) positions. A single week-PFMT was conducted on women who agreed to determine the short-term responses of the diaphragm function. The muscle functions according to exercise positions were compared with Friedman Analysis of Variance, and the short-term effects of single-week PFMT on diaphragm function was analyzed with Wilcoxon Signed-Ranks Test. RESULTS: The diaphragm activity during voluntary PFM contraction was highest in P2 before and after single-week PFMT (P < .001). Positive significant correlations were found between the activities diaphragm and abdominal muscles in different exercise positions (P < .05). After single-week PFMT, diaphragm thickness increased (P = .030) in P1, but diaphragm activity did not change in all 3 exercise positions (P > .05). CONCLUSION: The synergy between the diaphragm and PFM was greater in the crawling position in women with pelvic floor dysfunction. The abdominal muscles seemed to contribute to maintaining this synergy. Therefore, PFMT combined with diaphragmatic breathing exercises in the crawling position should be considered. In addition, single-week PFMT may positively affect diaphragm function in the short-term.

Impact of pelvic floor ultrasound in diagnosis of postpartum pelvic floor dysfunction: A protocol of systematic review.

BACKGROUND: This study will appraise the impact of pelvic floor ultrasound (PFU) in diagnosis of postpartum pelvic floor dysfunction (PPPFD). METHODS: Studies that report the impact of PFU in diagnosis of PPPFD will be examined in Cochrane Library, MEDLINE, EMBASE, PSYCINFO, Scopus, Web of Science, Allied and Complementary Medicine Database, CNKI, and WANGFANG up to June 1, 2020. Grey literature sources will also be searched. All potential case-controlled studies (CCSs) exploring the impact of PFU in diagnosis of PPPFD will be considered for inclusion in this study. Data will be extracted from eligible CCSs for data pooling and meta-analysis. Whenever necessary, we will also perform summary effect size, heterogeneity across studies, study quality assessment, and reporting bias. RESULTS: The present study will estimate pooled outcome effects regarding the impact of PFU in diagnosis of PPPFD. CONCLUSION: This study may provide robust evidence to judge the impact of PFU on PPPFD SYSTEMATIC REVIEW REGISTRATION:: PROSPERO CRD42020187623.

Effect of different electrical stimulation protocols for pelvic floor rehabilitation of postpartum women with extremely weak muscle strength: Randomized control trial.

BACKGROUND: Pregnancy is one of the main risk factor of pelvic floor muscle dysfunction. Postpartum women with extremely weak muscle strength have difficulty to do voluntary pelvic floor muscle training. This study aims to evaluate the effects of different protocols of electrical stimulation in the treatment of postpartum women with extremely weak muscle strength. METHODS: A total of 67 women were randomized into 2 groups: group A received transvaginal electrical stimulation (TVES) for 5 times, and group B received TVES for 3 times with electromyogram (EMG)-triggered neuromuscular stimulation twice. Subjects were evaluated before and after treatment. Pelvic muscle strength was measured by both digital vaginal palpation and EMG variables, and quality of life was investigated by 4 kinds of pelvic floor disease-related questionnaires. RESULTS: According to the intention-to-treat principle, compared with baseline, in group A, EMG of contractile amplitude of endurance phase was significantly elevated (P = .03), variation of contractile amplitude in tonic phase was more stable after treatment (P = .004), and EMG of mean value of final rest was significantly elevated after treatment (P = .047). After 5 times treatments, the incidence of correct pelvic floor muscle contraction in group A was significantly elevated (P = .045). No significant difference of muscle strength test by digital vaginal palpation was detected between the 2 groups, so did questionnaires. CONCLUSION: For postpartum women with extremely weak muscle strength, TVES for 5 times might be more benefit for control ability of pelvic muscle contractions and elevating muscle strength even in short-time treatment.

Individualized pelvic physical therapy for the treatment of post-prostatectomy stress urinary incontinence and pelvic pain.

BACKGROUND: The rehabilitation of post-prostatectomy urinary incontinence has traditionally focused on pelvic floor strengthening exercise. The goal of this study was to determine whether an individualized pelvic physical therapy (PT) program aimed at normalizing both underactive and overactive pelvic floor dysfunction (PFD) can result in improvement in post-prostatectomy stress urinary incontinence (SUI) and pelvic pain. METHODS: A retrospective chart review of 136 patients with post-prostatectomy SUI and treated with pelvic PT. Patients were identified as having either underactive, overactive, or mixed-type PFD and treated accordingly with a tailored program to normalize pelvic floor function. Outcomes including decrease in SUI as measured in pad usage per day and pain rated on the numeric pain rating scale. RESULTS: Twenty five patients were found to have underactive PFD and were treated with strengthening. Thirteen patients had overactive PFD and were treated with relaxation training. Ninety eight patients had mixed-type PFD and were treated with a combination of relaxation training followed by strengthening. Patients demonstrated statistically significant decrease in pad usage per day (p < 0.001), decreased pelvic pain (p < 0.001), and increased pelvic floor strength (p = 0.049), even in patients who received predominantly pelvic floor relaxation training to normalize pelvic floor overactivity. CONCLUSIONS: A majority of post-prostatectomy men with SUI have pelvic floor overactivity in addition to pelvic floor underactivity. An individualized pelvic PT program aimed at normalizing pelvic floor function (as opposed to a pure Kegel strengthening program) can be helpful in reducing SUI and pelvic pain.

Traditional Biofeedback vs. Pelvic Floor Physical Therapy-Is One Clearly Superior?

PURPOSE OF REVIEW: Pelvic floor physical therapy is a worldwide accepted therapy that has been exclusively used to manage many pelvic floor disorders in adults and children. The aim of this review is to suggest to clinicians an updated understanding of this therapeutic approach in management of children with non-neuropathic voiding dysfunction. RECENT FINDINGS: Today, pelvic floor muscle training through biofeedback is widely used as a part of a voiding retraining program aiming to help children with voiding dysfunction which is caused by pelvic floor overactivity. Biofeedback on its own, without a pelvic floor training component, is not an effective treatment. Biofeedback is an adjunct to the pelvic floor training. In the current review, we develop the role of pelvic floor physical therapy in management of children with non-neuropathic voiding dysfunction and compare it with biofeedback therapy alone.

A Practical Guide to Biofeedback Therapy for Pelvic Floor Disorders.

PURPOSE OF REVIEW: Biofeedback therapy (BFT) is effective for managing pelvic floor disorders (i.e., defecatory disorders and fecal incontinence). However, even in controlled clinical trials, only approximately 60% of patients with defecatory disorders experienced long-term improvement. The review serves to update practitioners on recent advances and to identify practical obstacles to providing biofeedback therapy. RECENT FINDINGS: The efficacy and safety of biofeedback therapy have been evaluated in defecatory disorders, fecal incontinence, and levator ani syndrome. Recent studies looked at outcomes in specific patient sub-populations and predictors of a response to biofeedback therapy. Biofeedback therapy is effective for managing defecatory disorders, fecal incontinence, and levator ani syndrome. Patients who have a lower bowel satisfaction score and use digital maneuvers fare better. Biofeedback therapy is recommended for patients with fecal incontinence who do not respond to conservative management. A subset of patients with levator ani syndrome who have dyssynergic defecation are more likely to respond to biofeedback therapy.

Successful Treatment of Paradoxical Puborectalis Contraction and Intractable Anorectal Pain With Sacral Neuromodulation.

BACKGROUND: Paradoxical puborectalis contraction (PPC) is a syndrome of obstructed defecation associated with a cluster of complaints including rectal pain, incomplete evacuatory sensation, prolonged repetitive straining with bowel movements, and the need for digital manipulation. Traditional treatment has yielded mixed results. CASE: We present a case of PPC successfully treated with staged sacral neuromodulation and review her diagnostic features, medical regimen, and prior unsuccessful interventions tried. Symptoms were analyzed using a visual analog scale pain score (0-10). Criteria to progress to implantation of the pulse generator included a pain score less than 3 during test stimulation and/or greater than 50% decrease in the pain score compared to baseline.Our patient had a pain score of 0 (baseline 8) with stage 1 sacral neuromodulation. In addition, she had dramatic relief in her straining with bowel movements and need for digital manipulation. Her pulse generator was implanted after a 2-week trial, and she has experienced a lasting improvement at her follow-up of 2 years. CONCLUSIONS: Sacral neuromodulation is an established therapy for overactive bladder syndrome, urinary retention, and fecal incontinence. In urology, the use of sacral neuromodulation has been described to benefit some patients with pelvic floor pain. Sacral neuromodulation can be a successful treatment for PPC and functional anorectal pain with resulting improvement in quality of life without the sequelae of an invasive and irreversible surgery.

ICS Educational Module: Electromyography in the assessment and therapy of lower urinary tract dysfunction in adults.

AIM: To present the teaching module "Electromyography in the assessment and therapy of lower urinary tract dysfunction in adults." This teaching module embodies a presentation, in combination with this manuscript. This manuscript serves as a scientific background review; the evidence base made available on ICS website to summarize current knowledge and recommendations. METHODS: This review has been prepared by a Working Group of The ICS Urodynamics Committee. The methodology used included comprehensive literature review, consensus formation by the members of the Working Group, and review by members of the ICS Urodynamics Committee core panel. RESULTS: Electromyography (EMG) is a method to record spontaneous or artificially induced electrical activity of the nerve-muscle unit or to test nerve conductivity. EMG of the anal sphincter using surface electrode is most widely used screening technique to detect detrusor-sphincter dyssynergia in urology. It is non-invasive and easy to perform. EMG methods using needle electrodes are reserved for diagnostics in well selected group of mainly neurogenic patients. These methods require expertise in the field of general EMG and are usually performed by neurologist and neuro-physiologist. The evidence in many aspects of use of EMG in urology remains sparse. CONCLUSIONS: Currently EMG methods rarely play a decision making role in selecting proper treatment of lower urinary tract dysfunction. With the current efforts to improve phenotyping of these patients in order to provide individualized treatment, the role of EMG could increase.

Physical, Complementary, and Alternative Medicine in the Treatment of Pelvic Floor Disorders.

PURPOSE OF REVIEW: The purpose of the study was to catalog the most recent available literature regarding the use of conservative measures in treatment of pelvic floor disorders. RECENT FINDINGS: Pelvic floor disorders encompass abnormalities of urination, defecation, sexual function, pelvic organ prolapse, and chronic pain, and can have significant quality of life implications for patients. Current guidelines recommend behavioral modifications and conservative treatments as first-line therapy for pelvic floor disorders. We have reviewed the literature for articles published on physical, complementary, and alternative treatments for pelvic floor disorders over the past 5 years. Review of pelvic floor muscle physiotherapy (PFMT) and biofeedback (BF) shows a benefit for patients suffering from bladder dysfunction (incontinence, overactive bladder), bowel dysfunction (constipation, fecal incontinence), pelvic organ prolapse, and sexual dysfunction (pelvic pain). Combination of PFMT and BF has shown improved results compared to PFMT alone, and some studies find that electrical stimulation can augment the benefit of BF and PFMT. Additionally, acupuncture and cognitive behavioral therapy has shown to be an effective treatment for pelvic floor disorders, particularly with respect to pelvic pain. This update highlights beneficial conservative treatments available for pelvic floor dysfunction, and supplements the current literature on treatment options for patients suffering from these disorders.

Short-term outcome of percutaneous tibial nerve stimulation for low anterior resection syndrome: results of a pilot study.

AIM: Percutaneous tibial nerve stimulation (PTNS) is a minimally invasive procedure which has been demonstrated to be effective in faecal/urinary incontinence but has never been tested in low anterior resection syndrome (LARS). The severity of LARS may be evaluated by the LARS score, but rectal cancer treatments may also affect urinary and sexual function, which are not explored by the LARS score. The Three Axial Perineal Evaluation (TAPE) score is a new validated index addressing the overall pelvic floor functions. This study aims to assess the efficacy of PTNS in LARS patients and to evaluate the results by the LARS and TAPE scores. METHODS: Twenty-one patients operated on for rectal cancer between 2009 and 2014 complaining of LARS underwent PTNS (12 sessions of 30 min each). Six patients reported urinary incontinence and all except two (men) were sexually inactive. The LARS score and the TAPE score questionnaires were administered at baseline and after 6 months of follow-up. RESULTS: At 6 months' follow-up, nine patients reported a significant improvement of faecal incontinence and 3/6 an improvement of urinary incontinence after PTNS. Median LARS score significantly decreased from 32 to 27 (P = 0.009), while the median TAPE score improved significantly from 55 to 58 (P = 0.004). CONCLUSIONS: PTNS may be a further option in the treatment of selected patients with LARS and in addition may improve associated urinary incontinence. The severity of LARS can be detected by the LARS score; however, the adoption of the TAPE score is preferred in the case of concomitant urinary and/or sexual problems not explored by the LARS score.

Ultrasound-based motor control training for the pelvic floor pre- and post-prostatectomy: Scoring reliability and skill acquisition.

AIM: This study documents a protocol designed to evaluate pelvic floor motor control in men with prostate cancer. It also aims to evaluate the reliability of therapists in rating motor control of pelvic floor muscles (PFMs) using real time ultrasound imaging (RUSI) video clips. We further determine predictors of acquiring motor control. METHODS: Ninety-one men diagnosed with prostate cancer attending a physiotherapy clinic for pelvic floor exercises were taught detailed pelvic floor motor control exercises by a physiotherapist using trans-abdominal RUSI for biofeedback. A new protocol to rate motor control skill acquisition was developed. Three independent physiotherapists assessed motor control skill attainment by viewing RUSI videos of the contractions. Inter-rater reliability was evaluated using intra-class correlation coefficients. Logistic regression analysis was conducted to identify predictors of successful skill attainment. Acquisition of the skill was compared between pre- and post-operative participants using an independent-group t-test. RESULTS: There was good reliability for rating the RUSI video clips (ICC 0.73 (95%CI 0.59-0.82)) for experienced therapists. Having low BMI and being seen pre-operatively predicted motor skill attainment, accounting for 46.3% of the variance. Significantly more patients trained pre-operatively acquired the skill of pelvic floor control compared with patients initially seen post-operatively (OR 11.87, 95%CI 1.4 to 99.5, p = 0.02). CONCLUSIONS: A new protocol to evaluate attainment of pelvic floor control in men with prostate cancer can be assessed reliably from RUSI images, and is most effectively delivered pre-operatively.

Evaluation of the effectiveness of biofeedback therapy for functional constipation in children.

BACKGROUND/AIMS: Defecation disorders are one of the most common problems in pediatric gastroenterology. Treatment includes changes in the diet, pharmacotherapy, and biofeedback therapy. The aim of the present study was to evaluate the effectiveness of biofeedback therapy as assessed by clinical improvement as well as by changes in manometric parameters in children with constipation and pelvic floor dyssynergia (PFD). MATERIALS AND METHODS: A total of 44 children with constipation and PFD hospitalized between 2000 and 2015 were enrolled in this retrospective study. All patients underwent anorectal manometry, and in case of diagnosed PFD, the patient qualified for biofeedback therapy. Amplitudes between extreme and basic pressures during defecation maneuvers in the first and last sessions as well as the difference between them were compared between groups with and without clinical improvement after the last session. RESULTS: A clinical improvement was achieved in 38 (86%) patients. There were no significant differences found in the amplitudes in the first session (mmHg), 94, 65, 115 vs. 112, 55, 170 (median, first quartile, third quartile, respectively; NS: not significant); last session, 36, 27, 52 vs. 41, -38, 66, respectively; or between them, 71, 11, 124 vs. 81, 17, 109, respectively, in the group with versus the group without clinical improvement, respectively. CONCLUSION: Biofeedback therapy has high clinical efficacy, and despite the lack of manometric improvement, it should be used as a treatment method in children in whom dietary and pharmacological procedures do not work, even if we consider the exercises more as a form of psychological training.

Fecal Incontinence and Pelvic Floor Dysfunction in Women: A Review.

Pelvic floor dysfunction and fecal incontinence is a common and debilitating condition in women, particularly as women age, and often goes under-reported to health care providers. It is important for providers to ask patients about possible symptoms. An algorithm for evaluation and treatment is presented. Current and future therapies are described and discussed.

Does percutaneous tibial nerve stimulation improve global pelvic function in women with faecal incontinence?

AIM: Percutaneous tibial nerve stimulation (PTNS) is a minimally invasive treatment for faecal incontinence. Many patients with faecal incontinence have coexisting pelvic floor disorders such as urinary incontinence and vaginal symptoms. We utilized a pelvic floor assessment tool to analyse any effect of PTNS on global pelvic floor function. METHODS: Patients with faecal incontinence attending our institution who had failed to respond sufficiently to biofeedback were offered a course of PTNS. Patients underwent pre- and post-stimulation assessment with a validated electronic Personal Assessment Questionnaire - Pelvic Floor (ePAQ-PF) for pelvic floor disorders. Scores were compared to assess the effect of treatment on global pelvic floor function. RESULTS: During the study period pre- and post-stimulation ePAQ-PF data were available for 60 patients (55% of all patients starting PTNS). In this cohort there was a significant improvement in bowel continence, bowel related quality of life, irritable bowel syndrome and bowel evacuation with a large effect size for continence and bowel related quality of life. There was also a significant improvement in non-bowel related symptoms, including urinary pain and stress incontinence, urinary related quality of life and bowel related sexual function. Sixty-five per cent of those who answered the question reported improvement in global health after stimulation. CONCLUSION: For patients presenting with faecal incontinence, PTNS appears to have a positive effect on bowel related function in approximately two-thirds of patients. However, for treatment responders, improvement appears to relate mainly to improvement in bowel related function rather than a global pelvic floor effect.

New developments in therapies for fecal incontinence.

PURPOSE OF REVIEW: Fecal incontinence is a common problem among women, affecting between 2 and 7% of the general population. Although pelvic reconstructive surgeons have had many effective tools and techniques to treat other pelvic floor disorders, including pelvic organ prolapse and urinary incontinence, there has been a shortage of effective treatment options for fecal incontinence. RECENT FINDINGS: In the past few years, however, we have witnessed the introduction of several novel and intriguing treatments for this socially disabling condition. This renaissance of innovation speaks to the recognition that fecal incontinence is a significant pelvic floor disorder that we have not adequately addressed. Recent studies include research on a novel vaginal device to treat fecal incontinence, as well as long-term and comparative studies on neuromodulation, perianal bulking and transanal radiofrequency energy. There have also been recent studies on several novel, yet still unapproved, implantable devices, including a self-affixing rectal sling and a magnetic sphincter. SUMMARY: In the not-too-distant future, it appears that pelvic reconstructive surgeons will have a vast armamentarium of tools to manage one of the more vexing pelvic floor conditions we face in our daily practice. With the introduction of these new treatments, it will be important to develop a logical algorithm in our approach to fecal incontinence.

Pelvic floor spasm as a cause of voiding dysfunction.

PURPOSE OF REVIEW: Pelvic 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 FINDINGS: To 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. SUMMARY: Pelvic 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 patient's 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.

The Integral Theory System Questionnaire: an anatomically directed questionnaire to determine pelvic floor dysfunctions in women.

PURPOSE: Anatomical damage to pelvic floor structures may cause multiple symptoms. The Integral Theory System Questionnaire (ITSQ) is a holistic questionnaire that uses symptoms to help locate damage in specific connective tissue structures as a guide to reconstructive surgery. It is based on the integral theory, which states that pelvic floor symptoms and prolapse are both caused by lax suspensory ligaments. The aim of the present study was to psychometrically validate the ITSQ. MATERIALS AND METHODS: Established psychometric properties including validity, reliability, and responsiveness were considered for evaluation. Criterion validity was assessed in a cohort of 110 women with pelvic floor dysfunctions by analyzing the correlation of questionnaire responses with objective clinical data. Test-retest was performed with questionnaires from 47 patients. Cronbach's alpha and "split-half" reliability coefficients were calculated for inner consistency analysis. RESULTS: Psychometric properties of ITSQ were comparable to the ones of previously validated Pelvic Floor Questionnaires. Face validity and content validity were approved by an expert group of the International Collaboration of Pelvic Floor surgeons. Convergent validity assessed using Bayesian method was at least as accurate as the expert assessment of anatomical defects. Objective data measurement in patients demonstrated significant correlations with ITSQ domains fulfilling criterion validity. Internal consistency values ranked from 0.85 to 0.89 in different scenarios. CONCLUSIONS: The ITSQ proofed accurate and is able to serve as a holistic Pelvic Floor Questionnaire directing symptoms to site-specific pelvic floor reconstructive surgery.

Myofascial trigger points of the pelvic floor: associations with urological pain syndromes and treatment strategies including injection therapy.

Myofascial trigger points (MTrP), or muscle "contraction knots," of the pelvic floor may be identified in as many as 85 % of patients suffering from urological, colorectal and gynecological pelvic pain syndromes; and can be responsible for some, if not all, symptoms related to these syndromes. Identification and conservative treatment of MTrPs in these populations has often been associated with impressive clinical improvements. In refractory cases, more "aggressive" therapy with varied trigger point needling techniques, including dry needling, anesthetic injections, or onabotulinumtoxinA injections, may be used, in combination with conservative therapies.

Outcomes of a comprehensive nonsurgical approach to pelvic floor rehabilitation for urinary symptoms, defecatory dysfunction, and pelvic pain.

OBJECTIVE: The authors' intent was to determine the clinical efficacy of comprehensive pelvic floor rehabilitation among women with symptoms of pelvic floor dysfunction (PFD). METHODS: We performed a retrospective analysis of women referred to an academic female pelvic medicine and reconstructive surgery practice for PFD. Data were gathered from the records of 778 women referred for pelvic floor therapy for urinary, bowel, pelvic pain, and sexual symptoms over the course of 4 years. RESULTS: Patients who completed at least 5 therapy sessions reported a mean symptom improvement of 80% in each of the 3 main categories analyzed, namely, urinary incontinence, defecatory dysfunction, and pelvic pain. CONCLUSIONS: Comprehensive, nonoperative management of PFD including pelvic floor muscle training, biofeedback, electrogalvanic stimulation, constipation management, behavioral modification, incontinence devices, and pharmacotherapy including vaginal estrogen is effective in the treatment of women with PFD.