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BackgroundVaginal childbirth is a key risk factor for pelvic floor muscle injury and dysfunction, and subsequent pelvic floor disorders. Multiparity further exacerbates these risks. Using the rat model, validated for the studies of the human pelvic floor muscles, we have previously identified that a single simulated birth injury results in pelvic floor muscle atrophy and fibrosis.ObjectiveTo test the hypothesis that multiple birth injuries would further overwhelm the muscle regenerative capacity, leading to functionally relevant pathological alterations long-term.Study designSprague-Dawley rats underwent simulated birth injury and were allowed to recover for 8 weeks before undergoing additional birth injury. Animals were sacrificed at acute (3 and 7 days postinjury), subacute (21, 28, and 35 days postinjury), and long-term (8 and 12 weeks postinjury) time points post second injury (N=3-8/time point), and the pubocaudalis portion of the rat levator ani complex was harvested to assess the impact of repeated birth injuries on muscle mechanical and histomorphological properties. The accompanying transcriptional changes were assessed by a customized NanoString panel. Uninjured animals were used as controls. Data with a parametric distribution were analyzed by a 2-way analysis of variance followed by post hoc pairwise comparisons using Tukey's or Sidak's tests; nonparametrically distributed data were compared with Kruskal-Wallis test followed by pairwise comparisons with Dunn's test. Data, analyzed using GraphPad Prism v8.0, San Diego, CA, are presented as mean ± standard error of the mean or median (range).ResultsFollowing the first simulated birth injury, active muscle force decreased acutely relative to uninjured controls (12.9±0.9 vs 25.98±2.1 g/mm2, P.99). Similarly, precipitous decrease in active force was observed immediately after repeated birth injury (18.07±1.2 vs 25.98±2.1 g/mm2, P

OBJECTIVE: To develop evidence- and consensus-based clinical practice guidelines for management of high-tone pelvic floor dysfunction (HTPFD). High-tone pelvic floor dysfunction is a neuromuscular disorder of the pelvic floor characterized by non-relaxing pelvic floor muscles, resulting in lower urinary tract and defecatory symptoms, sexual dysfunction, and pelvic pain. Despite affecting 80% of women with chronic pelvic pain, there are no uniformly accepted guidelines to direct the management of these patients. METHODS: A Delphi method of consensus development was used, comprising three survey rounds administered anonymously via web-based platform (Qualtrics XM) to national experts in the field of HTPFD recruited through targeted invitation between September and December 2021. Eleven experts participated with backgrounds in urology, urogynecology, minimally invasive gynecology, and pelvic floor physical therapy (PFPT) participated. Panelists were asked to rate their agreement with rated evidence-based statements regarding HTPFD treatment. Statements reaching consensus were used to generate a consensus treatment algorithm. RESULTS: A total of 31 statements were reviewed by group members at the first Delphi round with 10 statements reaching consensus. 28 statements were reposed in the second round with 17 reaching consensus. The putative algorithm met clinical consensus in the third round. There was universal agreement for PFPT as first-line treatment for HTPFD. If satisfactory symptom improvement is reached with PFPT, the patient can be discharged with a home exercise program. If no improvement after PFPT, second-line options include trigger or tender point injections, vaginal muscle relaxants, and cognitive behavioral therapy, all of which can also be used in conjunction with PFPT. Onabotulinumtoxin A injections should be used as third line with symptom assessment after 2-4 weeks. There was universal agreement that sacral neuromodulation is fourth-line intervention. The largest identified barrier to care for these patients is access to PFPT. For patients who cannot access PFPT, experts recommend at-home, guided pelvic floor relaxation, self-massage with vaginal wands, and virtual PFPT visits. CONCLUSION: A stepwise approach to the treatment of HTPFD is recommended, with patients often necessitating multiple lines of treatment either sequentially or in conjunction. However, PFPT should be offered first line.

BackgroundMethodsResultsConclusionThe increase in survival rates among women treated for cervical cancer (CC) requires greater attention to the side effects of treatment. Although a high prevalence of pelvic floor disorders (PFD) in this population is documented, there is a lack of consensus regarding physical therapy approaches.Cross-sectional observational study with 56 physiotherapists who answered a questionnaire. The data were exported to Microsoft Excel® and analyzed descriptively.Most physiotherapists interviewed have postgraduate degrees in Women’s Health (74.5%). The most common PFDs treated are sexual dysfunctions (26%), mixed urinary incontinence (23.9%), urge urinary incontinence (14,3%), pelvic organ prolapse (8,9%) and anal incontinence (4,1%). The PERFECT scale is the most used (20.2%) to assess the pelvic floor muscles. Female Sexual Function Index is the most used questionnaire for evaluation of sexual dysfunctions (46.7%) and vaginal desensitization (23.3%) for treatment of this condition. To assess urinary incontinence, 45.9% of the physiotherapists use voiding diary and the most cited intervention are pelvic floor muscle training (32.9%), bladder training and behavioral therapy (31.7%). Most of the physiotherapist intervieweddo not use specific instruments (65.4%) to assess pelvic organ prolapse and use pelvic floor muscle training (77.4%) for treatment. Anal incontinence is usually evaluated by Bristol Stool Scale (42.2%) and treated by Electrostimulation of the posterior tibial nerve (38.8%).Most physiotherapists are qualified to manage PFDs. The variability in assessment methods and therapeutic approaches highlights the lack of consensus on managing PFD in women with cervical cancer, indicating the need for evidence-based guidelines. [ABSTRACT FROM AUTHOR]

The Canadian Association of Radiologists (CAR) Genitourinary Expert Panel is made up of physicians from the disciplines of radiology, emergency medicine, family medicine, nephrology, and urology, a patient advisor, and an epidemiologist/guideline methodologist. After developing a list of 22 clinical/diagnostic scenarios, a rapid scoping review was undertaken to identify systematically produced referral guidelines that provide recommendations for one or more of these clinical/diagnostic scenarios. Recommendations from 30 guidelines and contextualization criteria in the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) for guidelines framework were used to develop 65 recommendation statements across the 22 scenarios (2 scenarios point to the CAR Obstetrics and Gynecology Diagnostic Imaging Referral Guideline). This guideline presents the methods of development and the referral recommendations for haematuria, hypertension, renal disease (or failure), renal colic, renal calculi in the absence of acute colic, renal lesion, urinary tract obstruction, urinary tract infection, scrotal mass, or pain, including testicular torsion, adrenal mass, incontinence, urgency, and frequency, chronic pelvic pain, elevated PSA, infertility, and pelvic floor. [ABSTRACT FROM AUTHOR]

Background: Vaginal childbirth is one of the main risk factors for pelvic floor dysfunction. Magnetic resonance imaging (MRI) can facilitate quantitative evaluation of the morphology and function of the pelvic floor in static and dynamic environments. The objective of this study was to investigate the changes in pelvic floor morphology and function in primigravida women before pregnancy (BP) and after vaginal delivery. Methods: Primigravida women underwent pelvic floor MRI scans BP, at 3 months postpartum (3mPP), and at 6 months postpartum (6mPP). Various pelvic floor MRI data were measured, including the obturator internus muscle (OIM) area, anterior pelvic area, puborectalis muscle thickness (PRT), levator plate angle (LPA), iliococcygeal angle, bladder–pubococcygeal line (B-PCL), uterus–pubococcygeal line (U-PCL), puborectal hiatus line, muscular pelvic floor relaxation line, levator hiatus area, urethral mobility, bladder neck descent, and cervix descent. Results: In the resting state, the OIM area and PRT decreased whereas the anterior pelvic area increased from BP to 3mPP. During the straining maneuver, all parameters except U-PCL and urethral mobility showed statistically significant differences (P < 0.05). The OIM area and PRT increased whereas the anterior pelvic area decreased from 3mPP to 6mPP. During the straining maneuver, B-PCL, bladder neck descent, levator hiatus area, and LPA showed statistically significant differences (P < 0.05). In the resting state, the OIM area and PRT decreased whereas the anterior pelvic area increased from BP to 6mPP. During the straining maneuver, B-PCL, muscular pelvic floor relaxation line, and bladder neck descent showed statistically significant differences (P < 0.05). Conclusion: Vaginal delivery can cause pelvic floor injury that may gradually recover over time. However, the injury does not fully recover to the pre-pregnancy level within 6mPP. [ABSTRACT FROM AUTHOR]

Purpose: Chronic constipation is a common symptom. Constipation due to pelvic floor disorders remain a therapeutic challenge. Biofeedback therapy is considered as the first-choice treatment for pelvic floor disorders, whenever dedicated expertise is available. Type A botulinum toxin has been used to selectively weaken the external anal sphincter and puborectalis muscle in constipated patients. Method: Eighty-two patients with chronic outlet obstruction constipation were treated with 100 units type A botulinum toxin, injected into the puborectalis muscle and the external anal sphincter. Results: At the 2-month evaluation, a symptomatic improvement was noted in 69 patients. Seven (8.5%) patients had mild flatus incontinence. Stool frequency per week increased from 2.4 ± 0.9 to 5.1 ± 1.0 (P = 0.0001). Anorectal manometry demonstrated decreased tone during straining from 91 ± 28 mmHg to 61 ± 27 mmHg (P = 0.0001). Defecography after the treatment showed improvement in anorectal angle during straining, which increased from 96 ± 12° to 124 ± 14° (P = 0.0001). Conclusion: Type A botulinum toxin relaxes the puborectalis muscle. Pressure values decline after the treatment. Transrectal ultrasonography to guide injections is a safe procedure. Repeated injections were needed to maintain the clinical improvement. [ABSTRACT FROM AUTHOR]

Objectives: The aim of this study is to validate a uniform method for measuring perineal descent which can be used for different imaging methods, to establish cut-off values for this measurement, and to assess diagnostic test accuracy (DTA) of imaging techniques using these cut-off values. Secondly, the study aims to correlate perineal descent to symptoms, signs and imaging findings in women with obstructed defaecation syndrome (ODS) to assess its clinical relevance. Methods: Cross-sectional study of 131 women with symptoms of ODS. Symptoms and signs were assessed using validated methods. These women underwent evacuation proctography (EP), magnetic resonance imaging (MRI), transperineal ultrasound (TPUS) and endovaginal ultrasound (EVUS). Perineal descent was measured on EP and MRI as the position of anorectal junction (ARJ) with respect to the pubococcygeal line (PCL) at rest (i.e., static descent) and during evacuation (i.e., descent at Valsalva). Dynamic perineal descent was measured on all four imaging techniques as the difference between the position of the ARJ at rest and Valsalva. DTA of dynamic perineal descent was estimated using Latent Class Analysis in the absence of a reference standard. Results: Interobserver agreement of dynamic perineal descent measurements was good for MRI and EVUS (ICC 0.86 and 0.85) and moderate for EP and TPUS (ICC 0.61 and 0.59). The systematic differences in measurements between imaging techniques show the need for individual cut-off values. New established cut-off values for dynamic descent are for EP 20 mm, MRI 35 mm, TPUS 15 mm and EVUS 15 mm. Sensitivity was moderate for EP (0.78) and MRI (0.74), fair for TPUS (0.65) and poor for EVUS (0.58). Specificity was similar for all imaging techniques (0.73–0.77). Static perineal descent correlated with symptoms of pelvic organ prolapse (POP) (r = 0.19), prolapse of all three compartments (r = 0.19–0.36), presence of levator ani muscle avulsion (p = 0.01) and increased hiatal area (r = 0.51). Dynamic perineal descent correlated with excessive straining (r = 0.24) and use of laxatives (r = 0.24). Classic symptoms of ODS (incomplete evacuation and digitation) did not correlate with perineal descent measurements. Static and dynamic perineal descent were associated with presence of rectocele, enterocele, intussusception, and absence of anismus. Conclusions: Dynamic perineal descent is a reliable measurement that can be applied to different imaging techniques to allow standardisation. Static descent is more often present in women with POP and dynamic descent is more often present in women with constipation. Perineal descent does not correlate with typical symptoms of ODS. Specificity of TPUS and EVUS is comparable to EP and MRI, hence ultrasound could be used for the initial assessment of pelvic floor dysfunction. [ABSTRACT FROM AUTHOR]

Introduction: SUI is a common pelvic floor dysfunction in middle-aged and elderly women, which has a serious negative impact on the patient’s quality of life (QoL); pelvic floor muscle training (PFMT) and electrical stimulation (ES), as common non-surgical treatment modalities, have been widely used in the management of SUI. However, there is controversy about the effectiveness of the combined application of these two interventions. For this reason, this study evaluated the efficacy of PFMT combined with ES in the treatment of SUI by meta-analysis. To systematically evaluate the efficacy of PFMT combined with ES in improving urinary incontinence symptoms, increasing pelvic floor muscle strength, enhancing QoL, and improving clinical symptoms, with the aim of providing more adequate evidence to support clinical treatment. Methods: A literature search was conducted in PubMed, Embase, Web of Science, and Cochrane Library databases from database construction to October 2024 to include RCTs and case-control studies evaluating PFMT combined with ES for the treatment of SUI. The Cochrane Risk Assessment Tool and NOS were used to assess the quality of the included literature, and effect sizes were calculated by random-effects model and fixed-effects model, and the main outcome indicators included incontinence symptoms, pelvic floor muscle strength, QoL, and clinical symptoms. Results: Eight studies were ultimately included, with a total sample size of 885 cases. Meta-analysis showed that PFMT combined with ES was significantly better than the control group on all outcome measures. The combined effect size for improvement in urinary incontinence symptoms was OR = 1.42 (95% CI: 1.10, 1.85, p < 0.05), the combined effect size for pelvic floor muscle strength was OR = 1.55 (95% CI: 1.20, 2.05, p < 0.01), the combined effect size for QoL improvement was OR = 4.29 (95% CI: 3.68, 4.99, p < 0.0001), and the combined effect size for clinical symptom improvement was OR = 1.35 (95% CI: 1.05, 1.70, p < 0.05). Heterogeneity between studies was low (I2 values were less than 40%), indicating a high degree of consistency in the effect of the combination treatment. Conclusion: PFMT combined with ES showed significant benefits in improving incontinence symptoms, enhancing pelvic floor muscle strength, boosting QoL, and improving clinical symptoms. Future studies should further standardize the intervention parameters and extend the follow-up period to fully assess the long-term effects of the combined treatment. [ABSTRACT FROM AUTHOR]

Background: Pelvic floor dysfunction (PVD), a prevalent clinical issue impacting quality of life, can be effectively assessed using magnetic resonance defecography (MRD) with the patient either supine or in the lateral decubitus position. Purpose: To compare the measurement value and grading in dynamic MRD within the closed-magnet system of PFD patients performed in supine versus lateral decubitus position using the H line, M line, and organ prolapse (HMO) classification system. Material and Methods: During 2017–2019, 100 patients with PFD underwent MRD during defecation in both supine and lateral decubitus positions. MR images were measured and graded by two blinded radiologists. The mean value of each HMO parameter and grading severity were compared between supine and lateral positions. Image quality (IQ) between two positions was also evaluated. Paired t -test and Wilcoxon ranked test were performed for significant difference. P < 0.05 was considered statistically significant. Results: For HMO measurement, M-line, levator plate angle (LPA), urethral hypermobility (UH), uterine prolapse, and peritoneocele had significantly higher mean values when measured in the lateral decubitus position than in the supine position. For grading, M-line, uterine prolapse, and peritoneocele also had more grading severity in the lateral decubitus than supine position with statistical significance (P = 0.002, 0.004, and 0.001, respectively). Only anterior rectocele had a mean value and grading severity in the supine more than the lateral position (P = 0.003 and P = 0.005). IQ in the supine was better than in the lateral decubitus position (P < 0.001). Conclusion: MRD in lateral decubitus showed a more severe degree of PFD in most parameters based on the HMO grading system irrespective of inferior imaging quality. [ABSTRACT FROM AUTHOR]

Purpose: This study evaluated pelvic organ positions in primiparas with painful and painless deliveries using transperineal ultrasound (TPU) and assessed the effects of epidural anesthesia on pelvic floor function. Methods: From January 2022 to March 2023, 512 primiparas with vaginal deliveries at our hospital underwent pelvic floor ultrasound examinations 42 days postpartum. The study included 138 women with painful deliveries and 375 with painless deliveries. Measurements included the urethral tilt angle (UTA), retrovesical angle at rest (RVA-R), bladder neck-symphysis pubis distance (BSD) at rest, retrovesical angle at Valsalva maneuver (RVA-V), urethral rotation angle (URA), bladder neck descent (BND), rectal ampulla distance, and levator hiatal area (LHa) at maximum Valsalva maneuver. Statistical analysis was performed using SPSS 26.0. Results: No significant differences were found between the painful and painless delivery groups in terms of age, gestational age, newborn birth weight, BMI, UTA, RVA-R, RVA-V, URA, and BND (P > 0.05). Although the second stage and total duration of labor were significantly longer in the painless delivery group, there were no significant differences in the incidences of cystocele, internal urethral orifice opening, uterine prolapse, rectocele, and LHa expansion between the groups (P > 0.05). Conclusion: Transperineal ultrasound showed no significant difference in pelvic floor dysfunction incidence between primiparas with painful and painless deliveries. Epidural anesthesia did not significantly affect pelvic floor function in the early postpartum period. [ABSTRACT FROM AUTHOR]

Background/Objectives: Implementing and optimizing pelvic floor muscle (PFM) training programs is crucial for reducing the risk of dysfunctions, improving athletic performance, and enhancing quality of life for athletes. The aim of this study was to assess PFM activation in female athletes during postural challenges. Methods: An observational and descriptive study was conducted with twenty-five female rugby players. Surface electromyography was used to evaluate the PFMs in five different body positions under stable and unstable conditions. Results: The peak amplitude of the PFMs at baseline differed according to the physical demand of each position (p < 0.001). The lowest percentage activation was in the supine position (16.23%), while the highest recruitment was observed during the parallel squat (40.69%). The percentage of maximum voluntary contraction also differed according to each position (p = 0.001). The values were similar in supine position, side plank (104%), and standing position, being significantly lower (p < 0.05) than those reached during the off-knees quadruped hold (121.58%), full plank (121.97%), and parallel squat (151.40%); however, the values were comparable between stable and unstable positions (p = 1.000). Conclusions: Positions that challenge gravity and pelvic biomechanics, such as the squat, plank, and quadruped, facilitate greater activation of the PFMs. Contrary to previous recommendations, these exercises do not appear to have significant negative effects; therefore, consideration should be given to the implementation of these exercises for the management of pelvic floor dysfunction and as part of comprehensive exercise programs designed to improve overall core and pelvic floor function. [ABSTRACT FROM AUTHOR]

Introduction: The pelvic floor is exposed to differing stresses and trauma depending on the mode of birth. At the same time, the pelvic floor plays a crucial role in female sexual functioning (FSF). Whereby FSF encompasses different dimensions, from subjective satisfaction to physiological aspects, such as lack of pain and orgasm ability. The aim of the study presented here is to assess FSF in relationship to postpartum pelvic floor disorder based on the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, IUGA‐Revised (PISQ‐IR), in a large convenience sample and to identify whether there is an association between mode of birth as well as perineal injuries and FSF of women up to 24 months postpartum. Material and Methods: We conducted a cross‐sectional online survey and recruited via social media women up to 24 months after birth of their last child. FSF was surveyed using the PISQ‐IR. Details were also collected on all previous births and birth‐related perineal trauma, as well as current breastfeeding, obesity, and socio‐demographics. Multivariate models were then calculated to determine a possible association between FSF and birth mode. Results: The data basis is the responses of 2106 survey participants within the first 24 months postpartum. Even 12–24 months postpartum, 21% of respondents are not sexually active, which burdens almost 44% of these women. With regard to mode of delivery, differences in FSF are only evident in individual dimensions of the PISQ‐IR. The dimensions "Condition Impact" and "Condition Specific" were significantly associated with more impairments in sexually active respondents up to 12 months postpartum whose last mode of delivery was forceps or vacuum extraction. If a perineal tear had occurred during last birth, this was significantly associated with a lower PISQ‐IR subscore in the "Condition Impact," "Condition‐Specific," "Global Quality," "Partner‐Related," and "Arousal" models. The low variance explanation shows that further relevant factors on female sexuality may exist. Conclusions: The issue of impairments in FSF following childbirth, persisting for an extended period of time, is a significant postpartum concern. Due to the very different dimensions of FSF, the influence of the mode of delivery must be considered in a differentiated way. [ABSTRACT FROM AUTHOR]

Objectives: The aim of this study was to determine the prevalence of pelvic floor disorders (PFDs) and associated risk factors among parous Ugandan women. Methods: We performed a cross‐sectional study of parous Ugandan women. Demographics and assessment for PFD were obtained. The presence of PFD was defined by participant symptom report, standardized questionnaires, and standard physical examination (pelvic organ prolapse quantification [POP‐Q] and cough stress test [CST]). Results: A total of 159 women were enrolled in the study between June 2022 and June 2023. The median age was 35 years and median parity was 4. Forty‐four (28%) women in the cohort reported symptoms of urinary incontinence. No women reported symptoms of pelvic organ prolapse or anal incontinence. Seventy‐two (46%) participants had a positive CST and 93 (58.3%) had stage II or greater prolapse based on the POP‐Q. Cesarean section was found to have a protective effect for the development of PFD (odds ratio [OR] 0.22, 95% confidence interval [CI] 0.07–0.59, P = 0.004). Conclusion: PFDs are prevalent among parous Ugandan women at rates similar to cohorts in other low‐ and middle‐income countries. Cesarean section seems to be a protective factor against developing PFDs. Synopsis: Pelvic floor disorders are prevalent among parous Ugandan women. Cesarean delivery seems to be protective for the development of these disorders. [ABSTRACT FROM AUTHOR]

Sacral neuromodulation (SNM) as an advanced form of neuromodulation technique, which has demonstrated significant efficacy in alleviating clinical symptoms for patients with pelvic floor dysfunction (PFD) who do not respond to conventional treatments. This paper provides a comprehensive review of the application and progress of SNM in the treatment of PFD. It covers its historical development, mechanisms of action, clinical applications, optimization of stimulation parameters, and several technological innovations that have facilitated its clinical adoption. The aim is to promote wider clinical application of SNM and offer more precise treatment options for patients. [ABSTRACT FROM AUTHOR]

Introduction: Surgeries for pelvic organ prolapse (POP) and stress urinary incontinence (SUI) are commonly performed in older adults, many of whom are also frail. A surgical risk calculator for older adults undergoing POP/SUI surgeries that incorporates frailty, a factor known to increase the risk of surgical complications, would be helpful for preoperative counseling but currently does not exist. Materials and Methods: Medicare Carrier, Outpatient, and MedPAR files were examined for beneficiaries undergoing POP and SUI surgery between 2014 and 2016. A total of 15 POP/SUI categories were examined. The Claims‐Based Frailty Index (CFI), a validated measure of frailty in Medicare data, and Charlson Comorbidity Index were deconstructed into their individual variables, and individual variables were entered into stepwise logistic regression models to determine which variables were most highly predictive of 30‐day complications and 1‐year mortality. To verify the prognostic accuracy for each model for surgical complications of interest, calibration curves and tests of model fit, including C‐statistic, Brier scores, and Spiegelhalter p values, were determined. Results: In total, 108 479 beneficiaries were included. Among these, 4.7% had CFI scores consistent with mild to severe frailty (CFI≥0.25). A total of 13 prognostic variable categories were found to be most highly predictive of postoperative complications. Calibration curves for each outcome of interest showed models were well‐fit. Most models demonstrated high c‐statistic values (≥0.7) and high Spiegelhalter p values (≥0.9), indicating good model calibration and excellent discrimination, and low Brier scores (<0.02), indicating high model accuracy. Conclusions: Urologic surgery for older Adults Risk Calculator serves as a novel surgical risk calculator that is readily accessible to both patients and clinicians that specifically factors in components of frailty. Furthermore, this calculator accounts for the heterogeneity of an aging population and can assist in individualized surgical decision‐making for these common procedures. [ABSTRACT FROM AUTHOR]