Relationships Between 3-Dimensional Transperineal Ultrasound Imaging and Digital Intravaginal Palpation Assessments of the Pelvic Floor Muscles in Women With and Without Provoked Vestibulodynia.

BACKGROUND: Digital intravaginal palpation remains the favored method for clinical assessment of pelvic floor muscle (PFM) function in women; however, there is growing interest in using transperineal ultrasound imaging (TPUSI). TPUSI does not involve vaginal penetration, making it particularly relevant for PFM assessment in women with genito-pelvic pain and penetration disorders. AIMS: To study the relations between measures of PFM morphology and function assessed using 3-dimensional (3D) TPUSI and PFM assessment through intravaginal palpation. METHODS: 77 nulliparous premenopausal women with (n = 38) and without (n = 39) PVD participated. 3D TPUSI was used to measure levator hiatal dimensions at rest, at maximal voluntary contraction (MVC) of the PFMs, and at maximal Valsalva maneuver (MVM). Intravaginal palpation was used to assess PFM strength, PFM tone, PFM relaxation after contraction, and vaginal flexibility; each was scored using an ordinal grading scale. Ultrasound and palpation outcomes were compared using Spearman correlation coefficients and Kruskal-Wallis 1-way analyses of variance by rank. OUTCOMES: Outcomes included ultrasound measures of the levator hiatal area, anteroposterior diameter, and left-right transverse diameter at rest, at MVC, and at MVM; raw and relative changes in hiatal dimensions between rest and MVC and between rest and MVM; and palpation measures of PFM strength, tone, and relaxation after contraction, and vaginal flexibility. RESULTS: Weak to fair correlations were found between ultrasound and palpation measures. A smaller levator hiatus at rest was associated with greater PFM tone, less PFM relaxation, and less vaginal flexibility. Greater levator hiatal constriction and shortening of the hiatal anteroposterior diameter at MVC were associated with greater palpated PFM strength. Greater hiatal distention at MVM was associated with lower PFM tone and greater relaxation. CLINICAL TRANSLATION: 3D TPUSI and intravaginal palpation provide related but distinct information about PFM function in young women with and without PVD with high functioning PFMs. STRENGTHS AND LIMITATIONS: This was the first study to compare PFM assessment using 3D TPUSI and intravaginal palpation in nulliparous premenopausal women. A main strength of the study was the inclusion of women with PVD and asymptomatic controls, which provided a wide range in outcomes because differences in PFM morphology and function exist between women with and without PVD. The lack of inclusion of older women and women with weaker and/or hypotonic PFMs limits the generalizability of the findings. CONCLUSION: Although TPUSI has several advantages, including painless application, it is not recommended as a replacement for digital palpation in the clinical assessment of PFM function. Thibault-Gagnon S, Goldfinger C, Pukall C, et al. Relationships Between 3-Dimensional Transperineal Ultrasound Imaging and Digital Intravaginal Palpation Assessments of the Pelvic Floor Muscles in Women With and Without Provoked Vestibulodynia. J Sex Med 2018;15:346-360.

The temporal relationship between activity of the pelvic floor muscles and motion of selected urogenital landmarks in healthy nulliparous women.

AIMS: The purpose of this study was to investigate the relationship between pelvic floor muscle (PFM) electromyographic (EMG) activation and urogenital landmark motion measured using 2D transperineal ultrasound (US) imaging. METHODS: Eight healthy, nulliparous women performed maximum voluntary PFM contractions while EMG and transperineal US images were acquired simultaneously. Changes in the levator plate length (LPL), bladder neck (BN) position and urethral position were determined by visual inspection. The relative timing of EMG onset and the onset of landmark motion, and the correlation coefficients between EMG activation and landmark motion were computed. Comparisons between the correlation coefficients and onset latencies of each landmark motion were made using one-way analysis of variance models. RESULTS: Despite generally good reliability metrics for the onset of EMG and the onset of landmark motion, the relative timing of EMG onset and the onset of landmark motion demonstrated no systematic patterns of activation onset. That said, the overall motion of the different urogenital landmarks throughout the MVC task was highly correlated with the PFM EMG data; correlation coefficients were generally good (>0.90) and highly significant (p < .001). The correlation between PFM EMG and LPL motion was significantly better than the correlation between PFM EMG and motion of the other landmarks. The relevance of one outlier is discussed. CONCLUSIONS: The motion of all urogenital landmarks seen on US imaging is highly correlated with PFM EMG activation during maximum voluntary PFM contractions and may therefore be of value in the context of biofeedback training to infer that PFM activation has occurred. The motion of the BN, however, may require more cautious interpretation than the reduction of LPL. The timing of the onset of urogenital landmark motion on transperineal US imaging does not precede nor follow the timing of PFM activation, while the high variance of relative onset timing makes the onset of landmark motion of questionable value when training or evaluating co-ordination or motor control.

Differences in Pelvic Morphology Between Women With and Without Provoked Vestibulodynia.

OBJECTIVE: Pelvic morphology has been suggested to reflect increased tone and reduced strength of the pelvic floor muscles (PFMs) in women with provoked vestibulodynia (PVD) compared to healthy controls. We aimed to determine whether there are differences in pelvic morphology in the resting state, on maximum voluntary contraction (MVC), or on maximum effort Valsalva maneuver (MVM) between women with and without PVD. METHODS: While imaged using ultrasound, 38 women with PVD and 39 controls relaxed their PFMs, performed 3 MVCs and performed 3 MVMs. Levator plate length (LPL), levator plate angle (LPA), and anorectal angle (ARA) were determined at rest, at MVC and at MVM. The displacement of the bladder neck (BN) on MVC and on MVM was also determined. Two-way ANCOVAs were used to evaluate the main effects of group and task, the interaction between group and task, and the effect of resting morphology on LPL, LPA, and ARA. A 2-way repeated-measures ANOVA was used to determine whether the groups differed in terms of BN displacement during the tasks. RESULTS: Women with PVD had smaller LPLs and LPAs than controls across all tasks. The significant group differences in LPL and LPA at MVC and MVM were no longer significant once the resting values were included as covariates in the models. Bladder neck displacement differed between the groups at MVM but not at MVC. CONCLUSION: Women with PVD display shorter LPL sand smaller LPAs than controls but their behavior does not differ when MVC and MVMs are performed. Our results do not support the hypothesis that women with PVD demonstrate abnormalities in PFM contractility on MVC or compliance on MVM.

Effectiveness of Cognitive-Behavioral Therapy and Physical Therapy for Provoked Vestibulodynia: A Randomized Pilot Study.

INTRODUCTION: Non-medical and non-surgical treatments for provoked vestibulodynia target psychological, sexual, and pelvic floor muscle factors that maintain the condition. AIM: The goal of the study was to compare the effects of cognitive-behavioral therapy (CBT) and physical therapy (PT) on pain and psychosexual outcomes in women with provoked vestibulodynia. METHODS: In a clinical trial, 20 women with provoked vestibulodynia were randomly assigned to receive CBT or comprehensive PT. Participants were assessed before treatment, after treatment, and at 6-month follow-up by gynecologic examination, structured interviews, and standardized questionnaires measuring pain, psychological, and sexual variables. MAIN OUTCOME MEASURES: Outcome measurements were based on an adaptation of the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials recommendations. The primary outcome was change in intercourse pain intensity. Secondary outcomes included pain during the cotton swab test, pain with various sexual and non-sexual activities, and sexual functioning and negative pain cognitions. RESULTS: The two treatment groups demonstrated significant decreases in vulvar pain during sexual intercourse, with 70% and 80% of participants in the CBT and PT groups demonstrating a moderate clinically important decrease in pain (≥30%) after treatment. Participants in the two groups also had significant improvements in pain during the gynecologic examination, the percentage of painful intercourse attempts, the percentage of activities resulting in pain, and the ability to continue intercourse without stopping because of pain. Psychological outcomes, including pain catastrophizing and perceived control over pain, also showed improvement in the two groups. Significant improvements in sexual functioning were observed only in participants who completed CBT. Few between-group differences were identified other than the PT group showing earlier improvements in some outcomes. Nearly all improvements were maintained at the 6-month follow-up. CONCLUSION: The results of the study suggest that CBT and PT can lead to clinically meaningful improvements in pain and areas of psychosexual functioning.

Differences in the Biometry of the Levator Hiatus at Rest, During Contraction, and During Valsalva Maneuver Between Women With and Without Provoked Vestibulodynia Assessed by Transperineal Ultrasound Imaging.

INTRODUCTION: Pelvic floor muscle (PFM) involvement is suspected in the pathophysiology of provoked vestibulodynia (PVD); however, the underlying mechanisms are unclear. PFM morphology can be inferred from the biometry of the levator hiatus determined through dynamic ultrasound imaging. AIMS: The aim of this study was to determine the nature of PFM involvement in women with PVD via an evaluation of the biometry of the levator hiatus at rest, upon maximal voluntary contraction (MVC) of the PFMs, and upon maximal Valsalva maneuver (MVM). METHODS: Thirty-eight women with PVD and 39 asymptomatic controls were imaged using 3D transperineal ultrasound. Levator hiatal dimensions (area; left-right [LR] and anteroposterior [AP] diameters) were measured at rest, on MVC, and on MVM. Differences in hiatal dimensions and in relative changes in dimensions from rest to MVC and from rest to MVM were compared between groups using separate 1-way analyses of variance for each measure and task. Analysis of covariance models were used to investigate the impact of levator hiatal dimensions at rest on the relative changes in the levator hiatal dimensions during MVC and MVM. MAIN OUTCOME MEASURES: Levator hiatal area, LR, and AP diameters, at rest, on MVC, and on MVM were the main outcome measures. Relative changes in hiatal dimensions were assessed as the percent change in hiatal area, LR diameter, and AP diameter. RESULTS: In comparison with controls, women with PVD had smaller hiatal areas at rest, on MVC, and on MVM, concurrent with smaller LR diameters on MVM. Women with PVD had a significantly smaller change in hiatal area on MVM than controls, but no differences were evident on MVC. In both groups, smaller levator hiatal dimensions at rest were associated with smaller relative decreases in dimensions on MVC and larger relative increases in dimensions on MVM. CONCLUSION: In comparison to controls, women with PVD appear to have narrower levator hiatus' and less capacity to distend their hiatus on Valsalva. The state of the PFMs at rest appears to significantly influence biometric changes in the PFMs during contraction and Valsalva.

Active and Passive Components of Pelvic Floor Muscle Tone in Women with Provoked Vestibulodynia: A Perspective Based on a Review of the Literature.

AIM: Pelvic floor muscle (PFM) dysfunctions, especially elevated tone or tension, are suggested to play an important role in the pathophysiology of provoked vestibulodynia (PVD). However, the involvement of the PFMs remains misunderstood as the assessment of muscle tone is complex and requires a thorough understanding of muscle physiology in relation to the characteristics and limitations of current PFM assessment tools. The aim of this review was to describe the structures and mechanisms involved in muscle tone in normally innervated muscle, and to discuss and relate these concepts to the PFM findings in women with PVD. METHODS: A narrative overview of the literature retrieved from searches of electronic databases and hand searches. RESULTS: Muscle tone in a normally innervated muscle comprises both active (contractile) and passive (viscoelastic) components. Current methods for evaluating PFM tone such as digital palpation, ultrasound imaging, pressure perineometry, dynamometry, and electromyography may evaluate different components. Research findings suggestive of PFM hypertonicity in women with PVD include elevated general PFM tone, changes in viscoelastic properties, and at least in some women, abnormal increases in electrogenic activity. CONCLUSION: There is a growing body of evidence to support the involvement of PFM hypertonicity in the pathophysiology of PVD. Limitations of the instruments as well as their properties should be considered when evaluating PFM tone in order to obtain better insight into which component of PFM tone is assessed. Future research is required for further investigating the underlying mechanisms of PFM hypertonicity, and studying the specific effects of physiotherapeutic interventions on PFM tone in women with PVD.

Do women notice the impact of childbirth-related levator trauma on pelvic floor and sexual function? Results of an observational ultrasound study.

INTRODUCTION AND HYPOTHESIS: The levator ani is thought to play an important role in sexual function; however, to date little literature has been published on the impact of delivery-related levator trauma on female sexual function. We hypothesised that delivery-related levator trauma has a negative impact on women's reports of pelvic floor and sexual function postpartum. METHODS: In 294 primigravid women with a singleton pregnancy, four-dimensional (4D) translabial ultrasound imaging was used to assess delivery-related levator avulsion and levator hiatal over-distension, and postpartum pelvic floor and sexual function was assessed by an in-house validated questionnaire. Associations between questionnaire responses and levator avulsion and hiatal over-distension were investigated using standard linear modelling methods. RESULTS: Levator avulsion was diagnosed in 14% of women (42 out of 292; 25 unilateral, 17 bilateral) and was found to be significantly associated with lower scores for the pelvic floor integrity and function domain of the questionnaire (P < 0.0005). Avulsion was associated with lower scores for this domain (no avulsion = 2.78, unilateral avulsion = 2.61, bilateral avulsion = 2.29). This association remained significant after controlling for potential confounders (p = 0.013). Avulsion was not associated with any of the other domains of sexual function and levator hiatal over-distension was not associated with scores for any of the questionnaire domains. CONCLUSIONS: The effect of levator avulsion on pelvic floor and sexual function an average of 5.2 months after childbirth seems to be limited to a perception of increased vaginal and pelvic floor muscle laxity, and reduced pelvic floor muscle efficiency. The impact of levator hiatal over-distension on postpartum pelvic floor and sexual function appears to be negligible.

Pelvic floor ultrasound imaging: are physiotherapists interchangeable in the assessment of levator hiatal biometry?

PURPOSE: To evaluate inter-examiner reliability in the ultrasound (US) assessment of levator hiatal dimensions when different physiotherapists perform independent data acquisition and analysis. METHODS: In this cross-sectional observational study, 14 asymptomatic nulliparous women were imaged at rest, during pelvic floor muscle contraction, and during Valsalva manoeuvre by two physiotherapists using three-dimensional (3D) and four-dimensional (4D) transperineal US. Examiners each measured the dimensions of the levator hiatus (area and antero-posterior and transverse diameters) from the US volumes they respectively acquired. Inter-examiner reliability was determined using intra-class correlation coefficients (ICCs), and inter-examiner agreement was determined using Bland-Altman analyses. RESULTS: The ICC results demonstrated very good inter-examiner reliability (ICC=0.84-0.98); Bland-Altman results showed high inter-examiner agreement across all measurements. CONCLUSIONS: Trained examiners may be considered interchangeable in the US assessment of levator hiatal biometry. Overall, trained physiotherapists using transperineal US imaging to assess levator hiatal biometry can be confident when comparing their own clinical findings to those of their colleagues and to findings published in the literature.

Objectif : Examiner la fiabilité entre examinateurs de l'évaluation échographique des dimensions hiatales du muscle releveur de l'anus lorsque des physiothérapeutes différents procèdent à l'acquisition et à l'analyse indépendante de données. Méthodes : Au cours de cette étude par observation transversale, 14 femmes nullipares asymptomatiques ont subi un examen d'imagerie au repos, au cours d'une contraction des muscles du plancher pelvien et durant une manœuvre de Valsalva, effectué par deux physiothérapeutes utilisant l'échographie transpérinéale tridimensionnelle (3D) et quadridimensionnelle (4D). Chaque examinateur a mesuré les dimensions du hiatus du muscle releveur (superficie et diamètre antéropostérieur et transversal) à partir des volumes échographiques qu'ils ont acquis respectivement. On a déterminé la fiabilité entre examinateurs à partir des coefficients de corrélation intra-classe (CCI) et déterminé l'uniformité entre examinateur au moyen des analyses de Bland et d'Altman. Résultats : Les résultats de l'application des CCI ont révélé une très bonne fiabilité entre examinateurs pour toutes les mesures. (CCI=0.84­0.98); les résultats de Bland et Altman ont révélé une grande uniformité entre examinateurs pour toutes les mesures. Conclusions : Les examinateurs qui ont reçu une formation peuvent être considérés comme interchangeables dans l'évaluation échographique de la biométrie hiatale du muscle releveur. Dans l'ensemble, les physiothérapeutes qui ont suivi une formation et utilisent l'imagerie échographique transpérinéale pour évaluer la biométrie hiatale du muscle releveur peuvent comparer en toute confiance leurs constatations cliniques à celles de leurs collègues et à celles des publications.

Management of female sexual pain disorders.

Our understanding of the sexual pain disorders vaginismus and dyspareunia has been fundamentally altered over the past two decades due to increased attention and empirically sound research in this domain. This increased knowledge base has included a shift from a dualistic view of the etiology of painful and/or difficult vaginal penetration being due to either psychological or physiological causes, to a multifactorial perspective. The present chapter reviews current classification and prevalence rates, including ongoing definitional debates. Research regarding the etiology, assessment and management of sexual pain disorders is discussed from a biopsychosocial perspective. Cyclical theories of the development and maintenance of sexual pain disorders, which highlight the complex interplay among physiological, psychological and social factors, are described. Medical/surgical treatment options, pelvic floor rehabilitation and psychological approaches are reviewed, as well as future directions in treatment research.