Impact of Two Reflex Pelvic Floor Muscle Contraction Patterns on Female Stress Urinary Incontinence

Abstract

Purpose: To explore the impact of two reflex pelvic floor muscle contraction patterns during coughing on incontinence severity and incontinence-related quality of life in women with stress urinary incontinence (SUI).

Materials and Methods: A total of 208 women with the symptomatic and urodynamic evidence of SUI and 126 women with no experience of urinary incontinence were recruited in a 5-year period. During hard coughs, reflex pelvic floor muscle contraction was detected using introital ultrasound and two reflex contraction patterns were recognized: an inward clitoral motion and a superior-anterior anorectal lift. The assessment of incontinent severity and impact of quality of life included 1-hour pad tests and short forms of the Urogenital Distress Inventory and the Incontinence Impact Questionnaire.

Results: There is no significant difference in the demographics and the distribution and concordance of two reflex contractions between women with or without urinary incontinence. Neither type of reflex contraction during coughing was identified in 14 incontinent women (7 %) and 5 continent women (4 %). The concordant rate for synchronous activities of both reflex contractions during coughing was 80 % (167) and 81 % (102) for incontinent and continent women, respectively. Incontinent women without clitoral reflex motion had significantly greater incontinent severity on 1-hour pad tests (p = 0.018) and higher sum scores of the short form of Incontinence Impact Questionnaire (p = 0.026). By contrast, incontinent women with and without reflex anorectal lifts had similar incontinence severity and impact.

Conclusion: In women with SUI, loss of clitoral reflex motion is associated with worse incontinent severity and impact.

Zusammenfassung

Ziel: Untersuchung der Auswirkung von zwei reflektorischen Muskelkontraktionsmustern des Beckenbodens während des Hustens auf die Schwere der Inkontinenz und die durch die Inkontinenz bedingte Lebensqualität von Frauen mit stressbedingter Harninkontinenz (SUI).

Material und Methoden: Insgesamt 208 Frauen mit symptomatischem oder urodynamischem Nachweis einer SUI und 126 Frauen ohne Erfahrungen von Harninkontinenz wurden über einen Zeitraum von 5 Jahren einbestellt. Während eines starken Hustens wurde die reflektorische Muskelkontraktion des Beckenbodens mittels introitaler Sonografie nachgewiesen und zwei reflektorische Kontraktionsmuster erkannt: eine Bewegung der Klitoris nach innen und eine superior-anteriore anorektale Anhebung. Die Bewertung der Schwere der Inkontinenz und der Beeinträchtigung der Lebensqualität beinhaltete einen 1-stündigen Pad-Test und eine Kurzform des „Urogenital Distress Inventory“ und des „Incontinence Impact Questionnaire“.

Ergebnisse: Es gibt keinen signifikanten Unterschied zwischen Frauen mit und ohne Harninkontinenz in Bezug auf demografische Faktoren sowie der Verteilung und Übereinstimmung der beiden reflektorischen Kontraktionen. Bei 14 inkontinenten (7 %) und 5 kontinenten Frauen (4 %) wurde beim Husten keine der beiden Formen der reflektorischen Kontraktionen ermittelt. Die Übereinstimmungsrate für synchrone Aktivitäten der beiden reflektorischen Kontraktionen beim Husten betrug 80 % (167) bei den inkontinenten und 81 % (102) bei den kontinenten Frauen. Inkontinente Frauen ohne Reflexbewegung der Klitoris hatten eine signifikant stärkere Inkontinenz im 1-stündigen Pad-Test (p = 0,018) und eine größere Punktzahl bei der Kurzform des Inkontinenz-Fragebogens (p = 0,026). Im Gegensatz dazu hatten inkontinente Frauen mit und ohne reflektorische anorektale Anhebungen eine ähnliche Stärke der Inkontinenz und Beeinträchtigung.

Schlussfolgerung: Bei Frauen mit SUI ist der Verlust der Reflexbewegung der Klitoris mit einem größeren Ausmaß an Inkontinenz und Beeinträchtigung verbunden.

Key words

ultrasound - pelvis - incontinence severity - stress urinary incontinence - reflex pelvic floor muscle contraction

• References

• 1 Sapsford R, Hodges P. Contraction of the pelvic floor muscles during abdominal maneuvers. Arch Phys Med Rehabil 2001; 82: 1081-1088
• 2 Devreese A, Staes F, de Weerdt W et al. Clinical evaluation of pelvic floor muscle function in continent and incontinent women. Neurourol Urodyn 2004; 23: 190-197
• 3 Raizada V, Bhargava V, Jung SA et al. Dynamic assessment of the vaginal high-pressure zone using high-definition manometry, 3-dimensional ultrasound, and magnetic resonance imaging of the pelvic floor muscles. Am J Obstet Gynecol 2010; 203: 172.e1-172.e8
• 4 Constantinou CE, Hvistendahl G, Ryhammer A et al. Determining the displacement of the pelvic floor and pelvic organs during voluntary contraction using magnetic resonance imaging in younger and older women. BJU Int 2002; 90: 408-414
• 5 Najjari L, Blum R, Hennemann J et al. Using contrast inversion to extend the diagnostic value of perineal ultrasound for urethral and paraurethral pathologies. Ultraschall in Med 2011; 32: E182-E190
• 6 Lovegrove Jones RC, Peng Q, Stokes M et al. Mechanisms of pelvic floor muscle function and the effect on urethra during a cough. Eur Urol 2010; 57: 1101-1110
• 7 Flock F, Kohorst F, Kreienberg R et al. Ultrasound assessment of tension-free vaginal tape (TVT). Ultraschall in Med 2011; 32: S35-S40
• 8 Constantinou CE, Omata S. Direction sensitive sensor probe for the evaluation of voluntary and reflex pelvic floor contractions. Neurourol Urodyn 2007; 26: 386-391
• 9 Braekken IH, Majida M, Engh ME et al. Test-retest reliability of pelvic floor muscle contraction measured by 4D ultrasound. Neurourol Urodyn 2009; 28: 68-73
• 10 Dietz HP, Bond V, Shek KL. Does childbirth alter the reflex pelvic floor response to coughing?. Ultrasound Obstet Gynecol 2011; DOI: 10.1002/uog.10083.
• 11 Dietz HP, Wilson PD, Clarke B. The use of perineal ultrasound to quantify levator activity and teach pelvic floor muscle exercises. Int Urogynecol J Pelvci Floor Dysfunct 2001; 12: 166-168
• 12 Yang SH, Huang WC, Yang SY et al. Validation of new ultrasound parameters for quantifying pelvic floor muscle contraction. Ultrasound Obstet Gynecol 2009; 33: 465-471
• 13 Amarenco G, Ismael SS, Lagauche D et al. Cough anal reflex: strict relationship between intravesical pressure and pelvic floor muscle electromyographic activity during cough. Urodynamic and electrophysiological study. J Urol 2005; 173: 149-152
• 14 Miller JM, Perucchini D, Carchidi LT et al. Pelvic floor muscle contraction during a cough and decreased vesical neck mobility. Obstet Gynecol 2001; 97: 255-260
• 15 Miller JM, Sampselle C, Ashton-Miller J et al. Clarification and confirmation of the Knack maneuver: the effect of volitional pelvic floor muscle contraction to preempt expected stress incontinence. Int Urogynecol J Pelvic Floor Dysfunct 2008; 19: 773-782
• 16 Yang JM, Yang SH, Yang SY et al. Reliability of real-time ultrasound for the detection of involuntary or reflex pelvic floor muscle contraction in urinary incontinent women. J Urol 2009; 182: 2392-2396
• 17 Uebersax JS, Wyman JF, Shumaker SA et al. Short forms to assess life quality and symptom distress for urinary incontinence in women: the Incontinence Impact Questionnaire and the Urogenital Distress Inventory. Continence Program for Women Research Group. Neurourol Urodyn 1995; 14: 131-39
• 18 Yang JM, Huang WC. Discrimination of bladder disorders in female lower urinary tract symptoms on ultrasonographic cystourethrography. J Ultrasound Med 2002; 21: 1249-1255
• 19 Messelink B, Benson T, Berghmans B et al. Standardization of terminology of pelvic floor muscle function and dysfunction: report from the pelvic floor clinical assessment group of the International Continence Society. Neurourol Urodyn 2005; 24: 374-380
• 20 Deindl FM, Vodusek DB, Hesse U et al. Activity patterns of pubococcygeal muscles in nulliparous continent women. Br J Urol 1993; 72: 46-51
• 21 Peschers UM, Voduŝek DB, Fanger G et al. Pelvic muscle activity in nulliparous volunteers. Neurourol Urodyn 2001; 20: 269-275
• 22 Miller JM, Umek WH, DeLancey JO et al. Can women increase urethral closure pressure without their pubococcygeus muscles?. Am J Obstet Gynecol 2004; 191: 171-175
• 23 Jiang HH, Salcedo LB, Song B et al. Pelvic floor muscles and the external urethral sphincter have different response to applied bladder pressure during continence. Urology 2010; 75: 1515.e1-1515e.7
• 24 Kamo I, Kaiho Y, Canon TW et al. Functional analysis of active urethral closure mechanisms under sneeze induced stress condition in a rat model of birth trauma. J Urol 2006; 176: 2711-2715
• 25 Kamo I, Hashimoto T. Involvement of reflex urethral closure mechanisms in urethral resistance under momentary stress condition induced by electrical stimulation of rat abdomen. Am J Physiol Renal Physiol 2007; 293: F920-F926
• 26 Dietz HP, Steensma AB, Vancaillie TG. Levator function in nulliparous women. Int Urogynecol J Pelvic Floor Dysfunct 2003; 14: 24-26
• 27 Dietz HP, Erdmann M, Shek KL. Reflex contraction of the levator ani in women symptomatic for pelvic floor disorders. Ultrasound Obstet Gynecol 2012; DOI: 10.1002/uog.11087.
• 28 Shafik A, El-Sibai O. Levator ani muscle activity in pregnancy and the postpartum period: a myoelectric study. Clin Exp Obstet Gynecol 2000; 27: 129-132
• 29 Thind P, Lose G et al. Initial urethral pressure increase during stress episodes in genuine stress incontinent women. Br J Urol 1992; 69: 137-140
• 30 Devreese A, Staes F, Janssens L et al. Incontinent women have altered pelvic floor muscle contraction patterns. J Urol 2007; 178: 558-562