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An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for the conservative and nonpharmacological management of female pelvic floor dysfunction

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Abstract

Introduction and hypothesis

There has been an increasing need for the terminology on the conservative management of female pelvic floor dysfunction to be collated in a clinically based consensus report.

Methods

This Report combines the input of members and elected nominees of the Standardization and Terminology Committees of two International Organizations, the International Urogynecological Association (IUGA) and the International Continence Society (ICS), assisted at intervals by many external referees. An extensive process of nine rounds of internal and external review was developed to exhaustively examine each definition, with decision-making by collective opinion (consensus). Before opening up for comments on the webpages of ICS and IUGA, five experts from physiotherapy, neurology, urology, urogynecology, and nursing were invited to comment on the paper.

Results

A Terminology Report on the conservative management of female pelvic floor dysfunction, encompassing over 200 separate definitions, has been developed. It is clinically based, with the most common symptoms, signs, assessments, diagnoses, and treatments defined. Clarity and ease of use have been key aims to make it interpretable by practitioners and trainees in all the different specialty groups involved in female pelvic floor dysfunction. Ongoing review is not only anticipated, but will be required to keep the document updated and as widely acceptable as possible.

Conclusion

A consensus-based terminology report for the conservative management of female pelvic floor dysfunction has been produced, aimed at being a significant aid to clinical practice and a stimulus for research.

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Notes

  1. Terminology for Female Anorectal Dysfunction [18].

  2. A comprehensive definition of these terms is covered by Doggweiler et al. [123].

  3. Symptoms of pelvic floor myalgia should be described in terms of location, quality, intensity, pattern, duration, frequency, moderating factors, and associated symptoms. Pain details may include:

    1. a)

      Whether pain is present at rest or mechanical in nature (related to muscle contraction or relaxation or body posture) and/or altered with a change of posture (lying to sitting, sitting to standing) or movement (bending, walking, sexual activity

    2. b)

      Whether uni- or bilateral in nature

    3. c)

      Whether accompanied by bladder or bowel dysfunction, vulvodynia or dyspareunia (superficial/deep)

  4. The evidence for the existence of trigger points is debated [124].

  5. Atrophy of the urogenital tract is normal at certain points in the life cycle, mainly caused by aging and hypoestrogenism [8, 125].

  6. Muscle tone is evaluated clinically as the resistance provided by a muscle when a pressure/deformation or a stretch is applied to it [19–21]. Muscle tone may be altered in the presence or absence of pain. There is no single accepted or standardized way of measuring muscle tone, and there are no normative values.

  7. The terms hyper- and hypotonicity are commonly used in neurology and muscle physiology. Messelink et al. [2] introduced the terms overactivity and underactivity related to PFM. These terms are not defined with cut-off points, nor are they based on comparison with normal populations. As activity can only relate to the active (i.e., contractile) portion of muscle tone, activity cannot be used interchangeably with muscle tone, unless it can be shown that the active component of the muscle is altered. If increased (over-) or decreased (under-) activity in the PFM can be demonstrated using electromyography (EMG) or another measure, then these terms may be used appropriately.

  8. Muscle cramp either during or immediately after exercise is commonly referred to as “exercise-associated muscle cramping” [93]; however, cramps are not specific to exercise.

  9. Local or referred pain may be reproduced. An active TrP is said to have a characteristic “twitch” response when stimulated; however, the twitch response to palpation has been shown to be unreliable [126]. The most reliable sign of a TrP is sensitivity to applied pressure. Trigger points are implicated in myofascial pain; however, the validity of this theory is controversial and has recently been refuted [124].

  10. Palpation is less reliable and responsive than manometers and dynamometers [42].

  11. The pressure measured does not confirm its origin, and pressure measurement is only valid when used in combination with other methods, e.g., simultaneous observation of the inward movement of the perineum or device during PFM contraction.

  12. The term perineometer is somewhat misleading as the pressure-sensitive region of the manometer probe is not placed at the perineum, but inside the vagina at the level of the levator ani. Vaginal pressure devices should be referred to as PFM manometers [42, 49].

  13. Today’s dynamometers for the pelvic floor also detect resting and contractile contributions from muscles other than the PFM, contributing to the force recordings. As dynamometers can be opened at different muscle lengths to measure PFM force, the process of measurement should respect the maximum achievable vaginal aperture without inducing discomfort, so as not to influence the validity of the measurement.

  14. EMG in this case usually means “concentric needle EMG,” but other EMG methods exist. EMG is typically distinguished as either intramuscular or surface. EMG diagnosis is often used as a synonym for “neurophysiological diagnosis of the peripheral neuromuscular system,” and that would also include the measurement of motor and sensory conduction, the recording of reflex responses, etc. [36]. EMG does not directly measure muscle strength. The type of electrode being used should be specified.

  15. This is not typically used in clinical assessment, but may be included in research or advanced examinations, for example, to diagnose striated muscle denervation/re-innervation [36].

  16. Surface EMG is considered to be less specific than intramuscular EMG. The large surface area of the electrodes may result in cross-talk from adjacent muscles and other artifacts; therefore, technical expertise is required. EMG can reveal the pattern of activity of a particular muscle, as in the diagnosis of detrusor sphincter dyssynergia during urodynamics [2, 36].

  17. Because pain is multidimensional, a single rating scale combines these dimensions in unknown quantities. One may separately assess pain intensity, pain distress, and interference of pain with activities of daily life.

  18. Other urological, gynecological, gastrointestinal and colorectal pain conditions without related PFM dysfunction, are well described in standard texts. Many pelvic floor pain-related conditions or syndromes (e.g., vulvodynia, interstitial cystitis/bladder pain syndrome, irritable bowel syndrome) are described in the Standard for Terminology in Chronic Pelvic Pain Syndromes (CPPS): A Report from the Ad Hoc Working Group of the International Continence Society Standardization Steering Committee (ICS-SSC) on Chronic Pelvic Pain, ICS Standardization of Terminology document on Chronic Pelvic Pain [123]. Several other systemic disorders (e.g., chronic fatigue syndrome, diabetes) may have an impact on the pelvic floor; however, PFD is not part of their recognized etiology.

  19. We recommend that “behavioral” be limited to studies that evaluate how people do or do not behave as desired, e.g., commencement or cessation of PFM training or change of a diet.

  20. We recommend that the specific treatment is described, e.g., PFM training, electrical stimulation, rather than the unspecific term physiotherapy, the latter also referring to a specific profession. Publications should report the actual professional who provided the intervention (e.g., physiotherapist, general practitioner, urogynecologist, urologist, midwife, nurse, fitness instructor), rather than using the vague term, “therapist”/“clinician”/“researcher.”

  21. Adherence is usually reported as the number or percentage of clinical visits attended and home exercises or regimen components followed or completed by the client/patient.

  22. The term “adherence” is generally preferred within healthcare, as it acknowledges client/patient autonomy and implies a willingness on their part to participate and cooperate rather than the traditional view, inherent in “compliance,” of an expert clinician dictating to a naive patient [62, 63]. Simply, adherence is agreeing what to do; compliance is being told what to do.

  23. An increase in the physical activity level may affect UI positively via weight reduction in obese persons. Conversely, several studies have shown that there is a high prevalence of UI in physically active women during exercise (especially during high impact activity, defined as running and jumping). Strenuous exercise/work has been suggested to be a risk factor for the development of PFD [71]. A well-functioning pelvic floor responds before and during an increase in intra-abdominal pressure.

  24. Ideally, the voiding intervals should be increased by 15–30 min each week, according to the patient’s tolerance to the schedule, until a voiding interval of 3–4 h is achieved. Use of a bladder diary is recommended for self-monitoring of progress [70].

  25. A bowel habit intervention may: encourage bowel emptying at a specific time of day, mainly after a meal (to utilize the gastrocolic response), encourage patients to adopt a sitting or squatting position where possible while emptying the bowel, teach patients techniques to facilitate bowel evacuation and stress the importance of avoiding straining [74, 127, 128].

  26. Speed changes little with training. Thus, power is increased almost exclusively by gaining strength [35].

  27. PFM training can be isometric, concentric or eccentric or a combination of any of these.

  28. Whether PFMT is performed with or without previous assessment of the ability to contract should be reported.

  29. The original shape was conical; however, different shapes are currently available. Maintenance of the weight in position can be challenged via different body positions and activities.

  30. PFM feedback can be provided by the therapist or patient during manual palpation internally or externally, or with a mirror. The purpose of feedback is to increase accuracy of contraction for maximum benefit.

  31. Biofeedback can be visual, auditory or both. Biofeedback is not a treatment on its own. It is an adjunct to training and can be used to help the patient be more aware of muscle function, and to enhance and motivate patient effort during training [129]. The correct terminology should be PFM strength training with biofeedback or relaxation training with biofeedback. Types of PFM biofeedback include: perianal, vaginal, and anal surface EMG, urethral, vaginal or anal manometry, vaginal dynamometry, real-time ultrasound [129].

  32. Clinicians are to be cautious with regard to the interpretation of the information, as many factors influence amplitude, including muscle activity, skin conductance, and artifact. “EMG amplitude does not equal force” [87]. More microvolt activity means more muscle activity, but does not always mean more strength.

  33. Artifact examples include movement or contact quality artifact, cross talk, heart rate, skin electrode shear, and electrode bridging.

  34. Minimizing cross talk is essential in research into quality EMG tracings.

  35. Recording with surface electrodes is prone to artifact and cross talk. The user should be trained appropriately and understand the limits of the EMG instrument and of the methodology. It is not within the scope of this document to define all EMG terms. Readers are referred to other texts for further terminology [87, 88].

  36. Baseline EMG reading can be influenced by many factors and therapists must take into account the patient’s symptoms, digital palpation results, overall tension of the patient, the possibility of artifacts, and other factors in determining the meaning of the baseline muscle activity.

  37. Slow recruitment can be symptomatic of leakage during coughing and sneezing when a quick muscle contraction is needed to counteract increased intra-abdominal pressure.

  38. Slow de-recruitment can be indicative of a hypertonic PFM.

  39. The general principles of strength training are the same with and without biofeedback. (See the sections “Mode of exercise training” and “Dose–response issues related to exercise training”)

  40. The general principles of relaxation training are the same with and without biofeedback.

  41. Manual therapy is used to treat soft tissues and joint structures for the purpose of modulating pain; increasing the range of motion; reducing soft tissue edema; inducing relaxation; improving contractile and noncontractile tissue extensibility, and/or stability; facilitating movement; and improving function. This broad group of skilled hands-on treatments can be divided into two groups: joint therapies and soft-tissue therapies.

  42. Neither mobilization nor manipulation should be used when referring to muscle.

  43. The notion of trigger points causing myofascial pain is controversial [124].

  44. Depending on the particular device being used, the type of electrical current, the specific health problem and condition being treated, and the individual’s needs and circumstances, many electrical stimulation parameters may be adjusted by the therapist administering the treatment.

  45. The slower the current intensity rises to the preset amplitude or threshold level, the more comfortable the stimulation may feel. Conversely, the faster the ramp, or the more vertical the ramping up signal, the more discomfort may be felt.

  46. Terminology for female anorectal dysfunction [18].

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Acknowledgements

We thank Professors Jacques Corcos (Urologist McGill University, Montreal Canada, Mandy Fader (Nurse, University of Southampton, UK), Ingrid Nygaard (Urogynecologist, University of Utah, Salt Lake City, USA), Marijke van Kampen (Physiotherapist, University Hospital Gasthuisberg, K.U. Leuven, Belgium) and David Vodusek (Neurophysiologist, University of Ljubljana, Slovenia) for expert advice on the draft manuscript.

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Authors and Affiliations

  1. Department of Sports Medicine, Norwegian School of Sport Sciences, PO Box 4014, Ullevål Stadion, 0806, Oslo, Norway

    Kari Bo

  2. Cabrini Health, La Trobe University, Melbourne, Australia

    Helena C. Frawley

  3. University of New South Wales, Sydney, NSW, Australia

    Bernard T. Haylen

  4. Technion University, Haifa, Israel

    Yoram Abramov

  5. Federal University, São Paolo, Brazil

    Fernando G. Almeida & Maria Bortolini

  6. Maastricht University Medical Centre, Maastricht, Netherlands

    Bary Berghmans

  7. University of Montreal, Montreal, QC, Canada

    Chantale Dumoulin

  8. Centro Hospitalar Porto, Oporto, Portugal

    Mario Gomes

  9. Glasgow Caledonian University, Glasgow, UK

    Doreen McClurg

  10. Naarden, Netherlands

    Jane Meijlink

  11. Moline, IL, USA

    Elizabeth Shelly

  12. Mayo Clinic, Minnesota, USA

    Emanuel Trabuco

  13. Hospital Universitario Quirón, Madrid, Spain

    Carolina Walker

  14. University of Exeter, Exeter, UK

    Amanda Wells

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  1. Kari Bo
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Correspondence to Kari Bo.

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Conflicts of interest

Elizabeth Shelly is a consultant to Analytica and Amanda Wells is a consultant to ARC Health Services. None of the other authors have any conflicts of interest.

Additional information

This document is being published simultaneously in Neurourology and Urodynamics (NAU) and the International Urogynecology Journal (IUJ), the respective journals of the sponsoring organizations, the International Continence Society (ICS) and the International Urogynecological Association (IUGA)

Standardization and Terminology Committees of the IUGA* and ICS#: Bernard T. Haylen*, Jane Meijlink#, Elizabeth Shelly#

Joint IUGA/ICS Working Group on the Conservative Management of Pelvic Floor Dysfunction: Kari Bo, Helena Frawley, Bernard Haylen, Yoram Abramov, Fernando Almeida, Bary Berghmans, Maria Bortolini, Chantale Dumoulin, Mario Gomes, Doreen McClurg, Jane Meijlink, Elizabeth Shelly, Emanuel Trabuco, Carolina Walker, and Amanda Wells

Published online in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/nau.23107

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Bo, K., Frawley, H.C., Haylen, B.T. et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for the conservative and nonpharmacological management of female pelvic floor dysfunction. Int Urogynecol J 28, 191–213 (2017). https://doi.org/10.1007/s00192-016-3123-4

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