Effects of perineal massage at different stages on perineal and postpartum pelvic floor function in primiparous women: a systematic review and meta-analysis.

BACKGROUND: Perineal massage, as a preventive intervention, has been shown to reduce the risk of perineal injuries and may have a positive impact on pelvic floor function in the early postpartum period. However, there is still debate concerning the best period to apply perineal massage, which is either antenatal or in the second stage of labor, as well as its safety and effectiveness. Meta-analysis was used to evaluate the effect of implementing perineal massage in antenatal versus the second stage of labor on the prevention of perineal injuries during labor and early postpartum pelvic floor function in primiparous women. METHODS: We searched nine different electronic databases from inception to April 16, 2024. The randomized controlled trials (RCTs) we included assessed the effects of antenatal and second-stage labor perineal massage in primiparous women. All data were analyzed with Revman 5.3, Stata Statistical Software, and Risk of Bias 2 was used to assess the risk of bias. Subgroup analyses were performed based on the different periods of perineal massage. The primary outcomes were the incidence of perineal integrity and perineal injury. Secondary outcomes were perineal pain, duration of the second stage of labor, postpartum hemorrhage, urinary incontinence, fecal incontinence, and flatus incontinence. RESULTS: This review comprised a total of 10 studies that covered 1057 primigravid women. The results of the analysis showed that perineal massage during the second stage of labor reduced the perineal pain of primigravid women in the immediate postpartum period compared to the antenatal period, with a statistical value of (MD = -2.29, 95% CI [-2.53, -2.05], P < 0.001). Additionally, only the antenatal stage reported that perineal massage reduced fecal incontinence (P = 0.04) and flatus incontinence (P = 0.01) in primiparous women at three months postpartum, but had no significant effect on urinary incontinence in primiparous women at three months postpartum (P = 0.80). CONCLUSIONS: Reducing perineal injuries in primiparous women can be achieved by providing perineal massage both antenatally and during the second stage of labor. Pelvic floor function is improved in the postnatal phase by perineal massage during the antenatal stage. TRIAL REGISTRATION: CRD42023415996 (PROSPERO).

Current evidence for hypopressive exercises in healthy women: A systematic review.

BACKGROUND: Hypopressive exercises have been mainly used in the treatment of pelvic floor dysfunctions. Recently it has started to spread among healthy women. However, no comprehensive review is available in this population. PURPOSE: Assess the current evidence of the effects of hypopressive exercises on healthy women. METHODS: This study was registered on PROSPERO (CRD42020203103). The search was performed in Scielo, Pubmed, Lilacs, Embase, Scopus, Pedro, Trip Database, Web of Science, and Google Scholar. The last search was performed on November 1st, 2021. Inclusion criteria were randomized controlled trials and single-arm trials, healthy women, acute or late effects of hypopressive exercises, and pre and post-training analysis. Exclusion criteria included non-original research, conference proceedings, dissertations and theses. Downs and Black checklist were used to assess the methodological quality. Study design, participants characteristics, description of the intervention, follow-up period, variables, instruments, and outcomes were extracted and recorded. RESULTS: From the 410 studies, five were selected. The variable of major interest was waist circumference, which showed a decrease with exercise. It also seemed to have plausible positive effects on height, lower back mobility, abdominal and pelvic floor muscle contraction, respiratory flow and apnea, and hemodynamic responses. CONCLUSION: This study suggests that the current literature on the effects of hypopressive exercise on healthy women is very limited. Despite the plausible positive effects identified, we cannot recommend its practice due to the serious methodological problems. Therefore, more studies are needed to elucidate the benefits and adverse effects of hypopressive exercises.

Pelvic floor muscle contraction automatic evaluation algorithm for pelvic floor muscle training biofeedback using self-performed ultrasound.

INTRODUCTION: Non-invasive biofeedback of pelvic floor muscle training (PFMT) is required for continuous training in home care. Therefore, we considered self-performed ultrasound (US) in adult women with a handheld US device applied to the bladder. However, US images are difficult to read and require assistance when using US at home. In this study, we aimed to develop an algorithm for the automatic evaluation of pelvic floor muscle (PFM) contraction using self-performed bladder US videos to verify whether it is possible to automatically determine PFM contraction from US videos. METHODS: Women aged ≥ 20 years were recruited from the outpatient Urology and Gynecology departments of a general hospital or through snowball sampling. The researcher supported the participants in their self-performed bladder US and videos were obtained several times during PFMT. The US videos obtained were used to develop an automatic evaluation algorithm. Supervised machine learning was then performed using expert PFM contraction classifications as ground truth data. Time-series features were generated from the x- and y-coordinate values of the bladder area including the bladder base. The final model was evaluated for accuracy, area under the curve (AUC), recall, precision, and F1. The contribution of each feature variable to the classification ability of the model was estimated. RESULTS: The 1144 videos obtained from 56 participants were analyzed. We split the data into training and test sets with 7894 time series features. A light gradient boosting machine model (Light GBM) was selected, and the final model resulted in an accuracy of 0.73, AUC = 0.91, recall = 0.66, precision = 0.73, and F1 = 0.73. Movement of the y-coordinate of the bladder base was shown as the most important. CONCLUSION: This study showed that automated classification of PFM contraction from self-performed US videos is possible with high accuracy.

Shift from Pro- to Anti-Inflammatory Phase in Pelvic Floor Muscles at Postpartum Matches Histological Signs of Regeneration in Multiparous Rabbits.

Background and Objectives: Pelvic floor muscles (PFM) play a core role in defecation and micturition. Weakening of PFM underlies urogynecological disorders such as pelvic organ prolapse and stress urinary incontinence. Vaginal delivery damages PFM. Muscle trauma implies an inflammatory response mediated by myeloid cells, essential for subsequent recovery. Molecular signaling characterizing the pro-inflammatory phase shifts M1 macrophages to M2 macrophages, which modulate muscle repair. The present study aimed to evaluate histological characteristics and the presence of M1 and M2 macrophages in bulbospongiosus (Bsm) and pubococcygeus muscles (Pcm). Materials and Methods: Muscles from young nulliparous (N) and multiparous rabbits on postpartum days three (M3) and twenty (M20) were excised and histologically processed to measure the myofiber cross-sectional area (CSA) and count the centralized myonuclei in hematoxylin-eosinstained sections. Using immunohistochemistry, M1 and M2 macrophages were estimated in muscle sections. Kruskal-Wallis or one-way ANOVA testing, followed by post hoc tests, were conducted to identify significant differences (p < 0.05). Results: The myofiber CSA of both the Bsm and Pcm of the M3 group were more extensive than those of the N and M20 groups. Centralized myonuclei estimated in sections from both muscles of M20 rabbits were higher than those of N rabbits. Such histological outcomes matched significant increases in HLA-DR immunostaining in M3 rabbits with the CD206 immunostaining in muscle sections from M20 rabbits. Conclusions: A shift from the pro- to anti-inflammatory phase in the bulbospongiosus and pubococcygeus muscles of multiparous rabbits matches with centralized myonuclei, suggesting the ongoing regeneration of muscles.

Ultrasound imaging of core muscles activity in multiparous women with vaginal laxity: a cross-sectional study.

Vaginal laxity (VL) is a common condition among multiparous women, especially those who have delivered vaginally. Since pelvic floor muscles (PFMs) work synergistically with other core muscles, physical therapy protocols that aim to treat VL should train the PFMs in combination with other core muscles. To investigate the activity of core muscles in multiparous women with and without VL, and its relation to sexual function. An observational, cross-sectional study. The study included 100 multiparous women, who were divided into two groups according to their scores on the vaginal laxity questionnaire (VLQ). Women who scored between 1 and 3 on the VLQ were categorized as having VL (n = 48), while those who scored between 5 and 7 were placed in the control group (n = 52). The primary outcomes were PFM displacement, diaphragmatic excursion, transversus abdominis activation ratio, and lumbar multifidus thickness measured by ultrasound imaging. The secondary outcome was sexual functioning, evaluated using the Arabic female sexual function index (ArFSFI). The VL group had significantly lower PFM displacement (mean difference (MD) - 0.42; 95% confidence interval (CI) - 0.49 to - 0.33; p = 0.001), diaphragmatic excursion (MD - 2.75; 95% CI - 2.95 to - 2.55; p = 0.001), lumbar multifidus thickness (MD - 10.08; 95% CI - 14.32 to - 5.82; p = 0.02), and ArFSFI scores (MD - 9.2; 95% CI - 10.59 to - 7.81; p = 0.001) in comparison to the control group (p < 0.05). Nevertheless, the transversus abdominis activation ratio demonstrated no significant difference between the two groups (MD 0.06; 95% CI - 0.05 to 0.17; p = 0.33). Multiparous women with VL had significantly lower PFM displacement, diaphragmatic excursion, lumbar multifidus thickness, and sexual function index scores than women in the control group. The only exception was transversus abdominis activation, which did not differ significantly between the VL and control groups.

The Development and Evaluation of the Kinesthetic Motor Imagery of Pelvic Floor Muscle Contraction Questionnaire (KMI-PFQ) in Spanish Women.

Practitioners have begun using motor imagery (MI) for preventing and treating some pelvic floor disorders. Due to requirements for imagining before performing a MI intervention and because there are few instruments available for assessing this specific ability in the pelvic floor musculature, we sought to develop and test a new MI questionnaire, the Kinesthetic Motor Imagery of Pelvic Floor Muscle Contraction Questionnaire (KMI-PFQ). We focused in this study on the development and analysis of the instrument's factorial structure and internal reliability in a participant sample of 162 healthy Spanish women (M age = 20.1, SD = 2.2 years). We developed and evaluated the KMI-PFQ's psychometric properties, finding it to have good internal consistency, with Cronbach's α = .838, ω coefficient = .839, and an intraclass correlation coefficient = .809, with two factors ("ability" and "mental effort") explaining 58.36% of response variance. The standard error of measurement was 3.58, and the minimal detectable change was 9.92. No floor or ceiling effects were identified. There was also good convergent validity as seen by statistically significant positive correlations between KMI-PFQ scores and the revised-Movement Image Questionnaire and Vividness of Visual Imagery Questionnaire. There were no statistically significant correlations between KMI-PFQ scores and the Orientation to Life Questionnaire. The KMI-PFQ is a valid and reliable instrument for measuring kinesthetic ability to feel/imagine pelvic floor muscle contractions in healthy Spanish women.

Techniques for Registration of Myoelectric Activity of Women's Pelvic Floor Muscles: A Scoping Review.

INTRODUCTION AND HYPOTHESIS: Surface electromyography is commonly applied to measure the electrophysiological activity of the neuromuscular system. However, there is no consensus regarding the best protocol to assess pelvic floor muscles. METHODS: A scoping literature review was carried out in six databases, using MeSH descriptors. It included studies with electromyographic assessment in adult women presenting or not with pelvic floor dysfunction. The results were presented in categories to contribute to the development of a protocol considering the most used parameters for non-invasive assessment of myoelectric activity of pelvic floor muscles. RESULTS: A total of 1,074 articles were identified, and 146 studies were selected for analysis. The intravaginal probe was used in 80.8% of the studies, the bipolar sensor with metallic plates placed on both sides of the vagina was the most frequent (71.3%), with a reference electrode positioned on the anterior superior iliac spine (33.5%). The supine position with hip and knee flexed (45.2%) was the most frequent position used. Of the studies, 44.5% normalized the data by maximum voluntary contraction (MVC) whereas 44.5% performed an average of 3 MVCs. CONCLUSIONS: The most frequently used protocol for the pelvic floor is the bipolar intracavitary probe with metal plates positioned at 3-9 o'clock and introduced distally to the vaginal introitus with the volunteer in the supine position and the hip and knee flexed with the reference placed on the anterior-superior iliac spine.

Randomised controlled pilot trial to assess effect of electrical stimulation of weak pelvic floor muscles.

INTRODUCTION AND HYPOTHESIS: Pelvic floor muscle training (PFMT) has level 1A scientific evidence for the treatment of urinary incontinence and pelvic organ prolapse. Past studies, however, have often excluded women with very weak pelvic floor muscles (PFM). The aim was to investigate the hypothesis that intravaginal electrical stimulation (iES) improves PFM strength more than PFMT in women with weak PFM, and to use these results to calculate sample size required for a future large randomised controlled trial (RCT). METHODS: This assessor-blinded pilot RCT had a two arm, parallel design with computer-generated Randomisation. Both groups were offered 12 one-to-one physiotherapy sessions over a 6-month period. The iES group received individual tailored electrical pulse parameters. The PFMT group received PFM exercises, with the addition of facilitation techniques at therapy sessions. A power calculator was used to calculate sample size. RESULTS: Fifteen women were recruited. Eight were randomised to iES and 7 to PFMT. Two subjects dropped out of the iES group. Median age was 49 years (range 36-77) and parity 2.1 (range 1-3). Both groups showed increases in PFM strength measured by manometery (iES 12.3, SD 12.0 vs PFMT 10.0, SD 8.1) cmH2O. There was no significant difference between groups. With a power of 0.80 we need a sample size of 95 women in each group to detect a difference between groups. CONCLUSION: There was no significant difference between the groups in improvements in PFM strength. To detect a difference, we would have required 95 women in each group.

Coactivation of the Pelvic Floor and Gluteus Medius Muscles While Walking and Running in Female Runners.

(1) Background: Pelvic-floor-muscle (PFM) activation acts synergistically with multiple muscles while performing functional actions in humans. The purpose of this study was to characterize the activity of the PFMs and gluteus medius (GM) while walking and running in physically active nulliparous females. (2) Methods: The peak and average amplitude of maximal voluntary contractions (MVCs) during 60 s of walking (5 and 7 km/h) and running (9 and 11 km/h) were measured with electromyography of the GM and PFMs in 10 healthy female runners. (3) Results: The activation of both muscles increased (p < 0.001) while walking and running. The MVC of the GM was reached when walking and tripled when running, while the PFMs were activated at half their MVC when running. The global ratio of the GM (75.3%) was predominant over that of the PFMs (24.6%) while static and walking. The ratio reached 9/1 (GM/PFM) while running. (4) Conclusion: The GM and PFMs were active while walking and running. The GM's MVC tripled at high speeds, while the PFMs reached only half of their maximum contraction.

Pelvic floor muscle training in female functional fitness exercisers: an assessor-blinded randomised controlled trial.

OBJECTIVE: Stress urinary incontinence (SUI) is common among females during functional fitness training, such as CrossFit. The aim of this study was to assess the effect of pelvic floor muscle training (PFMT) on SUI in female functional fitness exercisers. METHODS: This was an assessor-blinded randomised controlled trial with a PFMT group (n=22) and a control group (n=25). The PFMT group followed a 16-week home-training programme with 3 sets of 8-12 maximum pelvic floor muscle (PFM) contractions daily and weekly follow-up/reminders by phone. The primary outcome was change in a total score of the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI-SF). The secondary outcomes were perceived change of symptoms of SUI, change of PFM strength measured by vaginal manometry and symptoms of anal incontinence (AI) and pelvic organ prolapse (POP). RESULTS: 47 women, mean age of 33.5 years (SD: 8.1), participated. At 16 weeks, there was a mean difference between groups of -1.4 (95% CI: -2.6 to -0.2) in the change of the ICIQ-UI-SF score in favour of the PFMT group. The PFMT group completed a mean of 70% (SD: 23) of the prescribed protocol. 64% in the PFMT group versus 8% in the control group reported improved symptoms of SUI (p<0.001, relative risk: 7.96, 95% CI, 2.03 to 31.19). There were no group differences in the change of PFM strength or AI/POP symptoms. CONCLUSION: A 16-week home-training programme of the PFM led to improvements in SUI in female functional fitness exercisers. However, PFM strength and AI and POP symptoms did not improve significantly in the PFMT group compared with the control group.

Pelvic floor muscle strength and influencing factors based on vaginal manometry among healthy women at different life stages: A multicentre cross-sectional study.

OBJECTIVE: To assess pelvic floor muscle (PFM) strength and influencing factors among healthy women at different life stages. DESIGN: Multicentre cross-sectional study. SETTING: Fourteen hospitals in China. POPULATION: A total of 5040 healthy women allocated to the following groups (with 1680 women per group): premenopausal nulliparous, premenopausal parous and postmenopausal. METHODS: The PFM strength was evaluated by vaginal manometry. Multivariate logistic regression was used to determine the influencing factors for low PFM strength. MAIN OUTCOME MEASURES: Maximum voluntary contraction pressure (MVCP). RESULTS: The median MVCP values were 36, 35 and 35 cmH2O in premenopausal nulliparous (aged 19-51 years), premenopausal parous (aged 22-61 years), and postmenopausal (aged 40-86 years) women, respectively. In the premenopausal nulliparous group, physical work (odds ratio, OR 2.05) was the risk factor for low PFM strength, which may be related to the chronic increased abdominal pressure caused by physical work. In the premenopausal parous group, the number of vaginal deliveries (OR 1.28) and diabetes (OR 2.70) were risk factors for low PFM strength, whereas sexual intercourse (<2 times per week vs. none, OR 0.55; ≥2 times per week vs. none, OR 0.56) and PFM exercise (OR 0.50) may have protective effects. In the postmenopausal group, the number of vaginal deliveries (OR 1.32) and family history of pelvic organ prolapse (POP) (OR 1.83) were risk factors for low PFM strength. CONCLUSIONS: Physical work, vaginal delivery, diabetes and a family history of POP are all risk factors for low PFM strength, whereas PFM exercises and sexual life can have a protective effect. The importance of these factors varies at different stages of a woman's life.

Comparative analysis of pelvic floor muscle training and Pilates in managing urinary incontinence among postmenopausal women: a randomized controlled trial.

INTRODUCTION AND HYPOTHESIS: This study is aimed at comparing the effectiveness of pelvic floor muscle training (PFMT) and Pilates on the improvement of urinary incontinence (UI), strength, and endurance of the pelvic floor muscles (PFMs), and the impact of UI on the quality of life in postmenopausal women. METHODS: Forty postmenopausal women were randomly divided in to two groups: PFMT (n = 20) and Pilates (n = 20). The participants were followed for 12 weeks, three times a week on nonconsecutive days. UI was assessed using the pad test and the voiding diary, PFM strength and resistance using bidigital assessment and manometry, and the impact of UI on quality of life using the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF), before and after the 3-month treatment. RESULTS: There was a significant intra-group improvement in both groups for the pad test, mean daily urinary loss, and ICIQ-SF. The strength was significantly improved only in the PFMT group, and the endurance in both groups. Peak strength manometry was significantly improved only in the Pilates group, and the mean strength manometry in both groups. There was also an improvement in both groups for peak endurance manometry and mean endurance manometry. In the inter-group comparison, there was a significant improvement only in muscle strength, which was positive for group. CONCLUSIONS: There was no difference between Pilates and PFMT for the management of women in post-menopause with stress urinary incontinence, provided that voluntary contraction of the PFMs is performed. However, further randomized clinical trials need to be carried out.

Enhancement of Levator Ani Muscle Strength in Postpartum Women: The Impact of Pelvic Floor Muscle Training.

BACKGROUND Levator ani muscle injuries during vaginal childbirth can lead to pelvic organ prolapse (POP). Pelvic floor muscle training (PFMT) is an effective conservative approach to alleviate these symptoms. This study aimed to compare outcomes with and without 3 months of PFMT in 34 women with levator ani muscle injury following vaginal delivery. MATERIAL AND METHODS In a quasi-experimental study, 34 postpartum women were divided into 2 groups: one received PFMT along with home-based materials and regular follow-ups, while the other served as the control. We measured basal tone and maximal levator ani muscle contraction using the Peritron perineometer and assessed changes after 3 months. RESULTS The basal tone and maximal contraction of the levator ani muscle significantly increased following a 3-month intervention period both in PFMT and control group (P=0.0001). The maximal contraction of the levator ani muscle after a 3-month intervention period was significantly higher in PFMT group compared with control group (36.59±1.45 vs 27.76±13.35, P=0.0001), respectively. A significant positive correlation was found between basal tone and maximal contraction (r=0.806, P=0.0001). CONCLUSIONS A 3-month PFMT program effectively increased levator ani muscle strength in postpartum women compared to those who did not undergo PFMT.

Deep Diaphragmatic Breathing-Anatomical and Biomechanical Consideration.

Background: Deep diaphragmatic breathing (DDB) involves slow and fully contraction of the diaphragm with expansion of the belly during inhalation, and slow and fully contraction of the abdominal muscles with reduction of the belly during exhalation. It is the key component of the holistic mind-body exercises commonly used for patients with multimorbidity. Purpose: The purpose of this study was to re-visit and address the fundamental anatomical and biomechanical consideration of the DDB with the relevant literature. Method: Peer-reviewed publications from last the 15 years were retrieved, reviewed, and analyzed. Findings: In this article, we described the updated morphological and anatomical characteristics of the diaphragm. Then, we elucidated in a biomechanical approach how and why the DDB can work on the gastrointestinal, cardiopulmonary, and nervous systems as well as on regulating the intra-abdominopelvic pressure and mind-body interaction to coordinate the diaphragm-pelvic floor-abdominal complex for a variety of physical and physiological activities. Conclusion: Understanding of this updated DDB knowledge may help holistic healthcare professionals including holistic nurses provide better patient education and care management during the DDB or DDB-based mind-body intervention time.

Acute Effect of Heavy Weightlifting on the Pelvic Floor Muscles in Strength-Trained Women: An Experimental Crossover Study.

INTRODUCTION/PURPOSE: Heavy lifting may produce strain on the pelvic floor muscles (PFM) due to high increases in intra-abdominal pressure, but knowledge of the impact of weightlifting on the PFM is lacking. Therefore, this study aimed to investigate acute effects of heavy weightlifting on the PFM in strength-trained women and whether general strength in whole-body exercises correlated to PFM strength. METHODS: Forty-seven nulliparous women between 18 and 35 yr who regularly performed weightlifting and were able to lift their own body weight × 1.2 in back squat and 1.5 in deadlift were included in this experimental crossover study. They participated in baseline evaluations (questionnaire/measurements of background characteristics and pelvic floor disorders, one-repetition maximum (1RM) tests in back squat and deadlift) and one test day where they were randomized to start with 60 min of weightlifting (four sets of four repetitions at 75%-85% of 1RM in back squat and deadlift) or seated rest of 60 min. Vaginal pressure measurements of PFM resting pressure, strength, and endurance and surface electromyography measurements of PFM resting activity were performed before/after weightlifting and rest. RESULTS: No statistically significant differences were found when comparing the change in PFM resting pressure, strength, endurance, and resting activity after heavy weightlifting and rest. There were no statistically significant correlations between PFM strength and maximum (1RM) or relative strength (1RM/bodyweight) in either back squat or deadlift. CONCLUSIONS: Our results imply that heavy weightlifting is well tolerated by the PFM in short term among young, nulliparous, and strength-trained women. Strength in whole-body exercises was not correlated to PFM strength.

Effects of Different Delivery Modes on the Expression of Vesicle Transport-Related Genes in Female Pelvic Floor Muscle Repair After Injury.

A sudden rise in intra-abdominal pressure that causes the pressure in the bladder to rise during physical movement and/or activity, such as coughing, sneezing, laughing, running, or weightlifting, is known as stress urinary incontinence. This condition causes an uncontrollable overflow of urine. The study's goal was to determine whether effector molecules, specifically ADP ribosylation factor GTPase activated protein 3, might play a part in the female pelvic floor muscle's ability to heal after suffering damage during vaginal delivery. Pelvic floor muscle samples were taken from women who had at least one vaginal delivery and were enrolled in either the IU group (n = 45; issue of stress urinary incontinence) or the NL group (n = 85; no issue of stress urinary incontinence) depending on whether they had a problem with stress urinary incontinence. Vesicle transport-related genes in female pelvic floor muscle injury repair were discovered using Gene Expression Omnibus. For gene analysis and screening, RT-qPCR was employed. On the first day following injury, the expression level of ARFGAP3 mRNA increased by 2.8 times (p 0.05) and by 5 times (p 0.01) on the third day. On the first day following damage, STMN1 mRNA expression rose by 0.3 times (p 0.05). On the first day following injury, the expression level of THBS2 mRNA increased by 1.6 times (p 0.01). On the third day following the injury, the expression level of PLXNB2 mRNA increased by 1.2 times (p 0. 01), and on the fifth day following the injury, it increased by 2.5 times (p 0. 01). After pelvic floor muscle damage, the mRNA expression levels of the CSF1R, ANXA4, and EMR1 genes dropped. Between those with and without pelvic floor muscle damage, there was no statistically significant difference in the expression levels of LGARLS3, KDELR3, and KIF20A mRNA (p > 0. 05 for all). The differential expression of genes after pelvic floor muscle injury can identify the target in the process of pelvic floor muscle injury repair and regeneration.

Effect of nonsteroidal anti-inflammatory drugs on pelvic floor muscle regeneration in a preclinical birth injury rat model.

BACKGROUND: Pelvic floor muscle injury is a common consequence of vaginal childbirth. Nonsteroidal anti-inflammatory drugs are widely used postpartum analgesics. Multiple studies have reported negative effects of these drugs on limb muscle regeneration, but their impact on pelvic floor muscle recovery following birth injury has not been explored. OBJECTIVE: Using a validated rat model, we assessed the effects of nonsteroidal anti-inflammatory drug on acute and longer-term pelvic floor muscle recovery following simulated birth injury. STUDY DESIGN: Three-month old Sprague Dawley rats were randomly assigned to the following groups: (1) controls, (2) simulated birth injury, (3) simulated birth injury+nonsteroidal anti-inflammatory drug, or (4) nonsteroidal anti-inflammatory drug. Simulated birth injury was induced using a well-established vaginal balloon distension protocol. Ibuprofen was administered in drinking water (0.2 mg/mL), which was consumed by the animals ad libitum. Animals were euthanized at 1, 3, 5, 7, 10, and 28 days after birth injury/ibuprofen administration. The pubocaudalis portion of the rat levator ani, which, like the human pubococcygeus, undergoes greater parturition-associated strains, was harvested (N=3-9/time point/group). The cross-sectional areas of regenerating (embryonic myosin heavy chain+) and mature myofibers were assessed at the acute and 28-day time points, respectively. The intramuscular collagen content was assessed at the 28-day time point. Myogenesis was evaluated using anti-Pax7 and anti-myogenin antibodies to identify activated and differentiated muscle stem cells, respectively. The overall immune infiltrate was assessed using anti-CD45 antibody. Expression of genes coding for pro- and anti-inflammatory cytokines was assessed by quantitative reverse transcriptase polymerase chain reaction at 3, 5, and 10 days after injury. RESULTS: The pubocaudalis fiber size was significantly smaller in the simulated birth injury+nonsteroidal anti-inflammatory drug compared with the simulated birth injury group at 28 days after injury (P<.0001). The median size of embryonic myosin heavy chain+ fibers was also significantly reduced, with the fiber area distribution enriched with smaller fibers in the simulated birth injury+nonsteroidal anti-inflammatory drug group relative to the simulated birth injury group at 3 days after injury (P<.0001), suggesting a delay in the onset of regeneration in the presence of nonsteroidal anti-inflammatory drugs. By 10 days after injury, the median embryonic myosin heavy chain+ fiber size in the simulated birth injury group decreased from 7 days after injury (P<.0001) with a tight cross-sectional area distribution, indicating nearing completion of this state of regeneration. However, in the simulated birth injury+nonsteroidal anti-inflammatory drug group, the size of embryonic myosin heavy chain+ fibers continued to increase (P<.0001) with expansion of the cross-sectional area distribution, signifying a delay in regeneration in these animals. Nonsteroidal anti-inflammatory drugs decreased the muscle stem cell pool at 7 days after injury (P<.0001) and delayed muscle stem cell differentiation, as indicated by persistently elevated number of myogenin+ cells 7 days after injury (P<.05). In contrast, a proportion of myogenin+ cells returned to baseline by 5 days after injury in the simulated birth injury group. The analysis of expression of genes coding for pro- and anti-inflammatory cytokines demonstrated only transient elevation of Tgfb1 in the simulated birth injury+nonsteroidal anti-inflammatory drug group at 5 but not at 10 days after injury. Consistently with previous studies, nonsteroidal anti-inflammatory drug administration following simulated birth injury resulted in increased deposition of intramuscular collagen relative to uninjured animals. There were no significant differences in any outcomes of interest between the nonsteroidal anti-inflammatory drug group and the unperturbed controls. CONCLUSION: Nonsteroidal anti-inflammatory drugs negatively impacted pelvic floor muscle regeneration in a preclinical simulated birth injury model. This appears to be driven by the negative impact of these drugs on pelvic muscle stem cell function, resulting in delayed temporal progression of pelvic floor muscle regeneration following birth injury. These findings provide impetus to investigate the impact of postpartum nonsteroidal anti-inflammatory drug administration on muscle regeneration in women at high risk for pelvic floor muscle injury.

Efficacy of educational instructions on pelvic floor muscle training in the treatment of urinary incontinence: Systematic review and meta-analysis.

OBJECTIVE: The present study aimed to investigate the efficacy of educational interventions on pelvic floor (PF) muscle training in the treatment of urinary incontinence (UI). METHODS: This is a systematic review of literature with meta-analysis, performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). To do so, randomized clinical trials that performed educational interventions of PF, UI, and developed the training of PF muscles (TPFM) for incontinent women, performing group or individual comparisons, with control and experimental groups or with two or more experimental groups were selected. The search for papers was performed in the following databases: PubMed, Scopus, Embase, Web of Science, and SciELO, no specific publication date was chosen. The risk of bias was performed using the PEDro scale and the quality of the evidence was performed using GRADE. RESULTS: The review included six studies with 1003 participants. Most studies presented 5-8 points regarding risk of bias. Most of the studies were performed in the last 5 years, with women of various ages, high educational level and prevalence of UI of effort. The present study showed that offering educational instructions and guiding women on TPFM was capable of reducing urinary symptoms. When compared to control, significant between-group differences were found in the studies, in which the control group did not receive any kind of instructions or treatment (p < 0.05). The use of technologies through mobile apps was efficient in the treatment of incontinent women (p < 0.05). Performing TPFM individually or in groups did not present differences in the results, with both improving urinary symptoms. The meta-analysis presented a mean effect and a clinically important difference in three studies. CONCLUSION: The interventions involving instructions to TPFM associated to health education brought improvements to urinary symptoms.