Review of pelvic and perineal neuromuscular fatigue: Evaluation and impact on therapeutic strategies.

ABSTRACT

BACKGROUND: Pelvic floor fatigue is known by its clinical consequences (fecal incontinence, stress urinary incontinence, pelvic organ prolapse), but there are still few studies on the subject. OBJECTIVE: This article presents an overview of the current knowledge of pelvic and perineal fatigue, focusing on its assessment and consequences in terms of evaluation and therapeutic strategies, to propose an evaluation that could be routinely performed. METHODS: We performed a systematic review of the literature in MEDLINE via PubMed and Cochrane Library databases by using the keywords pelvic floor, muscular fatigue, physiopathology, stress urinary incontinence, pelvic organ prolapse, fecal incontinence, physical activity, and pelvic rehabilitation. We included reports of systematic reviews and retrospective and prospective studies on adult humans and animals in English or French published up to April 2018 with no restriction on start date. RESULTS: We selected 59 articles by keyword search, 18 by hand-search and 3 specific guidelines (including the 2009 International Continence Society recommendations); finally 45 articles were included; 14 are described in the Results section (2 reviews of 6 and 20 studies, and 12 prospective observational or cross-over studies of 5 to 317 patients including 1 of animals). Perineal fatigue can be assessed by direct assessment, electromyography and spectral analysis and during urodynamics. Because pelvic floor fatigue assessments are not evaluated routinely, this fatigability is not always identified and is often falsely considered an exclusive pelvic floor weakness, as suggested by some rehabilitation methods that also weaken the pelvic floor instead of enhancing it. CONCLUSION: Pelvic floor fatigue is not evaluated enough on a routine basis and the assessment is heterogeneous. A better knowledge of pelvic floor fatigue by standardized routine evaluation could lead to targeted therapeutic strategies.