Verbal instruction to obtain voluntary pelvic floor muscle contraction: Acceptability, and understanding.

PURPOSE: The aim of this study was to describe verbal instructions used to obtain a voluntary pelvic floor muscle contraction and to evaluate their understanding and acceptability. METHODS: This prospective study led in two phases. A questionnaire was submitted to experts to collect the most frequently used instructions to obtain a PFMC. Then a questionnaire was submitted to subjects in order to: estimate the pelvic floor anatomical knowledge; estimate understanding and acceptability of these instructions; select the best instruction. RESULTS: First phase: 46 experts proposed 356 instructions. Forty-four percent were functional instructions ("hold a gas"), 40% anatomical ("squeeze your anus") and 16% allied both. Fifteen instructions for the women and 11 for the men were selected. Second phase: 33 subjects completed the questionnaire. More than 75% had correct answers for anatomical knowledge. The instructions judged by the subjects as the most adapted to obtain a PFMC were: "contract the anus", "do as if you wanted to hold a strong desire to void". The items including "perineum" or "vagina" were less understood. CONCLUSIONS: The more understandable and acceptable instruction to assess the PFMC is the association of two simple instructions: one anatomical and one functional. LEVEL OF EVIDENCE: 4.

Lack of repercussions of sleep apnea syndrome on recovery and attention disorders at the subacute stage after stroke: a study of 45 patients.

INTRODUCTION: Sleep apnea syndrome (SAS) frequently occurs after a stroke. Its association with a poor prognosis is open to discussion. OBJECTIVE: To study, in a physical and rehabilitation medicine (PRM) unit, the possible repercussions of SAS on neurological and functional recovery as well as attentional abilities following a stroke. PATIENTS AND METHODS: Forty-five patients, all of whom had recently had a stroke without previously documented SAS, were screened using the ApneaLink(®) system. An apnea-hypopnea index (AHI) score ≥10 was considered as indicative of SAS. The NIHSS, Fugl-Meyer (FM) and Functional Independence Measure (FIM) Scales were applied on admission and at two months as means of assessing neurological and functional recovery, which was expressed by the difference between the first and the second scores (delta FM, delta NIHSS, delta FIM). The Battery Attention William Lennox (BAWL) Test was given once in order to evaluate attention disorders. SAS severity was categorized according to the AHI. We compared the groups formed (mild, moderate and severe) using the same method. RESULTS: Twenty-eight patients (62.2%) presented AHI ≥ 10. Stroke characteristics were comparable in the SAS+ and the SAS- groups, with average post-stroke time lapse of 26 days, initial average FIM score of 71.2 points ± 26.3 and initial average NIHSS score of 8.9 ± 4.9. The demographic characteristics of the two groups were likewise comparable with the exception of age, as the SAS+ group was pronouncedly older (65.4 vs. 53.5 years). As for delta FIM, which evaluated functional recovery, it averaged 31.8 ± 20.6. Cases of SAS were found to be mild (37.1%), moderate (28.6%) or severe (34.3%). No significant difference was observed on admission or at 2 months as regards the clinical scales or the BAWL test between the two groups or according to severity, except for the NIHSS score at 2 months in the severe sub-group. DISCUSSION AND CONCLUSION: This study did not demonstrate the supposed repercussions of SAS on the recovery or attentional abilities of post-stroke patients. The tests were maybe given too early; they should take place at a lengthier time interval after the stroke, and also to be more complete.

[Lazy bladder syndrome: review of 126 cases]. / Mégavessie congénitale: analyse clinique et urodynamique de 126 cas.

PURPOSE: The lazy bladder syndrome (LBS) is characterized by an infrequent voiding, a large bladder capacity without neurological or urological disorders. In spite of being relatively common, there is little literature about it. The aim of our study was to compare the clinical features and urodynamic findings in asymptomatic or symptomatic patients with lazy bladder syndrome. PATIENTS AND METHODS: We reviewed the charts of 126 adult patients diagnosed with lazy bladder syndrome. Clinical and radiological features, urodynamic findings and therapeutic management were evaluated. With these data, we divided patients into 2 groups: asymptomatic and symptomatic patients. After, we performed a comparative analysis of the data. RESULTS: The incident of LBS was significantly higher in women (81%). Twenty-one patients were asymptomatic (17%), 105 patients were symptomatic (83%). The patients with symptomatic LBS were significantly older (54.3 years ± 14.7). Voiding dysfunction (53%) and urinary retention (27%) were the most common symptoms in symptomatic group. In the uroflowmetry test, maximum and mean uroflow were significantly higher in asymptomatic group (P=0.0074). Reduced bladder sensation revealed no difference in the 2 groups, but in the symptomatic group, detrusor has also a poor contractility (P=0.0001). Nineteen patients (18%) had uro-nephrological complications. CONCLUSION: LBS is certainly underestimated. Voiding dysfunction, urinary retention in infrequent voiders or uro-nephrological complication (urinary tract infection with fever, ureteral reflux…) should recall LBS diagnosis. The hypothesis of bladder structural failure or autonomic nervous system dysfunction may be discussed (suggested). LEVEL OF EVIDENCE: 5.

[Bacterial ecology and resistance to antibiotics in patients with neurogenic overactive bladder treated with intravesical botulinum toxin injections]. / Écologie bactérienne et profils de résistance aux antibiotiques chez les patients avec hyperactivité du détrusor d'origine neurologique, traités par injections de toxine botulique intradétrusoriennes.

INTRODUCTION: For the last ten years, botulinum neurotoxin type A has become the gold standard for the treatment of neurogenic overactive detrusor. Bacterial colonization is common for these patients using clean intermittent self-catheterization, and toxin injections are at risk of urinary tract infections. OBJECTIVES: The aim of our study was to determine the prevalence of different germs and their resistance to antibiotics in patients with neurogenic bladder, treated with intravesical botulinum toxin injections. MATERIAL AND METHOD: This epidemiologic study took place from September to October 2012 in a urodynamic and neurourology unit in a teaching hospital in Paris, France. RESULTS: Eighty patients with a valid urine culture according to our protocol, were included. Fourty-four culture were positive with 45 bacteria. We found an Escherichia coli in 42.5%, a Klebsiella pneumoniae in 7.5%, a Citrobacter freundii and an enterococcus in 2.5%, and a Staphylococcus aureus in 1.25%. Penicillin resistance were found in 51.11%, 3rd generation cephalosporins in 8.89%, quinolones in 28.89% and sulfamids in 24.44%. None were resistant to fosfomycin. CONCLUSION: E. coli was the most frequent bacterium. No resistance to fosfomycin was found.

Validation of the InCaSaQ, a new tool for the evaluation of patient satisfaction with clean intermittent self-catheterization.

AIMS: In neurourology, the choice of catheter is of paramount importance. At the time of our study, no simple validated questionnaire has been published, evaluating patient satisfaction with the use of urinary catheters. Our objective was to construct and validate a specific tool referred to as the Intermittent Catheterization Satisfaction Questionnaire (InCaSaQ), for the purposes of evaluating patient satisfaction with intermittent self-catheterization. METHODS: A simple tool was developed and validated in a neurourology referral centre, with 113 patients affected by a neurological bladder condition, between November 2011 and February 2012. Eight items, separated into four categories ("packaging", "lubrication", "catheter itself", "after catheterization") were selected. The mean score obtained with the eight-question questionnaire was calculated for each patient. Face validity was evaluated. Reliability based on internal consistency and test-retest reliability using the intraclass correlation coefficient (ICC) was carried out. RESULTS: The patients' comprehension and acceptance of the questionnaire were good. The questionnaire appears to have been well designed, with a significant Cronbach's alpha coefficient, and the ICC demonstrated good test-retest reliability. CONCLUSIONS: The InCaSaQ was found to be a valid tool for the evaluation of patient satisfaction with a urinary catheter. It is thus possible to compare the comfort and effectiveness of different types of catheter, and to objectify the need to change the type of catheter, in cases where patients express their dissatisfaction.

[Severe neonatal acidosis: comparison and analysis of obstetrical practices in two French perinatal centers]. / Comparaison des taux d'acidose néonatale sévère et analyse des pratiques obstétricales dans deux maternités françaises.

OBJECTIVES: To identify and compare risk factors for severe neonatal acidosis, defined by an umbilical artery pH inferior to 7.00, and clinical practices in two different perinatal centers. PATIENTS AND METHODS: In a retrospective study, from 2003 to 2008, in two university perinatal centers (Poitiers and Saint-Antoine in Paris) on all term pregnancies complicated by severe neonatal acidosis (umbilical artery pH<7.00), we elected to compare the following risk factors: maternal characteristics, medical and obstetrical histories, progress of pregnancy, labour and delivery as well as the neonatal status. RESULTS: Among 23,508 births, 177 term newborns had severe neonatal acidosis. The rate was similar for both perinatal centers of Poitiers and Saint-Antoine (0.92% and 0.77% respectively). Factors associated with severe neonatal acidosis were similar in both centers: maternal age, thick meconium, prior cesarean section. There were differences in obstetrical practices between the two centers: there were more caesarean sections and assisted vaginal deliveries in Paris and more inductions of labour in Poitiers. CONCLUSION: Severe neonatal acidosis is associated with the geographical origin, the progress of labour and the mode of delivery. It seems that severe neonatal acidosis is unrelated to cesarean delivery.

[Autonomic nervous system alteration in multiple sclerosis patients with urinary symptoms. Clinical, urodynamic and cardiovascular study]. / Dysautonomie et troubles urinaires au cours de la sclérose en plaques. Étude clinique, urodynamique et cardiovasculaire.

OBJECTIVE: To assess symptoms related to autonomic nervous system alteration in a population of patients suffering from multiple sclerosis (MS) and presenting with urinary symptoms. PATIENTS AND METHODS: We investigated 65 patients (mean age 47.5 years) suffering from MS, and presenting with urological dysfunction by means of symptom scores, urodynamic investigation, cardiovascular autonomic function tests (orthostatic hypotension testing, Valsalva test, deep breath test, cold pressor test) and sympathetic skin responses. RESULTS: Forty-five (69%) patients suffered from overactive bladder, 48 (73%) from voiding dysfunction, 14 (21%) from urinary retention and 13 (20%) from fecal incontinence. Urodynamic investigation demonstrated overactive detrusor in 46 (70%) cases, and underactive detrusor in four (6%) cases. Twenty-five (38%) patients had dysautonomia without correlation neither with clinical or urodynamic data, nor gravity of multiple sclerosis (EDSS). CONCLUSION: In this series, the prevalence of dysautonomia was high in patients suffering from MS and presenting with urinary disorders.

[Micturition and cognition]. / Cognition et miction.

PURPOSE: The physiopathology of the voiding and urinary continence was one of the hot topic of research these last few years. Unfortunately, anyone have already found a unique cause which could explain urinary incontinence (urge or stress). The concept of cognitive function highlights new ways of research to show the fundamental role of the cortex and the sub-cortex in these diseases. METHODS: A comprehensive literature review using Pubmed, Medline, Embase and Cochrane: "cognition, urinary tract, urinary continence, neuroimaging, IRMf, micturition, urge, brain factor and cognitive therapy". In all the articles, 72 really dealt with micturition and cognition. RESULTS: New imaging techniques allowed to show the relationship between the different brain area involved in the bladder control such as the periaqueductal gray, the hypothalamus, the insula, the anterior cingulated cortex and the prefrontal cortex. These cortical area are equally involved in cognition. An alteration of urinary continence implies a modification of activation of these cortical areas. CONCLUSION: A better knowledge of the cognitive side of micturition and urinary continence will allow to improve the treatment of their associated diseases.

[Comparison between autonomic nervous system cardiovascular tests (ANSCVT) and lacrymal and or salivary secretion tests (LSST) in overactive bladder syndrome and voiding dysfunction]. / Apport des tests sécrétoires dans la mise en évidence d'une dysrégulation végétative au cours des troubles vésicosphinctériens idiopathiques. Comparaison avec les tests cardiovasculaires de la fonction autonome.

PURPOSE: To compare autonomic nervous system cardiovascular tests (ANSCVT) and lacrymal and or salivary secretion tests (LSST). METHOD: One hundred and twenty-four patients (57 females, 67 males, mean age 45) with lower urinary tract symptoms (overactive bladder syndrome or voiding dysfunction) without neurogenic or urological causes, were included. Urodynamic was performed in all the patients with LSST (saliva flowmetry-sialometry [SFS], candy weight-loss test [CWT], Schirmer test [SchT]) and ANSCVT (ratio 30:15, orthostatic hypotension analysis, deep breath test [DBT], Valsalva maneuver [VM], cold pressor test [CPT] and hand grip test [HGT]). RESULTS: In eight cases, ANSCVT were altered (four in OAB syndrome, four in voiding dysfunction). No correlation was found between positive ANSCVT and LSST (P=0.72 for CWT, P=1 for SFS, P=0.1 for SchT). In contrary, there is a significant correlation between SchT and CWT (P=0.049), but not between SchT and SFS (P=0.69) or SFS vs CWT (P=0.06). CONCLUSION: In this series LSST were not sufficient to track down autonomic nervous system alterations and ANSCVT always necessary. Autonomic dysfunctions were infrequent in OAB syndrome and "idiopathic" voiding dysfunctions (6.5%).

[Persistent genital arousal disorder: a systematic review]. / Le syndrome d'excitation génital permanent : revue de la littérature.

PURPOSE: Persistent genital arousal disorder (PGAD) is a newly recognized condition rarely reported. Its recognition is useful to avoid labelling women suffering from PGAD as "mad". METHODS: A comprehensive literature review using Pubmed, Medline, Embase and Cochrane: "persistant genital arousal", "restless genital syndrome", "persitant genital arousal syndrome" and "persistant sexual arousal syndrome". In the 300 articles, 37 really dealt with PGAD. RESULTS: PGAD prevalence seemed to be more common than suspected (1%). PGAD has officially been defined in terms of five diagnostic criteria. Patients were on average from 35 to 54 years old. Among them, 29.9% to 67% were menopausal. PGAD was highly associated with overactive bladder (OAB) (67%), restless legs syndrome (RLS) (67%) and pelvic varices (55%). Genital sensations were experienced as unwanted, intrusive, on the verge of an orgasm. The unwanted genital sensations were experienced at the clitoris, labia and vagina or a combination of these localizations in 78%, 28%, 55% and 44% women, respectively. There are many suspected etiologies. Clinical management is the need of an electric and multidisciplinary approach (history, examination, investigation as pelvic MRI, pelvic ultrasound, biological exam). Treatments were various including psychological therapies, psychotropic treatment (56% women reported a persistent reduction of symptom [50%-90%] with clonazepam), transcutaneous electrical nerve stimulation (TENS)… CONCLUSION: This literature review provides readers with guidance on the management of PGAD.

[Self intermittent catheterization and voiding duration: in vitro flow rate assessment of catheters used in self-catheterization]. / Autosondages urinaires et temps de vidange : étude expérimentale de la vitesse de drainage des différentes sondes d'autocathétérisme.

OBJECTIVE: To assess the flow rate obtained by catheters used in self intermittent catheterization. MATERIAL: In vitro comparative study designed to compare the average flow rate obtained by intravesical catheters, by repeated flowmetric measures. The catheters studied were the most used in France in Fr10, 12 and 14 for female catheters and in Fr12, 14 and 16 for male catheters. RESULTS: We observed a strict relationship between Charriere and flow rate, both in female and male catheters These results were statistically significant (P<0.05). For female catheters, the average flow rate varied from 2.83 to 3.7 mL/s for Fr10 catheters, from 4.31 to 5.35 mL/s for Fr12 catheters and from 7.00 to 7.85 mL/s for Fr14 catheters (P<0.05). For male catheters, the average flow rate varied from 4.53 to 5.00 mL/s for Fr12 catheters, from 6.95 to 8.17 mL/s for Fr14 catheters and from 10.4 to 11.07 mL/s for Fr16 catheters (P<0.05). In female and male population, despite the observed flow rate differences between catheters, there were no statistically significant differences. CONCLUSION: This study demonstrated a better flow rate when Charriere increases. Thus, an objective adaptation of self catheterization's materiel is possible when the patient wishes to improve flow rate in order to reduce self intermittent catheterization duration.

[Female overactive bladder syndrome and autonomic nervous system]. / Hyperactivité vésicale idiopathique de la femme et système nerveux autonome.

PURPOSE: To analyse the hypothesis of an autonomic nervous system dysfunction in the female's idiopathic overactive bladder syndrome, by a literature review. METHOD: A systematic literature review (Pubmed, Medline, Cochrane database) concerning women presenting with overactive bladder syndrome and cardiovascular explorations of the autonomic nervous system (heart rate variability and cardiovascular tests). Keywords used for search: overactive bladder syndrome, female urinary incontinence, urge incontinence, autonomic nervous system. RESULTS: Heart rate variability (HRV) analysis among women with overactive bladder syndrome and controls has shown a difference between both, with is a global decrease of the heart rate variability parameters, or a relative increase of the sympathetic tone in overactive bladder syndrome. The sympathetic cardiovascular tests were more frequently abnormal among women presenting with overactive bladder syndrome than controls. CONCLUSION: All these studies suggest a sympathetic dysfunction of the autonomic nervous system in female's overactive bladder syndrome, but methodologies are too variable and the studies population too small to establish a pathophysiological link.

[Evidence of pudendal neuropathy in Proctalgia Fugax: perineal neurophysiological assessment in 55 patients]. / Proctalgies fugaces et neuropathie pudendale : étude neurophysiologique périnéale chez 55 patients.

OBJECTIVE: Proctalgia fugax (PF) is a very common condition especially in women. Causes and pathophysiological mechanisms of PF are unknown. Recently, a pudendal neuropathy was clinically suspected in women with PF. The goal of our study was to demonstrate, or not, such abnormalities by means electrophysiological testing. PATIENTS AND METHODS: Fifty-five patients with PF (45 female and 10 male, mean age 50.2 years) were evaluated. EMG testing with motor unit potential analysis of pelvic floor muscles (bulbocavernosus muscle and striated external anal sphincter), study of bulbocavernosus reflex and pudendal nerve terminal motor latencies (PNTML) were performed. RESULTS: EMG testing was altered in two males out of 10 (20%) and 29/45 females (64%). In women, denervation was found bilateral in 25/29 (86%). Sacral latency was delayed in eight out of 29 (bilateral in five cases, unilateral in three cases) and PNTML altered in 17 cases (13 bilateral alteration, four unilateral). A significant difference (P<0.002 Chi(2) test) was demonstrated between male and female concerning pelvic floor muscles denervation. CONCLUSION: Pelvic floor muscles denervation was a common feature in women suffering from PF, due to a stretch bilateral pudendal neuropathy. Distal lesions of the pudendal nerves, principally due to a stretch perineal neuropathy, can be imagined as a factor or co-factor of PF.

Therapeutic education and intermittent self-catheterization: recommendations for an educational program and a literature review.

PURPOSE: To review the literature and to clarify the recommendations for therapeutic education programs for intermittent self-catheterization. MATERIALS AND METHODS: The literature on Medline, Pubmed, and Cochrane Library, with specific keywords, as well as the recommendations based on expert consensus. RESULTS: Clean intermittent self-catheterization (CICS) is the gold standard for managing chronic urinary retention, which allows the patients to improve their quality of life and to reduce the complications of upper urinary tract infections. Patient education needs to have a structured procedure in order to evaluate the ability to understand, accept and perform CISC. CONCLUSION: Teaching self-catheterization is now well known; nevertheless, the effectiveness of CISC educational therapeutic programs remains to be demonstrated.

[Convalescence recommendations after incontinence and pelvic organ prolapse surgery: A study of opinions among French surgeons]. / Recommandations concernant la convalescence après chirurgie de l'incontinence ou du prolapsus génital : une enquête chez des chirurgiens français.

INTRODUCTION: Since increased intra-abdominal pressure contributes to pelvic floor disorders, physicians commonly restrict various activities postoperatively: most patients are instructed to avoid lifting, exercise and heavy labour after surgery. The aim of this study was to describe advice and restrictions given by French surgeons to patients after urogynecological surgery. METHODS: In 2009, French urologists and gynaecologists surgeons received a tested questionnaire about postoperative treatment and convalescence recommendations following stress urinary incontinence and pelvic organ prolapse surgery. RESULTS: After 13 exclusions (missing data), 76 (85%) of the questionnaires were suitable for analysis. The expected postoperative hospital stay was median 3 days (range, 3-4) following surgery by vaginal route or laparoscopic sacral colpopexy and 5 days (range, 4-6) following laparotomy (P<0.0001). The recommended sick leave was median 4 weeks (range, 2-8) for patients following pelvic organ prolapse surgery. The recommended time till recommencement of sexual intercourse was median 4 weeks (range, 2-12) following laparoscopic sacral colpopexy. The overall, great variance could not be explained by demographic differences between gynaecologists (male/female, private or public hospital, urologist/gynaecologist), but by surgical experience. Recommended lifting restrictions were median 6 weeks (range, 4-10) and 4 weeks (range, 2-8) following laparoscopic sacral colpopexy for low-experienced surgeons and high-experienced surgeons, respectively. CONCLUSION: Current activity restrictions often placed on postoperative patients show substantial variability. Evidence-based guidelines and consensus are desirable.

[Urinary disorders associated with bilharziasis. Urodynamic evaluation. Findings in 10 cases]. / Troubles vésico-sphinctériens des bilharzioses. Etude urodynamique. A propos de 10 cas.

UNLABELLED: Bilharziasis urinary disorders are characterized by recurent hematuria, overactive bladder symptoms (urgency, frequency and urge incontinence) and sometimes weak stream with or without urinary retention. We report 10 cases of urodynamic assessment. RESULTS: The main urodynamic symptom was overactive detrusor with uninhibited detrusor contraction during the filling phase. Only 1 patient had underactive detrusor leading to urinary retention. Urinary symptoms were secondary to a neurogenic abnormality (spinal lesion) in 2 cases, and to a specific lesion of bladder mucosa in 8 cases. CONCLUSION: Urodynamic investigations are usefull in bilharziasis urinary disorders in order to specify the pathophysiology of urinary symptoms and to point a specific neurogenic (spinal) alteration in the genesis of the urinary symptoms.

Cold perception of the bladder during ice water test. Study on 120 patients.

OBJECTIVE: If the pathophysiology of bladder cooling reflex (BCR) elicited during an ice water test (IWT) is well-known (triggered by activation of cold receptors within the bladder wall supplied by unmyelinated C fiber afferents) and is widely used for the diagnosis of upper motor neurological lesions, the significance of having a perception of cold in the bladder (PCB) during IWT has not been properly defined yet. PATIENT AND METHODS: Hundred and twenty patients undergoing IWT were analyzed and separated into four groups: group 1 (G1): patients with idiopathic overactive bladder syndrome (OAB); group 2 (G2): patients with functional dysuria (difficult urination due to bladder-neck obstruction, or congenital large bladder); group 3 (G3): patients with multiple sclerosis (MS) and group 4 (G4): patients with cauda equina syndrome (CES). All patients had a cystometry and IWT. After performing IWT, the patients were asked specific questions regarding the various sensations experienced during the cystometry and IWT, especially for detecting the presence or not of a cold sensation when their bladder was filling up. RESULTS: Patients with idiopathic OAB had more frequently a PCB than patients with MS (P<0.02). Patients with bladder-neck obstruction were more likely to retain a PCB than patients with CES (P<0.01). Lack of PCB is more frequent in patients with neurological diseases (P<0.001), with a sensitivity of 66% and specificity of 65%. CONCLUSION: Patients without neurological disease have a heightened PCB during the IWT than patients with neurological diseases. The lack of PCB may reflect an alteration of the afferent pathways or spinal reflex pathways or central neural pathways.

[Medico-legal incidence of instrumental delivery]. / Aspects médico-légaux de l'extraction instrumentale.

The aim of this data analysis on medical liability in professional guidelines on instrumental delivery, is to point out the most common difficulties to which obstetricians are exposed, and to discuss some aspects confronted to literature. Firstly, instrumental delivery is replaced in whole labour ward activity by unpublished results of a national enquiry on instrumental delivery concerning 239 337 deliveries during the year 2007. Then, the analysis of 61 data from legal claims in relation with instrumental deliveries between 1995 and 2007, to allow educational lessons. At last, few specific aspects of judicial expert opinion are confronted to literature and discussed: the effects of debriefing after operative childbirth; discussion on decision making and decision-to-delivery intervals. This chapter is concluded by different points on risk management in labour ward, mainly with potential interest of auditable standards and training with computer assisted simulation.

Perineal neuromuscular fatigue.

AIM: The physiology of urinary continence during stress is complex and the role of passive and active mechanisms remains unclear. Coughing leads to a contraction of urethral rhabdomyosphincter and pelvic floor muscles leading to a positive urethro-vesical gradient and continence. Neuromuscular fatigue can involve all striated muscles, including rhabdomyosphincter, peri-urethral and pelvic floor muscles. This article reviews results of studies assessing perineal muscular fatigue in urinary incontinence. MATERIALS AND METHODS: A systematic review of the literature (Medline, Pascal and Embase) with use of the MESH keywords fatigue, stress, urinary incontinence, pelvic floor, urethra, urethral pressure, and muscle. RESULTS: Animal models have shown that the pelvic muscles (iliococcygeus and pubococcygeous) exhibit more neuromuscular fatigue than classical skeletal striated muscles (i.e. soleus muscle). Although the human external urethral sphincter is considered to be a highly fatigue-resistant muscle with its high proportion of slow muscle fibers, repeated coughing seems to lead to decreased urethral pressure in numerous women affected with stress urinary incontinence. In this case, "urethral fatigue" might be a possibility. CONCLUSIONS: Although few studies have focused on perineal muscular fatigue, such increased fatigue in pelvic floor muscles may play a role in the pathophysiologic features of stress urinary incontinence in women.