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Clinical and MRI changes of puborectalis and iliococcygeus after a short period of intensive pelvic floor muscles training with or without instrumentation

A prospective randomized controlled trial
  • Frédéric Dierick
  • Ekaterina Galtsova
  • Clara Lauer
  • Fabien Buisseret
  • Anne-France Bouché
  • Laurent Martin
Original Article
  • 8 Downloads

Abstract

Purpose

This study evaluates the impact of a 3-week period of intensive pelvic floor muscles training (PFMT), with or without instrumentation, on clinical and static magnetic resonance imaging (MRI) changes of puborectalis (PR) and iliococcygeus (IL) muscles.

Methods

24 healthy young women were enrolled in the study and 17 achieved the 9 sessions of 30 min training exercises and conducted all assessments. Participants were randomly assigned in two training groups: voluntary contractions combined with hypopressive exercises (HYPO) or biofeedback exercises combined with transvaginal electrical stimulations (ELEC). Clinical and T2-weighted MRI assessments were realized before and after training.

Results

Modified Oxford Grading System (MOGS) scores for left PR and perineal body significantly increased in the two groups (p = 0.039, p = 0.008), but MOGS score for right PR significantly increased only in HYPO (p = 0.020). Muscle volumes of right and left IL significantly decreased (p = 0.040, p = 0.045) after training as well as signal intensities of right and left PR (p = 0.040, p = 0.021) and thickness of right and left IL at mid-vagina location (p = 0.012, p = 0.011).

Conclusions

A short period of intensive PFMT induces clinical and morphological changes in PFMs at rest suggesting a decrease in IL volume and adipose content of PR. Although the results suggested that an intensive non-instrumented PFMT is as effective as an instrumented training, future controlled studies with greater sample sizes are needed to establish the relative and absolute effectiveness of each of the two interventions.

Keywords

Anatomy Levator ani Transversus abdominis Strengthening Morphology Hypopressive Biofeedback Electrical stimulation 

Abbreviations

BMI

Body mass index

CONSORT

Consolidated standards of reporting trials

DA

Diaphragmatic aspiration

DTI

Diffusion tensor imaging

ELEC

Biofeedback exercises and transvaginal electrical stimulations group

HYPO

Voluntary contractions and hypopressive exercises group

ICC

Intraclass correlation coefficient

IL

Iliococcygeus

LA

Levator ani

MOGS

Modified Oxford grading system

MPL

Mid-pubic line

MRI

Magnetic resonance imaging

OI

Obturator internus

PB

Perineal body

PC

Pubococcygeus

PCL

Pubococcygeal line

PFD

Pelvic floor dysfunction

PFDI-20

Pelvic floor distress inventory

PFIQ-7

Pelvic floor impact questionnaire

PFM

Pelvic floor muscle

PFMT

Pelvic floor muscle training

PLP

Posterior levator plate

PR

Puborectalis

PV

Pubovisceralis

RM ANOVA

Repeated measures analysis of variance

RT

Resting tone

SD

Standard deviation

TUI

Translabial tomographic ultrasound imaging

UI

Urinary incontinence

Notes

Acknowledgements

The authors would like to thank Caroline Lahaye and Jean-Louis Greffe for their assistance in the development of the protocol, and Jean-Claude Malherbe (Enraf-Nonius) for making the stimulation/biofeedback material available throughout the experiment. They also thank the financial support of Grand Hôpital de Charleroi (GHdC asbl), Philips SA, and the Haute Ecole Louvain en Hainaut for the MRI.

Author contributions

FD and AFB conceived and designed research. FD, EG, CL and LM conducted experiments. FD, EG and CL analyzed data. FD, EG, CL, FB, AFB and LM wrote the manuscript. All authors read and approved the manuscript.

References

  1. Ashton-Miller JA, Zielinski R, DeLancey JOL, Miller JM (2014) Validity and reliability of an instrumented speculum designed to minimize the effect of intra-abdominal pressure on the measurement of pelvic floor muscle strength. Clin Biomech (Bristol, Avon) 29(10):1146–1150.  https://doi.org/10.1016/j.clinbiomech.2014.09.011
  2. Barber M, Walters M, Bump R (2005) Short forms of two condition-specific quality-of-life questionnaires for women with pelvic floor disorders (PFDI-20 and PFIQ-7). Am J Obstet Gynecol 193(1):103–113.  https://doi.org/10.1016/j.ajog.2004.12.025
  3. Bernardes BT, Resende PA, Stüpp L, Oliveira E, Castro AR, Bella ZI, Girão MJ, Sartori MG (2012) Efficacy of pelvic floor muscle training and hypopressive exercises for treating pelvic organ prolapse in women: randomized controlled trial. Sao Paulo Med J 130(1):5–9CrossRefPubMedGoogle Scholar
  4. Bernstein IT (1997) The pelvic floor muscles: muscle thickness in healthy and urinary-incontinent women measured by perineal ultrasonography with reference to the effect of pelvic floor training. Estrogen receptor studies. Neurourol Urodyn 16(4):237–275CrossRefPubMedGoogle Scholar
  5. Betschart C, Kim J, Miller JM, Ashton-Miller JA, DeLancey JOL (2014) Comparison of muscle fiber directions between different levator ani muscle subdivisions: in vivo mri measurements in women. Int Urogynecol J 25(9):1263–1268.  https://doi.org/10.1007/s00192-014-2395-9
  6. Bø K, Sherburn M (2005) Evaluation of female pelvic-floor muscle function and strength. Phys Ther 85(3):269–282PubMedGoogle Scholar
  7. Bø K, Talseth T, Holme I (1999) Single blind, randomised controlled trial of pelvic floor exercises, electrical stimulation, vaginal cones, and no treatment in management of genuine stress incontinence in women. BMJ 318(7182):487–493CrossRefPubMedPubMedCentralGoogle Scholar
  8. Cai XR, Qiu L, Wu HJ, R LS (2013) Assessment of levator ani morphology and function in asymptomatic nulliparous women via static and dynamic magnetic resonance imaging. Int J Gynaecol Obstet 121(3):233–239.  https://doi.org/10.1016/j.ijgo.2013.01.022
  9. Castro R, Arruda R, Zanetti M, Santos P, Sartori M, MJ G (2008) Single-blind, randomized, controlled trial of pelvic floor muscle training, electrical stimulation, vaginal cones, and no active treatment in the management of stress urinary incontinence. Clinics (Sao Paulo) 63(4):465–472.  https://doi.org/10.1590/S1807-59322008000400009
  10. Caufriez M (1997) Gymnastique abdominale hypopressive. Editions M, Caufriez, BruxellesGoogle Scholar
  11. Da Roza T, de Araujo MP, Viana R, Viana S, Jorge RN, Bø K, Mascarenhas T (2012) Pelvic floor muscle training to improve urinary incontinence in young, nulliparous sport students: a pilot study. Int Urogynecol J 23(8):1069–1073.  https://doi.org/10.1007/s00192-012-1759-2
  12. DeLancey JO, Kearney R, Chou Q, Speights S, Binno S (2003) The appearance of levator ani muscle abnormalities in magnetic resonance images after vaginal delivery. Obstet Gynecol 101(1):46–53PubMedPubMedCentralGoogle Scholar
  13. de Tayrac R, Deval B, Fernandez H, Marès P (2007) Validation linguistique en français des versions courtes des questionnaires de symptômes (PFDI-20) et de qualité de vie (PFIQ-7) chez les patientes présentant un trouble de la statique pelvienne. J Gynecol Obstet Biol Reprod (Paris) 36(8):738–748.  https://doi.org/10.1016/j.jgyn.2007.08.002
  14. Dietz HP, Shek KL (2008) The quantification of levator muscle resting tone by digital assessment. Int Urogynecol J 19(11):1489–1493.  https://doi.org/10.1007/s00192-008-0682-z
  15. Dumoulin C, Peng Q, Stodkilde-Jorgensen H, Shishido K, Constantinou C (2007) Changes in levator ani anatomical configuration following physiotherapy in women with stress urinary incontinence. J Urol 178(3):970–977.  https://doi.org/10.1016/j.juro.2007.05.023
  16. Dumoulin C, Hay-Smith EJC, Mac Habée-Séguin G (2014) Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women (review). Cochrane Database Syst Rev 14(5):CD005, 654.  https://doi.org/10.1002/14651858.CD005654.pub3
  17. Dumoulin C, Hay-Smith J, Habée-Séguin GM, Mercier J (2015) Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women: A short version Cochrane systematic review with meta-analysis. Neurourol Urodyn 34(4):300–308.  https://doi.org/10.1002/nau.22700
  18. Federative Commitee on Anatomical Terminology (1998) Terminologia anatomica: international anatomical terminology. Thieme, StuttgartGoogle Scholar
  19. Fielding JR, Griffiths DJ, Versi E, Mulkern RV, Lee ML, Jolesz FA (1998) MR imaging of pelvic floor continence mechanisms in the supine and sitting positions. AJR Am J Roentgenol 171(6):1607–1610.  https://doi.org/10.2214/ajr.171.6.9843296
  20. Fitz FF, Resende APM, Stüpp L, Sartori MGF, Girão MJBC, Castro RA (2012) Biofeedback for the treatment of female pelvic floor muscle dysfunction: a systematic review and meta-analysis. Int Urogynecol J 23(11):1495–1516.  https://doi.org/10.1007/s00192-012-1707-1
  21. Goode PS, Burgio KL, Locher JL, Roth DL, Umlauf MG, Richter HE, Varner RE, Lloyd LK (2003) Effect of behavioral training with or without pelvic floor electrical stimulation on stress incontinence in women: a randomized controlled trial. JAMA 290(3):345–352.  https://doi.org/10.1001/jama.290.3.345
  22. Handa VL, Lockhart ME, Fielding JR, Bradley CS, Brubaker L, Cundiff GW, Ye W, Richter HE, Pelvic Floor Disorders Network (2008) Racial differences in pelvic anatomy by magnetic resonance imaging. Obstet Gynecol 111(4):914–920.  https://doi.org/10.1097/AOG.0b013e318169ce03
  23. Harvey MA (2003) Pelvic floor exercises during and after pregnancy: a systematic review of their role in preventing pelvic floor dysfunction. J Obstet Gynaecol Can 25(6):487–498CrossRefPubMedGoogle Scholar
  24. Howard D, DeLancey JOL, Tunn R, Ashton-Miller JA (2000) Racial differences in the structure and function of the stress urinary continence mechanism. Obstet Gynecol 95(5):713–717PubMedPubMedCentralGoogle Scholar
  25. Hsu Y, Summers A, Hussain HK, Guire KE, Delancey JO (2006) Levator plate angle in women with pelvic organ prolapse compared to women with normal support using dynamic MR imaging. Am J Obstet Gynecol 194(5):1427–1433.  https://doi.org/10.1016/j.ajog.2006.01.055
  26. Ibrahim IK, Hameed MMA, Taher EM, Shaheen EM, Elsawy MSAG (2015) Efficacy of biofeedback-assisted pelvic floor muscle training in females with pelvic floor dysfunction. Alexandria J Med 51:137–142CrossRefGoogle Scholar
  27. Isherwood PJ, Rane A (2000) Comparative assessment of pelvic floor strength using a perineometer and digital examination. BJOG 107(8):1007–1011CrossRefPubMedGoogle Scholar
  28. Jácome C, Oliveira D, Marques A, Sá-Couto P (2011) Prevalence and impact of urinary incontinence among female athletes. Int J Gynaecol Obstet 114(1):60–63.  https://doi.org/10.1016/j.ijgo.2011.02.004
  29. Kearney R, Sawhney R, DeLancey JOL (2004) Levator ani muscle anatomy evaluated by origin-insertion pairs. Obstet Gynecol 104(1):168–173.  https://doi.org/10.1097/01.AOG.0000128906.61529.6b
  30. Kirschner-Hermanns R, Wein B, Niehaus S, Schaefer W, Jakse G (1993) The contribution of magnetic resonance imaging of the pelvic floor to the understanding of urinary incontinence. Br J Urol 72(5 Pt 2):715–718CrossRefPubMedGoogle Scholar
  31. Lammers K, Prokop M, Vierhout ME, Kluivers KB, Fütterer JJ (2013) A pictorial overview of pubovisceral muscle avulsions on pelvic floor magnetic resonance imaging. Insights Imaging 4(4):431–441.  https://doi.org/10.1007/s13244-013-0261-9
  32. Lawson JO (1974) Pelvic anatomy. i. pelvic floor muscles. Ann R Coll Surg Engl 54(5):244–252PubMedPubMedCentralGoogle Scholar
  33. Margulies RU, Hsu Y, Kearney R, Stein T, Umek WH, DeLancey JOL (2006) Appearance of the levator ani muscle subdivisions in magnetic resonance images. Obstet Gynecol 107(5):1064–1069.  https://doi.org/10.1097/01.AOG.0000214952.28605.e8
  34. May DA, Disler DG, Jones EA, Balkissoon AA, Manaster BJ (2000) Abnormal signal intensity in skeletal muscle at MR imaging: patterns, pearls, and pitfalls. Radiographics 20:S295–S315.  https://doi.org/10.1148/radiographics.20.suppl_1.g00oc18s295
  35. Raizada V, Mittal RK (2008) Pelvic floor anatomy and applied physiology. Gastroenterol Clin N Am 37(3):493–509.  https://doi.org/10.1016/j.gtc.2008.06.003
  36. Resende APM, Stüpp L, Bernardes BT, Oliveira E, Castro RA, Girão MJBC, Sartori MGF (2012) Can hypopressive exercises provide additional benefits to pelvic floor muscle training in women with pelvic organ prolapse? Neurourol Urodyn 31(1):121–125.  https://doi.org/10.1002/nau.21149
  37. Rousset P, Delmas V, Buy JN, Rahmouni A, Vadrot D, Deux JF (2012) In vivo visualization of the levator ani muscle subdivisions using MR fiber tractography with diffusion tensor imaging. J Anat 221(3):221–228.  https://doi.org/10.1111/j.1469-7580.2012.01538.x
  38. Santa Mina D, Au D, Alibhai SMH, Jamnicky L, Faghani N, Hilton WJ, Stefanyk LE, Ritvo P, Jones J, Elterman D, et al. (2015) A pilot randomized trial of conventional versus advanced pelvic floor exercises to treat urinary incontinence after radical prostatectomy: a study protocol. BMC Urol .  https://doi.org/10.1186/s12894-015-0088-4
  39. Schwertner-Tiepelmann N, Thakar R, Sultan AH, Tunn R (2012) Obstetric levator ani muscle injuries: current status. Ultrasound Obstet Gynecol 39(4):372–383.  https://doi.org/10.1002/uog.11080
  40. Slieker-ten Hove MP, Pool-Goudzwaard AL, Eijkemans MJC, Steegers-Theunissen RPM, Burger CW, Vierhout ME (2009) Pelvic floor muscle function in a general female population in relation with age and parity and the relation between voluntary and involuntary contractions of the pelvic floor musculature. Int Urogynecol J 20(12):1497–1504.  https://doi.org/10.1007/s00192-009-0978-7
  41. Shrout PE, Fleiss JL (1979) Intraclass correlations: uses in assessing rater reliability. Psychol Bull 86(2):420–428CrossRefPubMedGoogle Scholar
  42. Singh K, Reid WM, Berger LA (2001) Assessment and grading of pelvic organ prolapse by use of dynamic magnetic resonance imaging. Am J Obstet Gynecol 185(1):71–77.  https://doi.org/10.1067/mob.2001.113876
  43. Singh K, Reid WMN, Berger LA (2002) Magnetic resonance imaging of normal levator ani anatomy and function. Obstet Gynecol 99(3):433–438PubMedGoogle Scholar
  44. Thorp J, Stephenson H, Jones L, Cooper G (1994) Pelvic floor (Kegel) exercises—a pilot study in nulliparous women. Int Urogynecol J 5(2):86–89CrossRefGoogle Scholar
  45. van Breda HMK, Bosch JLHR, de Kort LMO (2015) Hidden prevalence of lower urinary tract symptoms in healthy nulligravid young women. Int Urogynecol J 26(11):1637–1643.  https://doi.org/10.1007/s00192-015-2754-1
  46. Yan Y, Dou C, Wang X, Xi Y, Hu B, Ma L, Ying T (2017) Combination of tomographic ultrasound imaging and three-dimensional magnetic resonance imaging-based model to diagnose postpartum levator avulsion. Sci Rep.  https://doi.org/10.1038/s41598-017-08201-9
  47. Yang A, Mostwin JL, Rosenshein NB, Zerhouni EA (1991) Pelvic floor descent in women: dynamic evaluation with fast mr imaging and cinematic display. Radiology 179(1):25–33.  https://doi.org/10.1148/radiology.179.1.2006286
  48. Zijta FM, Froeling M, van der Paardt MP, Lakeman MME, Bipat S, Montauban van Swijndregt AD, Strijkers GJ, Nederveen AJ, Stoker J (2011) Feasibility of diffusion tensor imaging (dti) with fibre tractography of the normal female pelvic floor. Eur Radiol 21(6):1243–1249.  https://doi.org/10.1007/s00330-010-2044-8
  49. Zijta FM, Froeling M, Nederveen AJ, Stoker J (2013) Diffusion tensor imaging and fiber tractography for the visualization of the female pelvic floor. Clin Anat 26(1):110–114.  https://doi.org/10.1002/ca.22184

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • Frédéric Dierick
    • 1
  • Ekaterina Galtsova
    • 1
  • Clara Lauer
    • 1
  • Fabien Buisseret
    • 1
  • Anne-France Bouché
    • 2
  • Laurent Martin
    • 3
  1. 1.Forme and Fonctionnement Humain Lab, Department of Physical TherapyCERISIC, Haute Ecole Louvain en HainautMontignies-sur-SambreBelgium
  2. 2.Le RichemontBioulBelgium
  3. 3.Grand Hôpital de CharleroiGillyBelgium

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