Mechanisms for pelvic floor muscle training: Morphological changes and associations between changes in pelvic floor muscle variables and symptoms of female stress urinary incontinence and pelvic organ prolapse-A narrative review.

INTRODUCTION: Today there is Level 1, recommendation A for pelvic floor muscle training (PFMT) to be effective in treatment of stress urinary incontinence (SUI) and pelvic organ prolapse (POP). However, the mechanisms of action are discussed. The aim of the present overview was to give an update of studies evaluating the effect of PFMT on pelvic floor morphology and associations between changes in PFM strength and symptoms of female SUI and POP. MATERIALS AND METHODS: This was a narrative review retrieving studies from systematic reviews of PFMT for SUI and POP. In addition, an open search on PubMed with the search terms PFMT and morphology was conducted. Both randomized controlled trials (RCTs) and pre-posttest design studies were included. PEDro rating scale (0-10) was used to assess risk of bias. RESULTS: Ten studies were found reporting on morphological changes after PFMT. The four RCTs had PEDro score between 5 and 8/10. The studies found significant higher bladder neck position and narrower levator hiatus dimensions, thicker external urethral sphincter, increased cross-sectional area of PFM, improvement in PFM tears and blood flow. Twenty studies analyzed associations between changes in different PFMT variables and SUI and POP. Eleven studies found a positive weak to moderate association and six studies reported no association. Studies comparing responders and nonresponders to PFMT found statistically significant better PFM variables in responders. CONCLUSION: PFMT can change pelvic floor muscle and external urethral sphincter anatomy. This contributes to the understanding on how PFMT can be effective in prevention and treatment of SUI and POP.

ATRA regulates myoblast differentiation and fusion through the RARα/Pitx2 signaling pathway, causing abnormal development of PFMs in ARM fetal rats.

Anorectal malformation (ARM) is the most common congenital digestive tract anomaly in newborns, and children with ARM often have varying degrees of underdevelopment of the pelvic floor muscles (PFMs). To explore the effects of RARα and Pitx2 on the development of rat PFMs, we constructed a rat ARM animal model using all-trans retinoic acid (ATRA), and verified the expression of RARα and Pitx2 in the PFMs of fetal rats. Additionally, we used rat myoblasts (L6 cells) to investigate the regulatory roles of RARα and Pitx2 in skeletal muscle myoblast differentiation and their interactions. The results indicated a significant decrease in the expression of RARα and Pitx2 in the PFMs of fetal rats with ARM. ATRA can also decrease the expression of RARα and Pitx2 in the L6 cells, while affecting the differentiation and fusion of L6 cells. Knocking down RARα in L6 cells reduced the expression of Pitx2, MYOD1, MYMK, and decreased myogenic activity in L6 cells. When RARα is activated, the decreased expression of Pitx2, MYOD1, and MYMK and myogenic differentiation can be restored to different extents. At the same time, increasing or inhibiting the expression of Pitx2 can counteract the effects of knocking down RARα and activating RARα respectively. These results indicate that Pitx2 may be downstream of the transcription factor RARα, mediating the effects of ATRA on the development of fetal rat PFMs.

Transabdominal ultrasonography-guided biofeedback training for pelvic floor muscles integrated with stabilization exercise improved pregnancy-related pelvic girdle pain and disability: a randomized controlled trial.

OBJECTIVES: Investigate effects of integrated training for pelvic floor muscles (PFM) with and without transabdominal ultrasonography (TAUS) imaging-guided biofeedback in postpartum women with pregnancy-related pelvic girdle pain (PPGP). DESIGN: Three-arm, single-blinded randomized controlled trial SETTING: University laboratory PARTICIPANTS: Fifty-three postpartum women with PPGP randomized into stabilization exercise with TAUS-guided biofeedback (BIO+EXE), exercise (EXE), and control (CON) groups. INTERVENTIONS: The BIO+EXE and EXE groups underwent an 8-week exercise program, with the BIO+EXE group receiving additional TAUS-guided biofeedback for PFM training during the first 4 weeks. The CON group only received a pelvic educational session. MAIN OUTCOME MEASURES: Primary outcomes included self-reported pain (numeric rating scale) and disability (pelvic girdle questionnaire). Secondary outcomes included functional tests (active straight leg raising [ASLR] fatigue, timed up-and-go, and 6-meter walking tests) and muscle contractibility indicated by muscle thickness changes for abdominal muscles and bladder base displacement for PFM (ultrasonographic measures). RESULTS: The BIO+EXE group had lower pain [1.8 (1.5) vs. 4.4 (1.5), mean difference -2.6, 95% confidence interval (CI) -3.9 to -1.2] and disability [14% (10) vs. 28% (21), mean difference -14, 95% CI -25 to -2] and faster walking speed [3.1 seconds (1) vs. 3.3 seconds (1), mean difference -0.2, 95% CI -1.0 to -0.2] than the CON group. The EXE group only had lower pain intensity compared to the CON group [2.7 (2.0) vs. 4.4 (1.5), mean difference -1.7, 95% CI -3.1 to -0.4]. No significant differences were observed among groups in timed up-and-go, ASLR fatigue, or muscle contractibility. CONCLUSIONS: Integrated training for PFM and stabilization with TAUS-guided biofeedback seems to be beneficial for reducing pain and disability in postpartum women with PPGP. CONTRIBUTION OF THE PAPER.

Pelvic floor muscle strength and dysfunctions in women with pes planus: A case-control study.

BACKGROUND/AIM: Distal extremity misalignment may give rise to pelvic floor dysfunctions (PFDs). This study aimed to compare pelvic floor muscle strength (PFMS) and dysfunctions in women with and without pes planus. MATERIALS AND METHODS: Women with (pes planus group, n = 30) and without pes planus (control group, n = 30) were included. The presence of PFDs questioned. Pes planus with the Feiss Line Test, PFMS with the Modified Oxford Scale, and the severity of PFDs with the Pelvic Floor Distress Inventory-20 (PFDI-20), including three subscales (Pelvic Organ Distress Inventory-6 (POPDI-6) for pelvic organ prolapse, Colorectal-Anal Distress Inventory-8 (CRADI-8) for colorecto-anal symptoms, and Urinary Distress Inventory-6 (UDI-6) for urinary symptoms, were assessed. RESULTS: It was seen that no difference was found between groups in terms of PFMS (p > 0.05). However, urinary incontinence and anal incontinence were higher in women with pes planus than in women without pes planus (p < 0.05). Only the PFDI-20, CRADI-8, and UDI-6 scores were higher in women with pes planus compared to controls (p < 0.05). There was no difference was found between groups in terms of POPDI-6 scores (p > 0.05). CONCLUSION: The PFMS did not change according to the presence of pes planus. However, the prevalence of PFDs and their severity were higher in women with pes planus in comparison to controls. Posture assessments of individuals with PFDs, especially examination of foot posture, and pelvic floor assessments of individuals with posture disorders should be considered.

Structural, functional, and dysfunctional pelvic anatomy.

The structural basis of the Integral Theory is holistic. Four main pelvic muscles interact holistically with five main pelvic ligaments to maintain pelvic organ structure and function. The vagina is structurally weak. The support it provides to the bladder base is contingent on being stretched by opposite pelvic muscle forces, much like a trampoline. Its main role is to transmit muscle forces to facilitate continence, evacuation and control of urgency. Therefore, as an organ that cannot regenerate, the vagina should be conserved, and not excised. The ligaments provide the main structural support for the organs and are the most vulnerable part of the anatomical system to injury because their structural collagen is depolymerized prior to labour, and stretched during labour. Further ligament weakening occurs after menopause due to collagen breakdown. Hence, collagen loss is the main cause of organ prolapse and lower urinary tract symptoms (LUTS). The strengthening of damaged ligaments, whether surgically or non-surgically, can improve or cure symptoms and prolapse. Because collagen loss in ligaments is a principal cause of dysfunction in older women, collagen-creating techniques are advised: precisely inserted tapes to create neoligaments, or wide-bore No. 2 or No. 3 polyester ligament sutures instead of dissolvable sutures.

Quantitative 3D Analysis of Levator Ani Muscle Subdivisions in Nulliparous Women: MRI Feasibility Study.

BACKGROUND: The levator ani muscle (LAM) is crucial for pelvic floor stability, yet its quantitative MRI assessment is only a recent focus. Our study aims to standardize the quantitative analysis of the LAM morphology within the 3D Pelvic Inclination Correction System (3D-PICS). METHODS: We analyzed 35 static MR datasets from nulliparous women examining the pubovisceral (PVM), iliococcygeal (ICM), coccygeal (COC), and puborectal muscle (PRM). The PVM consists of three origin-insertion pairs, namely the puboanal (PAM), puboperineal (PPM) and pubovaginal muscle (PVaM). The analysis included a quantitative examination of the morphology of LAM, focusing on the median location (x/y/z) (x: anterior-posterior, y: superior-inferior, z: left-right) of the origin and insertion points (a), angles (b) and lengths (c) of LAM. Inter-rater reliability was calculated. RESULTS: Interindividual variations in 3D coordinates among muscle subdivisions were shown. In all, 93% of all origin and insertion points were found within an SD of <8 mm. Angles to the xz-plane range between -15.4° (right PRM) and 40.7° (left PAM). The PRM is the largest pelvic muscle in static MRI. The ICC indicated moderate-to-good agreement between raters. CONCLUSIONS: The accurate morphometry of the LAM and its subdivisions, along with reliable inter-rater agreement, was demonstrated, enhancing the understanding of normal pelvic anatomy in young nulliparous women.

Treatment of women with vaginal laxity: systematic review with meta-analysis.

BACKGROUND: Despite several treatments that have been used for women reporting vaginal laxity (VL), to our knowledge no systematic review is available on the topic so far. AIM: In this study, we sought to summarize the best available evidence about the efficacy and safety of interventions for treating VL, whether conservative or surgical. METHODS: A comprehensive search strategy was performed in Medline, Embase, Scopus, Web of Science, and Cochrane Library for reports of clinical trials published from database inception to September 2022. Studies selected for inclusion were in the English language and were performed to investigate any type of treatment for VL, with or without a comparator, whether nonrandomized studies or randomized controlled trials (RCTs). Case reports and studies without a clear definition of VL were excluded. OUTCOMES: The outcomes were interventions (laser, radiofrequency, surgery, and topical treatment), adverse effects, sexual function, pelvic floor muscle (PFM) strength, and improvement of VL by the VL questionnaire (VLQ). RESULTS: From 816 records, 38 studies remained in the final analysis. Laser and radiofrequency (RF) were the energy-based treatment devices most frequently studied. Pooled data from eight observational studies have shown improved sexual function assessed by a Female Sexual Function Index score mean difference (MD) of 6.51 (95% CI, 5.61-7.42; i2 = 85%, P < .01) before and after intervention, whether by RF (MD, 6.00; 95% CI, 4.26-7.73; i2 = 80%; P < .001) or laser (MD, 6.83; 95% CI, 5.01-8.65; i2 = 92%; P < .01). However, this finding was not shown when only 3 RCTs were included, even when separated by type of intervention (RF or laser). When RF treatment was compared to sham controls, VLQ scores did not improve (MD, 1.01; 95% CI, -0.38 to 2.40; i2 = 94%; P < .001). Patient PFM strength improved after interventions were performed (MD, 4.22; 95% CI, 1.02-7.42; i2 = 77%; P < .001). The ROBINS-I (Risk Of Bias In Nonrandomized Studies of Interventions) tool classified all non-RCTs at serious risk of bias, except for 1 study, and the risk of bias-1 analysis found a low and unclear risk of bias for all RCTs. The GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) certainty of the evidence was moderate for sexual function and the VLQ questionnaire and low for PFM strength. CLINICAL IMPLICATIONS: Sexual function in women with VL who underwent RF and laser treatment improved in observational studies but not in RCTs. Improvement in PFM strength was observed in women with VL after the intervention. STRENGTHS AND LIMITATIONS: Crucial issues were raised for the understanding of VL, such as lack of standardization of the definition and for the development of future prospective studies. A limitation of the study was that the heterogeneity of the interventions and different follow-up periods did not make it possible to pool all available data. CONCLUSIONS: Vaginal tightening did not improve sensation in women with VL after intervention, whereas RF and laser improved sexual function in women with VL according to data from observational studies, but not from RCTs. PFM strength was improved after intervention in women with VL.

Pregnant women may exercise both abdominal and pelvic floor muscles during pregnancy without increasing the diastasis recti abdominis: a randomised trial.

QUESTION: What is the effect of a 12-week abdominal and pelvic floor muscle exercise program during pregnancy on the inter-recti distance (IRD) in women with diastasis recti abdominis immediately after the 12-week intervention period and at follow-up 6 weeks postpartum? DESIGN: An exploratory, parallel-group, randomised controlled trial with concealed allocation, assessor blinding and intention-to-treat analysis. PARTICIPANTS: Ninety-six pregnant women aged ≥ 18 years, either primigravida or multigravida, in gestation week 24 with an IRD of ≥ 28 mm measured at rest and/or a protrusion on initial assessment. INTERVENTION: The experimental group participated in a 12-week abdominal and pelvic floor muscle exercise program during pregnancy. The control group received no intervention. OUTCOME MEASURES: Change (mm) in IRD 2 cm above and below the umbilicus at rest from pre-intervention to immediately post-intervention and to 6 weeks follow-up measured with ultrasonography. RESULTS: The IRD increased for both groups from baseline to immediately after the intervention and decreased from after the intervention to the follow-up at 6 weeks postpartum. The IRD was smallest for both groups at the follow-up. At 2 cm above the umbilicus, the intervention effect was 2 mm (95% CI -2 to 7) immediately after the intervention and -1 mm (95% CI -4 to 3) at follow-up. At 2 cm below the umbilicus, the intervention effect was -5 mm (95% CI -10 to 0) immediately after the intervention and 0 mm (95% CI -4 to 4) at follow-up. CONCLUSION: Abdominal and pelvic floor muscle training during pregnancy have a negligible effect on the IRD immediately after 12 weeks of intervention and at 6 weeks post-partum. REGISTRATION: NCT04960800.

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.

Morphological examination of pelvic floor muscles in a rat model of vaginal delivery.

OBJECTIVE: This study investigated morphological changes in the composition of the pelvic floor muscles, degree of atrophy, and urethral function in a rat of simulated birth trauma induced by vaginal distension (VD) model. METHODS: Female Sprague-Dawley rats were classified into four groups: a sham group, and 1, 2, and 4 weeks post-VD (1 W, 2 W, and 4 W, respectively) groups. We measured the amplitude of urethral response to electrical stimulation (A-URE) to evaluate urethral function. After measuring the muscle wet weight of the pubococcygeus (Pcm) and iliococcygeus (Icm) muscles, histochemical staining was used to classify muscle fibers into Types I, IIa, and IIb, and the occupancy and cross-sectional area of each muscle fiber were determined. RESULTS: There were 24 Sprague-Dawley rats used. A-URE was significantly lower in the 1 W group versus the other groups. Muscle wet weight was significantly lower in the VD groups versus the sham group for Pcm. The cross-sectional area of Type I Pcm and Icm was significantly lower in the VD groups versus the sham group. Type I muscle fiber composition in Pcm was significantly lower in the VD groups versus the sham groupand lowest in the 2 W group. Type I muscle fiber composition in Icm was significantly lower in the 2 and 4 W groups versus the sham group. CONCLUSION: Muscle atrophy and changes in muscle composition in the pelvic floor muscles were observed even after improvements in urethral function. These results may provide insight into the pathogenesis of stress urinary incontinence after VD.

Is there evidence for pelvic floor muscle relaxation training in nonneurogenic female bladder outlet obstruction?-A narrative review.

INTRODUCTION: Functional bladder outlet obstruction (BOO) in women is postulated to be caused by pelvic floor muscle (PFM) dyssynergia or increased tone. The aim of the present review was to investigate the effect of PFM relaxation training on PFM tone and female BOO symptoms. MATERIALS AND METHODS: This was a narrative review using an open search strategy on PubMed with the search terms "Bladder outlet obstruction" AND "female" AND ("pelvic floor muscles" OR "Kegel"). The risk of bias of the randomized controlled trials (RCTs) was scored with the Physiotherapy Evidence Database (PEDro) scale (0-10). RESULTS: Only three RCTs were found. All three RCTs compared different types of exercise, and no trial compared relaxation training with no or sham treatment. None of the trials reported the effect between groups on the reduction of PFM tone. There was a tendency toward positive effect of PFM relaxation training to improve BOO symptoms in women. PEDro score varied between 4 and 7. Few studies yielded information on the immediate effect of any type of PFM relaxation technique on PFM tone. CONCLUSION: Few RCTs have been conducted on the effect of PFM relaxation training on PFM tone and functional female BOO symptoms. There is an urgent need for RCTs with high methodological and interventional quality in addition to basic research on mechanisms of different relaxation techniques on PFM activity.

Bladder Neck Surgery is not Routinely Needed to Achieve Urinary Continence in Patients with Primary Epispadias.

BACKGROUND: This study aims at investigating the continence outcome in primary epispadias patients treated at a tertiary center. The authors hypothesized that additional continence procedures following primary epispadias repair is not routinely needed. METHODS: Patients treated for primary epispadias at the authors' institution between 2007 and 2019 and toilet trained, were identified from a prospective maintained database. Males underwent chordee correction, urethroplasty and glanuloplasty. Females underwent genitoplasty with reduction urethroplasty. If continence was not achieved by 4-5 years of age, pelvic floor muscle (PFM) biofeedback therapy was performed. Other continent procedures were discussed with family/patient if still incontinent. PRIMARY OUTCOME: urinary continence. SECONDARY OUTCOMES: PFM biofeedback therapy, continence surgery, hydronephrosis. Type of epispadias, age at repair and follow-up presented as median was also reported. RESULTS: Thirty-three patients (29 males) were included. Twelve had penopubic epispadias, 13 glanular/penile, 4 duplicated urethra, 4 females. Median age at repair: 2 years (IQR 1-3), at follow-up: 8 years (IQR 6-10). Daytime continence: 100 % in penile/glanular; 33 % in penopubic and 75 % in duplicated urethra. Nighttime continence: respectively 92 %, 50 % and 100 %. 24 % of males were intermittently incontinent. All patients except one voided urethrally. One patient underwent bladder neck closure, ileocystoplasty and Mitrofanoff. One girl achieved daytime continence, 2 were intermittently incontinent, one continuously incontinent. All were enuretic. 38 % of boys and 100 % of girls had biofeedback therapy. None had hydronephrosis/renal impairment. CONCLUSIONS: Most children with primary epispadias can achieve social urinary continence spontaneously or with the support of PFM biofeedback therapy. Other continence procedures should be reserved for patients who do not attain satisfactory continence. LEVEL OF EVIDENCE: Treatment study - level IV.

The effects of one-time soft tissue therapy on pelvic floor muscle electromyographic signals in women with urinary incontinence: A randomized intervention trial.

AIMS: To investigate the effects of one-time soft tissue therapy (STT) on pelvic floor muscle (PFM) electromyographic signals in women with stress and/or mixed urinary incontinence. METHODS: An intervention study conducted with 63 women with stress and/or mixed urinary incontinence. Participants were randomly assigned to either the one-time STT group (experimental group) or the control group. The same teaching model for voluntary contraction and relaxation of the PFM was used for all participants. Electromyographic signals from the PFM during functional tasks were the primary clinical outcome measures at baseline and immediately after the intervention. Electromyographic signals were analyzed using root mean square amplitude. RESULTS: There was no significant difference between groups in electromyographic PFM signals in prebaseline rest (mean difference: -0.146 [95% confidence interval (CI): -0.44 to 0.148; p = 0.470]), phasic contractions (mean difference: 0.807 [95% CI: 0.123-1.491; p = 0.459]), tonic contractions (mean difference: 1.06 [95% CI: 0.255-1.865; p = 0.302]), endurance contractions (mean difference: 0.896 [95% CI: 0.057-1.735; p = 0.352]) and postbaseline rest (mean difference: -0.123 [95% CI: -0.406 to 0.16; p = 0.591]) immediately after the one-time STT intervention. CONCLUSION: A one-time STT intervention does not appear to effectively alter electromyographic signal of the PFM in women with urinary incontinence. Due to the limitations of the study, further research is needed to confirm these results.

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.

Does transperineal ultrasound predict the risk of perineal trauma in women with term pregnancy? A prospective observational study.

PURPOSE: This study was conducted to evaluate the prevalence of perineal trauma during childbirth and to assess the correlations of the pelvic floor dimensions and fetal head station with obstetric trauma in a prospectively recruited cohort of women. METHODS: The study included women with a gestational age of at least 37 weeks, who were carrying a single fetus in a cephalic presentation. Transperineal ultrasound (TPU) was performed prior to the onset of labor or labor induction. The purpose was to measure the anteroposterior diameter (APD) of the levator ani muscle (LAM) and the angle of progression, at both rest and maximum Valsalva maneuver. The head-perineum distance was assessed only at rest. RESULTS: A total of 296 women were included. Of the 253 women who delivered vaginally, 19% (48/253) experienced no perineal trauma, 18.2% (46/253) received an episiotomy during childbirth, 34.4% (87/253) sustained a first-degree laceration, 25.3% (64/253) had a second-degree laceration, and 3.2% had a third- or fourth-degree laceration (8/253). Women with episiotomy had a significantly shorter median APD under Valsalva than women without perineal trauma. Furthermore, women with LAM coactivation (identified by a negative difference between the APD at Valsalva and the APD at rest) were approximately three times more likely to undergo an operative vaginal delivery and over five times more likely to sustain a third- or fourth-degree tear during childbirth than women who exhibited normal relaxation of the LAM during the Valsalva maneuver. CONCLUSION: TPU may predict the risk of perineal trauma in women with term pregnancy during childbirth.

Treatment of postpartum depression with integrated traditional Chinese and Western medicine nursing and electrical stimulation.

BACKGROUND: Postpartum depression (PPD) is a common psychological disease among puerperal women, and postpartum pelvic floor dysfunction is a common disease among pregnant women. The occurrence of postpartum pelvic floor dysfunction will increase the incidence of PPD. AIM: To explore the therapeutic effect of integrated traditional Chinese and Western medicine nursing combined with electrical stimulation of pelvic floor muscles and the rectus abdominis on PPD. METHODS: From April 2020 to January 2022, 100 parturients with a rectus abdominis muscle separation distance > 2.0 cm who underwent reexamination 6 wk after delivery at our hospital were selected as the research subjects. According to the random number table method, the patients were divided into either an observation group (n = 50) or a control group (n = 50). There was no significant difference in the general data between the two groups (P > 0.05). Both groups were treated by electrical stimulation. The observation group was additionally treated by integrated traditional Chinese and Western medicine nursing. A self-designed Depression Knowledge Questionnaire was used to evaluate the awareness of knowledge on depression in all patients 3 wk after intervention. The Hamilton Depression Scale (HAMD) was used to evaluate the depression before intervention and 1 wk and 3 wk after intervention, and the Morisky Medication Adherence Scale (MMAS-8) was used to evaluate the medication compliance. SPSS19.0 was used for statistical analyses. RESULTS: The rate of awareness of knowledge on depression in the observation group was significantly higher than that of the control group (P < 0.05). The scores of MMAS-8 were comparable between the two groups before intervention (P > 0.05), but were significantly higher in the observation group than in the control group at 1 wk and 3 wk after intervention (P < 0.05). The HAMD scores were comparable between the two groups before intervention (P > 0.05), but were significantly lower in the observation group than in the control group at 1 wk and 3 wk after intervention (P < 0.05). CONCLUSION: Integrated traditional Chinese and Western medicine nursing combined with electrical stimulation of pelvic floor muscles and the rectus abdominis is effective in the treatment of postpartum depression and worthy of clinical promotion.

Sitting on the fence: A qualitative study of perceptions regarding pelvic floor muscle training among pregnant women with urinary incontinence.

Objectives: To explore the perceptions of pregnant women with urinary incontinence toward pelvic floor muscle training (PFMT). Methods: Semi-structured personal interviews were used to collect data. Pregnant women with urinary incontinence and no contraindications to PFMT were recruited for semi-structured interviews in the Outpatient Department of Obstetrics in a Class A tertiary hospital in Shenzhen from October to November 2021. Purposive sampling was performed, and Braun & Clarke thematic analysis was used for the data analysis. Results: Sixteen pregnant women with urinary incontinence and a mean age of (30.81 ± 3.66) years participated in the interview. "Sitting on the fence" was the predominant theme acquired after analysis. Pregnant women had contradictory attitudes toward PFMT. A total of four themes and nine sub-themes have been extracted: "It is normal and does not really matter" (normalized urinary incontinence, insufficient attention to PFMT); "There is nothing I can do" (insufficient subjective motivations, limitation of objective conditions, lack of social support); "We have to take care of ourselves" (the increasing self-care awareness, emerging autonomous motivation to practice PFMT); "Training should be guaranteed" (requiring the guidance, suggestions, and surveillance of healthcare professionals; requiring the perceptive benefits). Conclusions: This study reveals varying attitudes towards PFMT among pregnant women with urinary incontinence. To better promote pregnant women's engagement in PFMT, it is necessary to provide professional guidance, increase self-care awareness, improve social support, and emphasize the benefits of PFMT.

Pelvic floor hypertension: possible factors for pelvic floor tenderness in endometriosis patients-a pilot study.

PURPOSE: Chronic pelvic pain (CPP) is one of the main problems of endometriosis, leading to a significant impairment of quality of life. Understanding the pain mechanisms and the pelvic floor muscles (PFM) changes in these patients is essential to integrate additional therapeutic strategies. We hypothesize that endometriosis patients have changes in PFM and that targeted vaginal electrostimulation can be a treatment option for CPP in this disease. METHODS: Fifteen patients with endometriosis and chronic acyclical pelvic pain were included. PFM electromyography with the Multiple Array Probe Leiden (MAPLe) was performed. Mapping of PFM was utilized and targeted electrostimulation of the hypertensive muscles was conducted. Control electromyography was performed afterward to evaluate the electrostimulation therapeutic effect. RESULTS: In 12/15 (80%) patients, the myofascial trigger point could be localized by digital examination. The most frequently affected muscle was the puborectalis (10/15-66.7%). Most of the patients showed serious changes in the average resting tone (aRT) of PFM. aRT was significantly increased in all patients and decreased after stimulation, whereby the difference prior to and after stimulation was not significant (p = 0.064). The detailed separated analysis of the hypertensive muscles showed a significant (p = 0.026) reduction in their resting tone (hRT), after targeted stimulation. CONCLUSION: Vaginal electrostimulation is a promising and feasible complementary treatment option for CPP in endometriosis patients. Targeted treatment of pelvic floor dysfunction should be included in clinical trials.

Neutral posture education during cough can reduce urine leakage in women with cough-related stress urinary incontinence.

BACKGROUND: Current literature highlights the difficulty in identifying an optimal educational technique for maintaining continence during cough. OBJECTIVE: To characterize the effects of an educational intervention focusing on neutral posture during cough in women with cough-induced urinary incontinence (UI). METHODS: This interventional study design included women with cough-induced UI. We recorded PFMs surface electromyographic (sEMG) peak activity, and assessed symptoms and quality of life (QoL) 6 weeks after the intervention. The effect of the experimental situation was estimated using a linear mixed model, sEMG measurements during coughing were indexed to each situation and adjusted to the resting value at, and a moderation analysis was used. RESULTS/FINDINGS: Eighteen participants were included. The measurement situations (control versus experimental) did not have a statistically significant impact on sEMG peak activity during coughing: mean effect [95% CI] 3.42 [-1.28; 7.66]. Six weeks post-intervention, participants reported statistically significant decrease in urinary symptoms (P=0.0246) and significant improvement in QoL (P=0.00776). This was also particularly marked on the dimension related to effort activities (P=0.00162). CONCLUSION: This study suggests that a brief educational intervention focusing on neutral posture during cough, without voluntary pre-contraction of the PFMs, has no clinically significant influence on sEMG peak activity of the PFMs in women with cough-induced UI. However, this intervention can lead to a significant improvement in urinary symptoms and QoL at 6 weeks. These improvements seem to be independent of electromyographic PFMs peak activity recorded during cough. As such, our preliminary results pave the way for future research. LEVEL OF EVIDENCE: NP4.

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.