ultrasound, manual muscle testing and vaginal squeeze ... Received: 19 August 2005 / Accepted: 27 January 2006 / Published online: 11 March ... School of Physiotherapy, Curtin University of Technology, ... degree of bladder neck elevation during PFM contraction ... Research Ethics Committee, Curtin University of Tech-.
Int Urogynecol J (2006) 17: 624–630 DOI 10.1007/s00192-006-0081-2
ORIGINA L ARTI CLE
Judith A. Thompson . Peter B. O’Sullivan . N. Kathryn Briffa . Patricia Neumann
Assessment of voluntary pelvic floor muscle contraction in continent and incontinent women using transperineal ultrasound, manual muscle testing and vaginal squeeze pressure measurements Received: 19 August 2005 / Accepted: 27 January 2006 / Published online: 11 March 2006 # International Urogynecology Journal 2006
Abstract The aims of the study were: (1) to assess women performing voluntary pelvic floor muscle (PFM) contractions, on initial instruction without biofeedback teaching, using transperineal ultrasound, manual muscle testing, and perineometry and (2) to assess for associations between the different measurements of PFM function. Sixty continent (30 nulliparous and 30 parous) and 60 incontinent (30 stress urinary incontinence (SUI) and 30 urge urinary incontinence (UUI)) women were assessed. Bladder neck depression during attempts to perform an elevating pelvic floor muscle (PFM) contraction occurred in 17% of continent and 30% of incontinent women. The UUI group had the highest proportion of women who depressed the bladder neck (40%), although this was not statistically significant (p=0.060). The continent women were stronger on manual muscle testing (p=0.001) and perineometry (p=0.019) and had greater PFM endurance (p0). The type of urinary incontinence was distinguished using a urinary symptoms questionnaire [11]. Based on the questionnaire, 30 women had symptoms classified as SUI and 30 women had UUI. The study received ethical approval from the Human Research Ethics Committee, Curtin University of Technology and all women gave informed consent. All women filled in a questionnaire regarding general and PFM exercise habits and a history of disorders that might result in the subjects generating high levels of IAP on an ongoing basis such as chronic cough, sinusitis, and constipation. All of the women in the study had previously heard of PFM exercises. Procedure A standardized bladder filling protocol was used. The women were asked to void 1 h before testing and then to drink 500 ml of water and not to void again until after the ultrasound test. All subjects were tested in supine lying with one pillow under the head, hips and knees flexed to 60°, and a small towel roll placed under the lumbar spine to place the spine in neutral. Transperineal ultrasound All women were assessed by the same qualified sonographer who was blinded to the subject group. The women were not able to observe the ultrasound screen to avoid a training biofeedback effect. Ultrasound imaging was performed via a transperineal approach using high-definition imaging (Philips HDI Sono 5000CT), with a curvilinear array probe (5–2 MHz). The reliability of the TP ultrasound measurements for this study, (intraclass correlations 0.91, standard error of measurements 0.11), and a detailed description of the methodology has previously been reported [13]. The ultrasound transducer was placed in the mid-sagittal plane at the perineum. A measure of the position of the bladder neck was taken at rest and the change from the resting position was measured during PFM contraction. The subjects were asked to perform a maximal PFM contraction; the instructions were “draw in and lift the PFM” and to hold the contraction while breathing normally. Once the contraction was visualized on the ultrasound screen, the image was frozen (2–3 s) and the subject could relax (5 s). A mean value was taken for the three tests. Once the ultrasound test was completed, the subjects were allowed to void.
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Manual muscle testing On the same day, after the ultrasound tests, the same continence physiotherapist assessed all the subjects. The subjects remained in supine lying with knees bent as described above. A digital vaginal examination was performed using two fingers. The instructions for performing the PFM contraction were the same as those used during ultrasound testing. The PFM strength was assessed by MMT using the modified Oxford scale as described by Sapsford et al. [14]. No biofeedback was given during the measurements. The PFM test was repeated three times and a median value was taken for the three tests. The subjects were then given a 5-min rest. Vaginal squeeze pressure measurements The vaginal pressure probe (Cardiodesign, Australia, Model 2005), connected to a Peritron perineometer (Model 9300V), was inserted into the vagina with the centre portion of the probe located 3.5 cm from the introitus [4]. The pressure sensor was set to zero at the start of each test. The subjects were asked to perform two tests: (1) maximal PFM contraction held for 3 s and (2) an endurance contraction, drawing in and lifting the PFM, holding the contraction for as long as possible up to a maximum of 30 s. No biofeedback was given during the measurements. The subjects were asked to breathe normally during the
PFM contraction. Respiration was closely monitored and the subjects were not allowed to do several small or “top up” contractions. The PFM endurance time was assessed using an built-in endurance setting on the Peritron perineometer. Both tests were repeated three times with a 10 s rest for the short holds, and 1-min rest for endurance holds. A mean value was taken for the three tests. Statistical analysis of the data Statistical analysis of the data was performed using SPSS (V10). A primary analysis was performed on the four groups followed by a secondary analysis to compare the differences between the continent and incontinent groups. As all hypotheses were developed a priori, therefore, corrections for multiple comparisons were not implemented. Data are for mean (SD) for all variables except for MMT, which was considered ordinal, and data are median (range). Analysis of differences in direction of movement of the bladder neck between groups The subjects were classified into two categories: elevator or depressor, depending on the direction of movement of the bladder neck during PFM contraction. Differences in the proportion of elevators in each group were assessed using Chi-squared test.
Table 1 Demographic data and proportion of women in each group Continent Nulliparous (n=30) Age Parity BMI ISI score [12] Stress score [11] Urge score [11] BN descent [n (%)] Hx cough [n (%)] Hx sinusitis [n (%)] Constipation [n (%)] Taught PFX [n (%)] Practicing PFX [n (%)] General exercise [n (%)] Taking HRT [n (%)] Previous bladder surgery [n (%)] Hysterectomy [n (%)]
39.7(9)a 0a 23(3) 0a 0a 0a 6(20%) 0a 4(13%) 6(20%) 0a 12(40%) 23(77%) 3(10%) 0 0
Incontinent Parous (n=30) 41.8(5)ab 2(1 to4)b,C,d 22(3) 0a 0a 0a 4(13%) 1(3%)a 2(7%) 4(13%) 0a 11(37%) 23(77%) 5(7%) 0 1(3%)
SUI (n=30) 46.4(5)b,c 2(1 to 4)b,d 24(4) 4(2)b 23(2)b 5(1)b 6(20%) 5(7%)b 8(27%) 7(23%) 7(23%)b 13(43%) 22(73%) 6(20%) 2(7%) 1(3%)
UUI (n=30) 43.3(8)a,b 2(0 to 4)b,c 24(4) 5(2)b 2(2)c 18(2)c 12(40%) 2(7%) 10(33%) 9(30%) 9(30%)b 16(53%) 18(60%) 4(13%) 3(10%) 2(7%)
p value 0.011
