Abstract
Introduction and hypothesis
An adequate pelvic floor muscle contraction (PFMC) elevates the bladder neck (BN) and stabilizes it during increased intra-abdominal pressure (IAP). A maximal PFMC may increase the IAP and thereby prevent BN elevation. The aim of this study was to assess BN elevation during submaximal and maximal PFMC and their achievable duration.
Methods
We recruited 68 women with stress urinary incontinence and 14 vaginally nulliparous continent controls who were able to perform a PFMC on vaginal palpation. Women were upright and performed a maximal PFMC as long as possible, followed by a submaximal PFMC, controlled by vaginal electromyogram (EMG). BN position was measured with perineal ultrasound, IAP and urethral pressure with a microtip catheter, and breathing with a circular thorax sensor.
Results
A submaximal PFMC elevated the bladder neck 4 mm in continent and incontinent women (p = 0.655) and 4.5 vs. 5 mm during maximal PFMC (0.528). Submaximal PFMC was maintained significantly longer than a maximal PFMC (33 vs 12 s) with no difference between groups. A maximal PFMC resulted in BN descent in 29% of continent and 28% of incontinent women, which was not observed during submaximal PFMC. Breathing was normal in 70% of continent and 71% of incontinent women during submaximal PFMC but stopped completely in 21 and 50%, respectively, during maximal PFMC (p = 0.011). IAP increase was significantly greater with maximal PFMC in both groups (24 vs. 9.6 cmH2O and 17 vs. 9 cmH2O, respectively).
Conclusion
Submaximal PFMC are sufficient to elevate the bladder neck, can be maintained longer, and breathing was not influenced.
Similar content being viewed by others
References
Dumoulin C, Hay-Smith EJ, Mac Habee-Seguin G. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database Syst Rev. 2014;5:CD005654. https://doi.org/10.1002/14651858.CD005654.pub3.
Baessler K, Aigmuller T, Albrich S, Anthuber C, Finas D, Fink T, et al. Diagnosis and therapy of female pelvic organ prolapse. Guideline of the DGGG, SGGG and OEGGG (S2e-level, AWMF registry number 015/006, April 2016). Geburtshilfe Frauenheilkd. 2016;76(12):1287–301. https://doi.org/10.1055/s-0042-119648.
Reisenauer C, Muche-Borowski C, Anthuber C, Finas D, Fink T, Gabriel B, et al. Interdisciplinary S2e guideline for the diagnosis and treatment of stress urinary incontinence in women: short version - AWMF registry no. 015-005, July 2013. Geburtshilfe Frauenheilkd. 2013;73(9):899–903. https://doi.org/10.1055/s-0033-1350871.
Howard D, Miller JM, Delancey JO, Ashton-Miller JA. Differential effects of cough, valsalva, and continence status on vesical neck movement. Obstet Gynecol. 2000;95(4):535–40.
Dietz HP, Clarke B, Herbison P. Bladder neck mobility and urethral closure pressure as predictors of genuine stress incontinence. Int Urogynecol J Pelvic Floor Dysfunct. 2002;13(5):289–93.
Peschers UM, Vodusek DB, Fanger G, Schaer GN, DeLancey JO, Schuessler B. Pelvic muscle activity in nulliparous volunteers. Neurourol Urodyn. 2001;20(3):269–75.
Miller JM, Perucchini D, Carchidi LT, DeLancey JO, Ashton Miller J. Pelvic floor muscle contraction during a cough and decreased vesical neck mobility. Obstet Gynecol. 2001;97(2):255–60.
Junginger B, Seibt E, Baessler K. Bladder-neck effective, integrative pelvic floor rehabilitation program: follow-up investigation. Eur J Obstet Gynecol Reprod Biol. 2014;174:150–3. https://doi.org/10.1016/j.ejogrb.2013.12.022.
Junginger B, Baessler K, Sapsford R, Hodges PW. Effect of abdominal and pelvic floor tasks on muscle activity, abdominal pressure and bladder neck. Int Urogynecol J. 2010;21(1):69–77. https://doi.org/10.1007/s00192-009-0981-z.
Baessler K, Junginger B. Traditional gymnastic exercises for the pelvic floor often lead to bladder neck descent - a study using perineal ultrasound. Geburtshilfe Frauenheilkd. 2017;77(7):765–70. https://doi.org/10.1055/s-0043-103460.
Lovegrove Jones RC, Peng Q, Stokes M, Humphrey VF, Payne C, Constantinou CE. Mechanisms of pelvic floor muscle function and the effect on the urethra during a cough. Eur Urol. 2009.
Smith MD, Coppieters MW, Hodges PW. Postural response of the pelvic floor and abdominal muscles in women with and without incontinence. Neurourol Urodyn. 2007;26(3):377–85. https://doi.org/10.1002/nau.20336.
Junginger B, Baessler K. The effect of maximal and submaximal pelvic floor contractions on bladder neck elevation and intraabdominal pressure. Int Urogynecol J. 2008;19(Suppl 1):S71.
Baessler K, O'Neill SM, Maher CF, Battistutta D. A validated self-administered female pelvic floor questionnaire. Int Urogynecol J. 2010;21(2):163–72. https://doi.org/10.1007/s00192-009-0997-4.
Bump RC, Mattiasson A, Bo K, Brubaker LP, DeLancey JOL, Klarskov P, et al. The standardisation of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol. 1996;175:10–7.
Anderson RS, Shepherd AM, Feneley RC. Microtransducer urethral profile methodology: variations caused by transducer orientation. J Urol. 1983;130(4):727–8.
Ulmsten U, Asmussen M, Lindstrom K. A new technique for simultaneous urethrocystometry including measurements of the urethral pressure profile. Urol Int. 1977;32(2-3):127–36.
Haylen BT, de Ridder D, Freeman RM, Swift SE, Berghmans B, Lee J, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Int Urogynecol J Pelvic Floor Dysfunct. 2010;21(1):5–26.
Dietz HP. Ultrasound imaging of the pelvic floor. Part I: two-dimensional aspects. Ultrasound Obstet Gynecol. 2004;23(1):80–92.
Reddy AP, DeLancey JO, Zwica LM, Ashton-Miller JA. On-screen vector-based ultrasound assessment of vesical neck movement. Am J Obstet Gynecol. 2001;185(1):65–70.
Peng Q, Jones R, Shishido K, Constantinou CE. Ultrasound evaluation of dynamic responses of female pelvic floor muscles. Ultrasound Med Biol. 2007;33(3):342–52.
Shek KL, Dietz HP. The urethral motion profile: a novel method to evaluate urethral support and mobility. Aust N Z J Obstet Gynaecol. 2008;48(3):337–42. https://doi.org/10.1111/j.1479-828X.2008.00877.x.
Rahmanian S, Jones R, Peng Q, Constantinou CE. Visualization of biomechanical properties of female pelvic floor function using video motion tracking of ultrasound imaging. Stud Health Technol Inform. 2008;132:390–5.
Smith MD, Coppieters MW, Hodges PW. Postural activity of the pelvic floor muscles is delayed during rapid arm movements in women with stress urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct. 2006.
Thompson JA, O'Sullivan PB, Briffa NK, Neumann P. Comparison of transperineal and transabdominal ultrasound in the assessment of voluntary pelvic floor muscle contractions and functional manoeuvres in continent and incontinent women. Int Urogynecol J Pelvic Floor Dysfunct. 2007;18(7):779–86.
Peschers UM, Gingelmaier A, Jundt K, Leib B, Dimpfl T. Evaluation of pelvic floor muscle strength using four different techniques. Int Urogynecol J Pelvic Floor Dysfunct. 2001;12(1):27–30.
Schaer GN, Perucchini D, Munz E, Peschers U, Koechli OR, Delancey JO. Sonographic evaluation of the bladder neck in continent and stress-incontinent women. Obstet Gynecol. 1999;93(3):412–6.
Peschers U, Schaer G, Anthuber C, Delancey JO, Schuessler B. Changes in vesical neck mobility following vaginal delivery. Obstet Gynecol. 1996;88(6):1001–6.
Thibault-Gagnon S, Auchincloss C, Graham R, McLean L. The temporal relationship between activity of the pelvic floor muscles and motion of selected urogenital landmarks in healthy nulliparous women. J Electromyogr Kinesiol. 2018;38:126–35. https://doi.org/10.1016/j.jelekin.2017.11.012.
Wijma J, Tinga DJ, Visser GH. Perineal ultrasonography in women with stress incontinence and controls: the role of the pelvic floor muscles. Gynecol Obstet Investig. 1991;32(3):176–9.
Van K, Hides JA, Richardson CA. The use of real-time ultrasound imaging for biofeedback of lumbar multifidus muscle contraction in healthy subjects. J Orthop Sports Phys Ther. 2006;36(12):920–5. https://doi.org/10.2519/jospt.2006.2304.
Baessler K, Junginger B. Which mechanisms keep us continent?-the role of pelvic floor muscles, bladder neck support and motor control. Int Urogynecol J. 2012;23(2 Suppl):219–20.
Hung HC, Hsiao SM, Chih SY, Lin HH, Tsauo JY. Effect of pelvic-floor muscle strengthening on bladder neck mobility: a clinical trial. Phys Ther. 2011;91(7):1030–8. https://doi.org/10.2522/ptj.20100186.
Miller JM, Ashton-Miller JA, DeLancey JO. A pelvic muscle precontraction can reduce cough-related urine loss in selected women with mild SUI. J Am Geriatr Soc. 1998;46(7):870–4.
Burgio KL, Kraus SR, Menefee S, Borello-France D, Corton M, Johnson HW, et al. Behavioral therapy to enable women with urge incontinence to discontinue drug treatment: a randomized trial. Ann Intern Med. 2008;149(3):161–9.
Bo K, Frawley HC, Haylen BT, Abramov Y, Almeida FG, Berghmans B, 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. 2017;28(2):191–213. https://doi.org/10.1007/s00192-016-3123-4.
Braekken IH, Majida M, Engh ME, Bo K. Morphological changes after pelvic floor muscle training measured by 3-dimensional ultrasonography: a randomized controlled trial. Obstet Gynecol. 2010;115(2 Pt 1):317–24. https://doi.org/10.1097/AOG.0b013e3181cbd35f.
Dolan LM, Dixon WE, Brown K, Ord T, Hilton P. Randomized comparison of vaginal and rectal measurement of intra-abdominal pressure during subtracted dual-channel cystometry. Urology. 2005;65(6):1059–63. https://doi.org/10.1016/j.urology.2004.12.025.
Acknowledgements
This study was part of a project supported by the German Research Foundation (Deutsche Forschungsgemeinschaft – DFG): Project number: 157173310.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflicts of interest
None.
Rights and permissions
About this article
Cite this article
Junginger, B., Vollhaber, H. & Baessler, K. Submaximal pelvic floor muscle contractions: similar bladder-neck elevation, longer duration, less intra-abdominal pressure. Int Urogynecol J 29, 1681–1687 (2018). https://doi.org/10.1007/s00192-018-3725-0
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00192-018-3725-0