Assessment of Involuntary PFM Contractions in Comparison with Existing Literature and IUGA/ICS Terminology Reports.

INTRODUCTION AND HYPOTHESIS: Involuntary pelvic floor muscle (PFM) contractions are thought to occur during an increase in intra-abdominal pressure (IAP). Although no studies have assessed their presence in women with normal pelvic floor (PF) function, existing literature links the absence of involuntary PFM contractions to various PF dysfunctions. This study rectifies this lacuna by evaluating involuntary PFM contractions during IAP in healthy nulliparous women with no PF dysfunction, using visual observation and vaginal palpation. Results were compared with the literature and the IUGA/ICS Terminology Reports. METHODS: Nulliparous (n=149) women performed three sets of three maximal coughs. Visual observation and vaginal palpation were conducted in the standing and supine positions. The women were not instructed to contract their PFMs. Occurrence rates were calculated for each assessment method and position; differences between positions were analyzed using the Chi-squared test. RESULTS: Rates of occurrence of involuntary PFM contraction were low across both assessments and positions (5-17%). Significant differences were found between standing (5%) and supine (15%) positions for visual observation, but not vaginal palpation (15%, 17% respectively). Occurrence rates also differed compared with the literature and terminology reports. CONCLUSIONS: Contrary to clinical expectations, rates of occurrence of involuntary PFM contraction among our cohort of nulliparous women were extremely low. Digital palpation results showed high agreement with the terminology reports, but only partial agreement was observed for the visual observation results. Our study underscores the need for more research aimed at defining normal involuntary PF functions, a review of our understanding of involuntary PFM contractions, and better standardized guidelines for involuntary PFM assessment methods.

Assessment of the bearing-down manoeuvre in pregnancy and detection of paradoxical levator ani muscle contraction using 2D transperineal ultrasound and vaginal palpation: a concurrent validity and inter-rater reliability study.

OBJECTIVE: To examine the concurrent validity and inter-rater reliability of vaginal palpation as a measure of the quality of the bearing-down manoeuvre (BDM) and the detection of a paradoxical levator ani muscle contraction (LAM) in pregnant women, compared with 2D transperineal ultrasound (TPUS). DESIGN: Concurrent validity and inter-rater reliability study. SETTING: Physiotherapy clinic. POPULATION: Twenty pregnant women in their third trimester. METHODS: The anterior posterior diameter (APD) was measured during the BDM using TPUS by one experienced physiotherapist. An APD that shortened by >2 mm from rest was described as LAM shortening, an APD that moved by 0-2 mm was described as no change and an APD that lengthened by >2 mm was described as LAM lengthening. Vaginal palpation described the LAM during the BDM as no movement, shortening or lengthening. Participants were allowed two attempts and the best attempt was measured. MAIN OUTCOME MEASURES: APD using TPUS and the assessor's subjective description of LAM during the BDM using vaginal palpation. RESULTS: TPUS detected more paradoxical LAM contractions during the BDM than palpation. Agreement between vaginal palpation and TPUS assessment for BDM was poor. The Fleiss kappa coefficients were 0.457 (90% CI 0.16-0.71) between TPUS and one assessor and 0.326 (90% CI 0.01-0.6) between TPUS and the other assessor. In addition, inter-rater reliability was poor between observers palpating the BDM, with a Fleiss kappa coefficient of 0.375 (90% CI 0.13-0.64). CONCLUSIONS: This study did not find vaginal palpation of the BDM in pregnant women to have concurrent validity or inter-rater reliability. Clinicians should be aware of potential inaccuracies when palpating the BDM, and, where possible, seek an assessment via TPUS.

Is there correlation between perineometry and Modified Oxford Scale in women? Systematic review with meta-analysis and grade recommendations.

BACKGROUND: The International Continence Society (ICS) recommends the use of perineometry and digital palpation to assess the pelvic floor muscles (PFM). Exploring the degree of correlation between both assessment strategies will serve to improve safety for clinical practice. Therefore, we performed a systematic review and meta-analysis on the correlation between assessment strategies. METHODS: Observational studies were included. Bias risk assessment based on Downs and Black scale and the evidence's level were assessed using the GRADE. The random effect model measured the correlation values and were quantitatively analyzed through meta-analysis. Registration in PROSPERO database - CRD42021253775. RESULTS: Six studies were selected. There was a high positive correlation between perineometry and MOS (r = 0.74; 95%-IC 0.61-0.83; I2: 81%, p < 0.01). Subgroup analysis was performed with 3 studies with continent women, and revealed a high positive correlation (r = 0.80; 95%-IC 0.62-0.90; I2: 90%, p < 0.01), while 2 studies with incontinent women revealed a moderate positive correlation (r = 0.64; 95%-IC 0.48-0.75; I2: 0%, p = 0.40). GRADE analysis revealed a low strength of evidence. CONCLUSION: The high positive correlation between perineometry and MOS suggests that if the assessment strategies are applied in a standardized way, these tests can be used together or separately to assess the functionality of PFMs in clinical practice. However, the results should be interpreted with caution due to the low strength of GRADE evidence.

Vaginal palpation versus transabdominal ultrasound in the comprehension of pelvic floor muscle contraction after vaginal delivery: a randomised controlled trial.

BACKGROUND: Pelvic floor muscles support the pelvic organs and control voiding. The first choice in the repair of pelvic floor function that is damaged during pregnancy and delivery is pelvic floor muscle training, which involves repeated muscle relaxation and contraction. However, as muscle contractions cannot be visualised, it is difficult to assess whether patients understand how to contract them. Therefore, we assessed patients' comprehension of pelvic floor muscle contraction by comparing two teaching methods, vaginal palpation and transabdominal ultrasound, following vaginal delivery. We hypothesised that vaginal palpation is better than transabdominal ultrasound in this regard. METHODS: This randomised controlled trial conducted in facilities in Tokyo, Japan between July 2018 and January 2019 included women aged ≥ 20 years at 4-6 weeks after vaginal delivery. The randomisation involved website-based centralised allocation. The primary outcome was a change in bladder base displacement during pelvic floor muscle contraction before and after training, which was measured using transabdominal ultrasound. Participants performed three contractions for 3 s, and the mean value was used for statistical analysis. The secondary outcome was a change in understanding the contraction before and after training, which was measured using a five-point Likert scale questionnaire. Outcomes were analysed using Welch's t-test. RESULTS: Sixty-five participants were randomly allocated to the vaginal palpation group (n = 32) and transabdominal ultrasound group (n = 33). Baseline characteristics were similar between the groups. Changes in bladder base displacement were not significantly different between the groups (p = 0.181). Within-group analyses showed that bladder base displacement was large in both groups after the respective intervention. There were no significant differences in any of the outcomes between the two groups before and after the intervention. CONCLUSIONS: Vaginal palpation and transabdominal ultrasound might be useful for comprehending pelvic floor muscle contraction after vaginal delivery. TRIAL REGISTRATION: UMIN 000032304. Registered 18 April 2018, https://upload.umin.ac.jp/cgi-open-bin/icdr_e/ctr_view.cgi?recptno=R000036820 .

Effects of three interventions in facilitating voluntary pelvic floor muscle contraction in women: a randomized controlled trial.

OBJECTIVE: To evaluate the effect of vaginal palpation, vaginal palpation associated with posterior pelvic tilt, and intravaginal electrical stimulation in facilitating voluntary contraction of the pelvic floor muscles in women. METHODS: A randomized controlled trial in which 132 women with pelvic floor muscles function graded at 0 or 1 using the Modified Oxford Scale were randomized into four groups: vaginal palpation (n=33); vaginal palpation with posterior pelvic tilt (n=33); intravaginal electrical stimulation (n=33) and a control group (n=33) that only received verbal instructions. The primary outcome was evaluated by the Modified Oxford Scale and the secondary using the ICIQ-UI-SF. The assessment was performed at baseline with follow-up assessment after eight weeks. RESULTS: A total of 69.7% of the women from posterior pelvic tilt; 63.6% from vaginal palpation; 33.3% from intravaginal electrical stimulation; and 18.2% from control group (p<0.001) were able to attain Modified Oxford Scale greater than or equal to 2 after eight weeks. In comparison with control group, the posterior pelvic tilt (OR=10.35; 95% CI=3.26-32.84) and vaginal palpation (OR=7.87; 95% CI=2.53-24.47) had the most significant improvement as opposed to intravaginal electrical stimulation (OR=2.25; 95% CI=0.72-7.06). There was significant improvement among all of the groups in UI. The largest changes respectively were noted in the vaginal palpation, posterior pelvic tilt, intravaginal electrical stimulation and control group. There were no reports of adverse effects. CONCLUSION: Vaginal palpation with posterior pelvic tilt and vaginal palpation were more effective interventions to facilitate pelvic floor muscles contraction when compared with intravaginal electrical stimulation and controls. Vaginal palpation was the most effective in improving urinary incontinence. Clinical Trials Identifier: ClinicalTrial.gov: NCT02062242.

The evaluation of pelvic floor muscle strength in women with pelvic floor dysfunction: A reliability and correlation study.

AIMS: The purposes of this study were: (i) to evaluate the reliability of vaginal palpation, vaginal manometry, vaginal dynamometry; and surface (transperineal) electromyography (sEMG), when evaluating pelvic floor muscle (PFM) strength and/or activation; and (ii) to determine the associations among PFM strength measured using these assessments. METHODS: One hundred and fifty women with pelvic floor disorders participated on one occasion, and 20 women returned for the same investigations by two different raters on 3 different days. At each session, PFM strength was assessed using palpation (both the modified Oxford Grading Scale and the Levator ani testing), manometry, and dynamometry; and PFM activation was assessed using sEMG. RESULTS: The interrater reliability of manometry, dynamometry, and sEMG (both root-mean-square [RMS] and integral average) was high (Lin's Concordance Correlation Coefficient [CCC] = 0.95, 0.93, 0.91, 0.86, respectively), whereas the interrater reliability of both palpation grading scales was low (Cohen's Kappa [k] = 0.27-0.38). The intrarater reliability of manometry (CCC = 0.96), and dynamometry (CCC = 0.96) were high, whereas intrarater reliability of both palpation scales (k = 0.78 for both), and of sEMG (CCC = 0.79 vs 0.80 for RMS vs integral average) was moderate. The Bland-Altman plot showed good inter and intrarater agreement, with little random variability for all instruments. The correlations among palpation, manometry, and dynamometry were moderate (coefficient of determination [r2 ] ranged from 0.52 to 0.75), however, transperineal sEMG amplitude was only weakly correlated with all measures of strength (r2 = 0.23-0.30). CONCLUSIONS: Manometry and dynamometry are more reliable tools than vaginal palpation for the assessment of PFM strength in women with pelvic floor disorders, especially when different raters are involved. The different PFM strength measures used clinically are moderately correlated; whereas, PFM activation recorded using transperineal sEMG is only weakly correlated with PFM strength. Results from perineal sEMG should not be interpreted in the context of reporting PFM strength.

Pelvic reconstruction improves pelvic floor strength in pelvic organ prolapse patients.

OBJECTIVE: To evaluate pelvic floor muscle strength after the modified pelvic reconstruction procedure for pelvic organ prolapse (POP). MATERIALS AND METHODS: Patients were assigned to two groups consisting of 37 patients diagnosed with POP and undergoing modified pelvic reconstruction (reconstruction group), and 30 patients admitted to our hospital during the same period for other surgical indications (control group). Vaginal palpation of pelvic floor muscle strength was performed according to the modified Oxford grading system before operating on the two groups and again in the 3(rd) month following surgery for the reconstruction group. A comparative study was performed to evaluate the differences between the two groups and the improvement of pelvic floor muscle strength in the reconstruction group. RESULTS: The pelvic floor muscle strength was significantly improved postoperatively when compared with preoperative results in the reconstruction group (t = -17.478, p < 0.001). However, pre- and postoperative muscle strength in the reconstruction group was significantly lower relative to the control group, respectively (χ(2) = 63.293, p < 0.001; χ(2) = 31.550, p < 0.001). CONCLUSION: The modified pelvic reconstruction procedure could improve pelvic floor muscle strength in POP patients, which remains lower when compared with the normal population. Pelvic floor muscle strength should be included in the assessment of surgical outcomes in POP.

Correlação do escore de Oxford modificado com as medidas perineométricas em pacientes incontinentes / Correlation between the modified Oxford scale and perineometry measurements in incontinent patients

Introdução: Diversas técnicas foram propostas para avaliação da musculatura do assoalho pélvico, porém, nenhum método mostrou-se capaz de medir as duas funções desses músculos: elevação e força de compressão. Na rotina de avaliação clínica é comumente empregada a palpação vaginal e, especialmente, o escore de Oxford modificado; entretanto, alguns trabalhos questionam a sensibilidade da escala de Oxford e sua correlação com medidas objetivas de força de contração muscular. Objetivo: neste estudo, propõe-se correlacionar as variáveis medidas na perineometria com o escore de Oxford modificado. Métodos: foram incluídas no estudo 45 pacientes com incontinência urinária que procuraram o ambulatório de Uroginecologia do Hospital de Clínicas de Porto Alegre. As pacientes foram submetidas à palpação vaginal, realizada por uma fisioterapeuta treinada na escala de Oxford, e a medição da força de compressão da musculatura pélvica por meio de balonete conectado a transdutor de pressão. As duas avaliações foram realizadas no mesmo dia. Resultados: encontrou-se correlação significativa (P <0,001) entre o escore de Oxford e as variáveis pressão máxima de contração e tempo de ativação muscular com coeficientes de Pearson de 0,69 e -0,532, respectivamente. Contudo, observa-se uma superposição entre as medidas perineométricas e do escore de Oxford entre categorias adjacentes. Conclusões: Os resultados mostram que apesar de estar incorporada a rotina clínica de avaliação, deve haver restrições quanto ao uso do escala de Oxford com propósitos científicos.

Background: Several techniques have been proposed for the assessment of pelvic floor muscles; however, none of them were able to measure the two main functions of these muscles: lifting and compressive force. Vaginal palpation and especially the Modified Oxford Scale (MOS) are frequently used during routine clinical evaluation, but some studies have questioned the sensitivity of the MOS and its correlation with objective measurements of muscle contraction force. Aim: the objective of this study is to correlate perineometry measurements with the MOS.Methods: Forty-five patients with urinary incontinence treated at the Urogynecology Outpatient Clinic of Hospital de Clínicas de Porto Alegre were included. The patients were submitted to vaginal palpation performed by a physical therapist trained in the MOS. The compression force of their pelvic muscles was measured by means of an air-filled ballonet connected to a pressure transducer. Both tests were carried out on the same day. Results: we found significant correlation (P < 0.001) between the MOS and the variables maximum contraction pressure andmuscular activation time with Pearson's coefficients of 0.69 and -0.532, respectively. However, we found overlapping results between the perineomtry measurements and the MOS scores in neighboring categories. Conclusions: these findings show that, although incorporated into routine clinical evaluation, there should be restrictions to the use of the MOS for scientific purposes.

Mechanical simulator for the Levator ani

O assoalho pélvico é uma estrutura muscular complexa e as disfunções uroginecológicas desta musculatura são inúmeras. O diagnóstico das disfunções uroginecológicas podem ser realizadas por anamnese, avaliação clínica (palpação digital, perineometria e observação), urodinâmica, ultrassom e ressonância magnética. Os fisioterapeutas utilizam a palpação digital vaginal para obter informações de força da musculatura do assoalho pélvico. O objetivo do presente trabalho foi desenvolver um dispositivo eletromecânico, capaz de simular in vitro o músculo levantador do ânus, a fim de treinar futuros examinadores na sensibilidade do toque digital vaginal. Cinco molas foram fixadas em um modelo anatômico de resina da pelve em uma configuração que poderia representar o músculo elevador do ânus. Uma unidade de tração composta por motor de passo interligado a uma célula de carga foi utilizada para a caracterização da força de tração do sistema mecânico. Uma fisioterapeuta bem treinada realizou quatorze séries de palpação bidigital entre as cinco molas. Neste sentido, foi possível estabelecer valores de força que se correlacionavam com os seis graus da escala modificada de Oxford. As forças médias para todas as palpações bidigitais foram comparadas usando-se o teste de ANOVA de um fator controlável. De acordo com os resultados, o grau zero representou o alongamento nulo das molas. Os graus de 1 a 5 mostraram os seguintes valores médios de força: 1 (55,69 N), 2 (56,17 N), 3 (56,94 N), 4 (59,61 N), 5 (65,36 N). O dispositivo proposto apresentou-se como uma útil ferramenta para estabelecer a relação entre a força das molas e a escala modificada de Oxford.

The pelvic floor is a complex muscular structure and the urogynaecological dysfunctions of this muscular structureare innumerable. The diagnosis of these urogynaecological dysfunctions can be performed by anamnesis, clinical evaluation (digital palpation, perineometry and observation), urodynamics and by ultrasound or magnetic resonance imaging. Physiotherapist relies on vaginal digital palpation to obtain relevant data about pelvic floor strength. The aim of the present application was to develop an electromechanical device able to simulate in vitro the levator ani muscle in order to train the sensitivity of future examiners during a vaginal digital palpation. Five springs were fixed on a resin anatomical model of the human pelvis in a configuration that could represent the levator ani muscle. A traction unit composed by a load cell and a step motor was used to produce the traction of the springs being able to measure the traction force. One well trained physiotherapist executed all the fourteen series of digital palpation procedures between the five springs. It was possible to establish force values that were correlated to the six scores of the modified Oxford scale. The meanforces obtained for the complete digital assessment were compared using one-way ANOVA. According to the results, score 0 of the modified Oxford scale represented no elongation of the springs. Scores 1 to 5 showed the following mean force values: 1 (55.69 N), 2 (56.17 N), 3 (56.94 N), 4 (59.61 N), 5 (65.36 N). The proposed device presented itself as a useful tool which is able to establish a relation between the forces of the springs and the modified Oxford scale.