link.springer.com10.1007/s00192... · Web viewPTR: Pressure transmission ratio = (Δ urethral...

34
Electronic Supplementary Material 2 Table 4: Data extraction form across all included studies SUI: stress urinary incontinence, stress urinary incontinent / CON: continence, continent / MUI: mixed urinary incontinence / UUI: Urge urinary incontinence / POP: pelvic organ prolapse / CLBP: chronic low back pain / US: ultrasound / TAUS: transabdominal ultrasound / TPUS: transperineal ultrasound / TLUS: translabial ultrasound / BN: bladder neck / PF: pelvic floor / PFM: pelvic floor muscle / EMG: electromyography / ARA: ano-rectal angle / AUI: angle of urethral inclination / IQR: interquartile range / PFMC: pelvic floor muscle contraction / PFMT: pelvic floor muscle training / IAP: intraabdominal pressure / TrA: Transversus abdominis / PRS: puborectalis muscle sling / MVC: Maximum Voluntary Contraction / PP: pubic point / -: not performed / ICC: intra-class correlation coefficient / PCL: pubococcygeal line / PS: pubic symphysis / PRS: puborectalis muscle sling / Author Year Type of study Subjects characterist ics: sample size (n), age (yrs, mean, SD), BMI (mean), Parity (mean, SD) Measurement method, test position, bladder filling Tested activit y Direction, quantity of displacement Measurement details Comparison CON versus SUI Secondary outcome(s) Conclusion Arab [1] 2009 Descripti ve, correlati onal study N=19 A ge: 30.6 ± 5.7 BMI: 25.4 ± 3.9 Parity: 1 ± 5 7 CON 3 SUI 9 CLBP TAUS for amount of bladder base movement, 2 trials (simultaneous and following digital palpation) Crook-lying supine Full bladder filling Voluntary PFMC Bladder base displacement: TAUS measurement in trial 1 (mm, mean, SD): 4.9 (6.9) 95%CI: 1.6–8.3 TAUS measurement in trial 2 (mm, mean, SD): 7.4 (6.5) 95%CI: 4.3–10.6 Marker at bladder base; displacement from resting position - Significant correlation between digital palpation and TA ultrasound for PFM assessment when measured simultaneously in one contraction (rho=0.62, p=0.01) and separately in a different contraction (rho=0.52, p=0.02) Digital palpation and TA ultrasound measurement are significantly correlated and measure comparable parameters in evaluation of PFM contraction. Baessler [2] 2008 Observati onal study N=34 N=14, healthy women, nulliparous Age range: 21-49 (median 35) TPUS to measure BN with different levels of effort of PFM contraction TAUS to measure transverse 1. Rest 2. maximal PFMC 3. perceiv ed 50% of BN elevation in mm (median, range): 25% PFMC Healthy: 3.7 (0.5- 10.3) Patients: 3.5 (1.4- Coordinate system through the pubic symphysis: basis for calculations of the movement Urogynaecologica l patients had a lower BN position at rest compared with healthy IAP increased significantly with increased amount of effort. There was a significant BN elevation already at 25% of PFMC. BN movements at 75% and 100% of PFMC were not statistically significantly different from 50% of PFMC

Transcript of link.springer.com10.1007/s00192... · Web viewPTR: Pressure transmission ratio = (Δ urethral...

Page 1: link.springer.com10.1007/s00192... · Web viewPTR: Pressure transmission ratio = (Δ urethral pressure/ Δ bladder pressure) x 100: significantly lower in the SUI group (p< 0,001)

Electronic Supplementary Material 2

Table 4: Data extraction form across all included studies

SUI: stress urinary incontinence, stress urinary incontinent / CON: continence, continent / MUI: mixed urinary incontinence / UUI: Urge urinary incontinence / POP: pelvic organ prolapse / CLBP: chronic low back pain / US: ultrasound / TAUS: transabdominal ultrasound / TPUS: transperineal ultrasound / TLUS: translabial ultrasound / BN: bladder neck / PF: pelvic floor / PFM: pelvic floor muscle / EMG: electromyography / ARA: ano-rectal angle / AUI: angle of urethral inclination / IQR: interquartile range / PFMC: pelvic floor muscle contraction / PFMT: pelvic floor muscle training / IAP: intraabdominal pressure / TrA: Transversus abdominis / PRS: puborectalis muscle sling / MVC: Maximum Voluntary Contraction / PP: pubic point / -: not performed / ICC: intra-class correlation coefficient / PCL: pubococcygeal line / PS: pubic symphysis / PRS: puborectalis muscle sling /

Author Year Type of study

Subjects characteristics: sample size (n),age (yrs, mean, SD), BMI (mean), Parity (mean, SD)

Measurement method,test position,bladder filling

Tested activity

Direction, quantity of displacement

Measurement details

Comparison CON versus SUI

Secondaryoutcome(s)

Conclusion

Arab [1] 2009 Descriptive, correlational study

N=19A ge: 30.6 ± 5.7 BMI: 25.4 ± 3.9Parity: 1 ± 57 CON3 SUI9 CLBP

TAUS for amount of bladder base movement, 2 trials (simultaneous and following digital palpation)Crook-lying supineFull bladder filling

Voluntary PFMC

Bladder base displacement: TAUS measurement in trial 1

(mm, mean, SD): 4.9 (6.9) 95%CI: 1.6–8.3TAUS measurement in trial 2 (mm, mean, SD): 7.4 (6.5) 95%CI: 4.3–10.6

Marker at bladder base; displacement from resting position

- Significant correlation between digital palpation and TA ultrasound for PFM assessment when measured simultaneously in one contraction (rho=0.62, p=0.01) and separately in a different contraction (rho=0.52, p=0.02)

Digital palpation and TA ultrasound measurement are significantly correlated and measure comparable parameters in evaluation of PFM contraction.

Baessler [2] 2008 Observational study

N=34N=14, healthy women, nulliparousAge range: 21-49 (median 35)

N=20 urogynaecological patientsAge range: 32-75 (median 50)

TPUS to measure BN with different levels of effort of PFM contractionTAUS to measure transverse abdominis (TrA) and internal oblique (IO)Intrarectal pressure probe to measure IAPHalf-sitting (30°) position

1. Rest2. maximal

PFMC3. perceived

50% ofmaximal PFMC

4. (perceived 25% of maximal PFMC

5. perceived 75% of maximal PFMC

BN elevation in mm (median, range):25% PFMCHealthy: 3.7 (0.5-10.3)Patients: 3.5 (1.4-5.1)

50% PFMCHealthy: 5.1 (1.6-18.4)Patients: 5.2 (1.8-14.9)

75% PFMCHealthy: 4.8 (0.9-32)Patients: 5.5 (1.0-15.9)

100% PFMCHealthy: 6.2 (1.8-32)Patients: 8.0 (2.4-26.8)

Coordinate system through the pubic symphysis: basis for calculations of the movement vectors (c2 = a2+b2)

Urogynaecological patients had a lower BN position at rest compared with healthy nulliparas (p=0.003)

IAP increased significantly with increased amount of effort.

There was a significant BN elevation already at 25% of PFMC. BN movements at 75% and 100% of PFMC were not statistically significantly different from 50% of PFMC (p<0.05).Results show that a perceived effort of only 25% of a maximal pelvic floor contraction leads to a significant elevation of the bladder neck. A maximal pelvic floor contraction does not further elevate the bladder neck after 50% of effort. There is a considerable increase in IAP with maximal power which might cause bladder neck descent.

Balmforth [3] 2006 Prospective observation

N=97 (SUI)Age: 49.5 ± 10.6

TPUS, to assess BN mobility (before and

1. Rest2. Valsalva

Elevation: BN moving cephalad = incursion (rest

x-y co-ordinate system according to

-Pre-post comparison

Pad-test: loss was reduced by over

After completion of the PFMT, the position of the BN in the patients was

Page 2: link.springer.com10.1007/s00192... · Web viewPTR: Pressure transmission ratio = (Δ urethral pressure/ Δ bladder pressure) x 100: significantly lower in the SUI group (p< 0,001)

Author Year Type of study

Subjects characteristics: sample size (n),age (yrs, mean, SD), BMI (mean), Parity (mean, SD)

Measurement method,test position,bladder filling

Tested activity

Direction, quantity of displacement

Measurement details

Comparison CON versus SUI

Secondaryoutcome(s)

Conclusion

al study N=84 completed PFMT program

after a 14-week-PFM training programme)Semi-recumbent position

3. Voluntary contraction

to max. squeeze)Changes in mean (95%CI):Before: 5.6° (0.08-11.5)After: 11.1° (6.5-16.5)

Displacement on straining = excursion (rest to max. Valsalva)Changes in mean (95%CI):Before: -25.7° (-20.2,-30.6)After: -20.7° (-14.1, -26.2)

Peschers et al. (1997); the two co-ordinates were then converted into the angle of bladder neck rotation with reference to the inferoposterior margin of the pubic symphysis, using the tangent of the co-ordinate variables

half; King’s Health Questionnaire: quality of life improved; no significant correlation between improvements in the objective outcome measures (pad test and KHQ) and any of the ultrasonographic bladder neck mobility variables

significantly elevated at rest, Valsalva and squeeze;magnitude of the BN elevation at maximum PFMC was greater than before treatment, and BN excursion at ‘maximum Valsalva’ less;This suggests that PFMT brings about an increase in the resting tone of the PF (increased ‘stiffness’)

Barbic [4] 2003 Observational study

N=60N=32 parous SUI womenAge: 43.03 (range 27-52)N=28 parous CON womenAge: 43.92 (range 30-52)

EMG (wire electrodes) of levator aniIntravesical and urethral pressure measurementsTPUS, combined with abdominal pressure measurement (rectal)Semilithotomy positionCystometry: bladder volume 250 mL

Coughing 3x Compliance (C) of the supporting structures (mm/cmH20) = a quotient between BN mobility during cough and rectal pressure during cough (bladder neck mobility/ Δ rectal pressure)Results: median (25/75 percentile)SUI: 0.081 (0.064/0.105)CON: 0.050 (0.031/0.073)(p< 0,001)

For BN position at rest, a central line of the symphysis was drawn (Schaer et al., 1995); from the inferior point of this line, a line parallel with the inferior border of the screen was drawn, which represented the imaginary pelvic floor level, and the angle between both lines was determined; BN position was determined at the junction of the BN and posterior urethral wall.

C was significantly greater in SUI group than in CON Definition of compliance: compliant supporting structures inefficient pressure transmission, hypermobility of BN.C is an inverted evaluation to ‘‘stiffness’’ of the BN support.

Tissue sampling: elastic fibers showed no differences between the groups.PTR: Pressure transmission ratio = (Δ urethral pressure/ Δ bladder pressure) x 100: significantly lower in the SUI group (p< 0,001)EMG: SUI group presented significant (p< 0,001) delayed onset of muscle activity regarding the onset of bladder pressure increment

Finding suggest that the greater the delay in muscular activation, the greater the compliance of BN support.An early onset of activation was registered on both sides of levator ani in the control group; this finding suggests a possible pretension of endopelvic fascia and vaginal wall tissues, which could change their elastic properties.

Bo [5] 2001 Observational study

N=16Mean age: 45.1 (range: 34-64)Mean parity: 2 (range: 0-4)9 CONAge: 39.4 ± 3.9Parity: 1.7 ± 1.27 SUIAge: 52.4 ± 8.3Parity: 2.3 ± 0.8

Dynamic MRIUpright sittingempty bladder

1. PFMC 3 x

2. Straining 3 x

Direction of movement was inward during PFMC and downward with straining.Mean inward lift during PFMC was 10.8 mm (SD 6.0) for all womenDuring straining the mean downward movement was 19.1 mm (SD 7.4) for all womenMovement of BN during PFMC (mm, mean, SD):

CON: 12.7 (4.7)

SUI: 8.3 (7.0)

Reference line: symphysis to sacral bone; distance from reference line to the BN was measured.

No significant differences between CON and SUI women were detected; P-values 0.114 and 0.181

PFM strength measurement (balloon catheter); movement of coccyx ( pressed dorsally during straining)

PFMC is concentric, moving the coccyx in a ventral, cranial direction; movement measured by MRI in upright sitting position is less than that concluded after clinical observation in supine position

Page 3: link.springer.com10.1007/s00192... · Web viewPTR: Pressure transmission ratio = (Δ urethral pressure/ Δ bladder pressure) x 100: significantly lower in the SUI group (p< 0,001)

Author Year Type of study

Subjects characteristics: sample size (n),age (yrs, mean, SD), BMI (mean), Parity (mean, SD)

Measurement method,test position,bladder filling

Tested activity

Direction, quantity of displacement

Measurement details

Comparison CON versus SUI

Secondaryoutcome(s)

Conclusion

p: 0.114Movement of BN during straining (mm):

CON: 17.0 (7.6)

SUI: 22.2 (6.5)p: 0.181

Braekken [6] 2008 Observational test-retest-study

N=17, healthy women 4D TPUS Standing

1. Rest2. Maximal

PFMC 3x

Displacements (=lift) in sagittal plane in cm (mean, 95%CI)

Bladder neck: Test 1: 1.13 (0.83-1.43)Test 2: 1.17 (0.92-1.41)Rectal ampulla: Test 1: 2.04 (1.46-2.61)Test 2: 2.09 (1.60-2.57)

Pubovisceralis back sling: Test 1: 1.98 (1.59-2.39)Test 2: 1.94 (1.32-2.56)

In sagittal plane 2 systems were used: a horizontal reference line and an on-screen vector-based method

- Reliability of measurement (ICC)Bladder neck: 0.81Rectal ampulla: 0.80Pubovisceralis back sling: 0.75

4D ultrasound can reliably assess squeeze and lift during PFM contraction.The back sling of the pubovisceral muscle and the rectal ampulla had greater displacement than the bladder neck (p>0.004).

Chehrehrazi [7]

2009 Descriptive correlational study

N=28, all SUI

Age: 41.19 ± 8.16BMI: 27.43 ± 4.03Parity: median 3 (range: 0-5)

TAUS, bladder base movementCrook-lying supine positionStandardized bladder filling for TAUS, perineometry after voiding

Voluntary PFMC, 3 sec (3 x, 10 sec rest in between)

Only contractions with cephalic movement of the bladder base were measured as correct.Amount of lift in mm (mean ± SD): 3.76 ± 3.10

Perineometry: vaginal squeeze pressureTAUS: Marker was located on the bladder base at the point of maximal displacement during muscle contraction, amount of bladder base displacement from resting position at the end of each contraction was measured in mm.

- Significant correlation of TAUS with vaginal squeeze pressure (r=0.72, R2=0.52, p<0.0001); high reliability for measurements

TAUS measurement may be an alternative measurement to perineometry when assessing PFM function. The two measurements may assess two different aspects of a PFMC; it means that strong muscles may not be able to lift high or, conversely, a weak and hanging pelvic floor may be lifted a long way.

Chen [8] 2010 Observational study

N=103(n=34 POP group, data not extracted)

n=33 SUI group Age: 53.26 ± 7.55BMI: 24.00 ± 2.21Parity: 2.65 ± 1.01n=29 Control Age: 53.24 ±8.55BMI: 23.38 ±2.57Parity: 2.51±1.15

TPUS,to measure BN displacement and to test validity/reliabilitySupineafter voiding

Maximal PFMC 3x, 10 s hold

Displacement of BN in cm (SD)SUI group: 0.80 ± 0.46Control group: 0.68 ± 0.25

Sagittal view: US parameters measured relative to a horizontal reference line at the level of symphysisAxial plane: area of levator hiatus was measured

Non-significant differences between the three groups (P-value 0.173).

Area of the levator hiatusSagittal hiatal diameterChange of levator hiatal angle

TPUS is reliable for quantitative analysis (ICC, 0.769-0.975)Methods determining morphological changes, from rest to contraction, may not be sensitive enough to distinguish the state of PFM function. POP group: large lift of BN because of lower starting position and increased fascia laxity.geometry of PF structural change may not represent levator function status.

Christensen [9]

1995 Observational study

N=6, asymptomaticAge: 34.0

MRI (sagittal and coronal plane)

1. Rest2. PFMC,

Movement of the bladder during PFMC in mm

Relative displacement of the

- - Contractions of the PF can be displayed using image processing

Page 4: link.springer.com10.1007/s00192... · Web viewPTR: Pressure transmission ratio = (Δ urethral pressure/ Δ bladder pressure) x 100: significantly lower in the SUI group (p< 0,001)

Author Year Type of study

Subjects characteristics: sample size (n),age (yrs, mean, SD), BMI (mean), Parity (mean, SD)

Measurement method,test position,bladder filling

Tested activity

Direction, quantity of displacement

Measurement details

Comparison CON versus SUI

Secondaryoutcome(s)

Conclusion

Parity: 0.67 (0-2) crook-lying supine position

submaximal

Sagittal planeSuperior wall: 3.8 ± 1.3Posterior wall: 7.0 ± 2.8Coronal planeSuperior wall: 3.5 ± 2.3lateral: 2.7 ± 2.6

bladder resulting from PFMC was measured; changes from the relaxed to the contracted stage were identified.

techniques.No significant displacement of the anterior aspect of the bladder, while posterior wall demonstrates maximum movement.Limitations of study: position (no effect of gravity) and duration of recording (1,5 min per image).

Constantinou [10]

2002 Observational study

N=34 asymptomatic women2 age groups:Younger (n=16)Age: 35 ± 6Parity: 0.7 (0-2)Older (n=18)Age: 55 ± 9Parity: 2.2 (1-3)

MRI SupineFull bladder

1. PFM relaxed

2. Sustained PFMC (10-20s)

Axial, coronal and sagittal planes were measuredA: posterior to anterior movement of the levator ani (displacement compresses the rectum towards the vagina and symphysis)Younger: 9.4 ± 1.2 mmOlder: 2.9 ± 0.5 mm(p<0.01)PN: displacement normal to posterior of the bladderYounger: 5.2 ± 1.2Older: 1.4 ± 0.4(p<0.01)B: anterior-dorsal displacement of the bladderYounger: 4.3 ± 0.5Older: 1.0 ± 0.2(p<0.001)

Difference image was added to the relaxed image and distances measured.

-Comparison: different age groups

LA: compression rectum towards vaginaPN: displacement normal to the posterior of the bladderAb: displacement normal to the anterior of the bladderAs: relative change of pubococcygeus muscleG: change of gluteus surface

Range of motion is age dependent (higher in young than older subjects); MRI supine is not comparable with MRI sitting; best position to evaluate PFM would be upright, using a fast MRI system (images at millisecond intervals) during stress, to visualize the guarding reflex

Crotty [11] 2011 Experimental study

N=32, pre-menopausal, nulliparous, CONAge: 34 ± 5.39BMI: 25 ± 4.08N=17 finally included

Surface-EMG to measure recruitment of PFM / TPUS to measure angle of urethral inclination (AUI)Supine and standingFor TPUS a standardized bladder filling (according to Miller et al.) routine was performed

Selective voluntary PFM contraction using 3 different cues: 1. anterior2. posterior3. anterior

and posterior combined

The cue to instruction that resulted in the smallest/most acute AUI was taken to be the most optimal cue.Mean AUI (mean degrees (SE)) for different cues and postures:Anterior cueSupine: 53.346 (1.251)Standing: 63.411 (1.251)Posterior cueSupine: 49.590 (1.251)Standing: 58.686 (1.251)CombinedSupine: 49.959 (1.251)Standing: 59.286 (1.251)

AUI: Angle between the x-axis through midline of the symphysis to its intersection with the urethra, and an axis through midline of the urethra.

- Reliability:Intra-class correlation for intra- rater reliability were excellent at 0.919 and for inter-rater reliability ranged from 0.756 to 0.820 which were considered acceptable.

AUI is approximately 4° more acute/optimal when either a posterior or combined cue to instruction is used as compared to an anterior cue to instruction alone; this difference is similar whether in the supine or the standing positions; this may be due to optimal recruitment of puborectalis and other posterior regional muscles which may be sub-maximally recruited with anterior cue; results indicate that there is overwhelming evidence that posture affects the AUI (p=0.000), as does cue to instruction (p= 0.001).

Da Roza [12] 2011 Observational study

N=2, swimming female athletes, nulliparousN=1 CONAge: 20

MRI, to assess displacement of PFM in different parts of the part of levator ani muscleSupine

PFMC Displacement (in mm) of different parts of the levator ani muscle:Puborectalis:SUI athlete: 1.82

Twenty images were selected to build the 3D computation model; these 3D solids were imported

Yes Measurement of muscle area:The SUI athlete showed a smaller area compared to

Findings suggest that in female athlete which cannot perform an effective contraction in puborectalis muscle, may have a decrease in displacement in this portion of the muscle and thus

Page 5: link.springer.com10.1007/s00192... · Web viewPTR: Pressure transmission ratio = (Δ urethral pressure/ Δ bladder pressure) x 100: significantly lower in the SUI group (p< 0,001)

Author Year Type of study

Subjects characteristics: sample size (n),age (yrs, mean, SD), BMI (mean), Parity (mean, SD)

Measurement method,test position,bladder filling

Tested activity

Direction, quantity of displacement

Measurement details

Comparison CON versus SUI

Secondaryoutcome(s)

Conclusion

BMI: 23.3N=1 SUIAge: 20BMI: 20.6

CON athlete: 2.75Pubococcygeus:SUI athlete: 2.02CON athlete: 1.62Iliococcygeus:SUI athlete: 0.41CON athlete: 0.30

into the software ABAQUS which applied the finite element method and simulated muscle contraction of 100% of maximum contraction.

the CON athlete in puborectalis muscle, 245 mm2 and 325mm2, respectively. total area of the muscle in SUI women is greater (10521mm2, in comparison with 7849 mm2).

have difficulties in maintaining the continence; puborectalis muscle may be more associated with the SUI, because it is more close to the urethral meatus

Delmas [13] 2010 Observational study, pilot

N=3, CON, nulliparousAge: 19-22

MRI, to analyse the contraction of iliococcygeus and pubococcygeus musclesupine

1. Rest2. Maximu

m PFMC

3. Valsalva

Muscle displacement (mean in mm):rest-contraction:pubococcygeus: 4.31Iliococcygeus: 5.67

rest-Valsalva:pubococcygeus: 2.78Iliococcygeus: -3.95

3D vectorial models were reconstructed by manual segmentation of the source images and were set up on bony landmarks; Illiococcygeus: highest point of the arch

- Volume of muscle, length, surface, height

MRI can evaluate PFM function; dynamic reconstruction can also be used in patient re-education; PFMC has to be held over 10 sec

Dietz [14] 2004 Prospective observational study

N=118, nonpregnant, nulligravid white womenAge: median 20 (range 18-24)BMI: mean 23 (range 16.9-36.7)Complaints:10: SUI06: UUI16: frequency03: nocturia

Only data of CON and SUI patients (no UUI) have been extracted

TLUSSupineAfter voiding

1. Rest2. Valsalva

Parameters of pelvic organ mobility (mean ± SD, in mm) on Valsalva:BN descent SUI: 18 ± 10CON:17 ± 9p= 0.7Urethral rotation (in degrees)SUI: 35 ± 28CON: 32 ± 24p=0.8

Urethral rotation and bladder neck descent calculated by comparing measurements at rest and on Valsalva; descent signifies lowest position reached on Valsalva relative to the symphysis pubis; negative measurements implying descent below the symphysis pubis

No significant differences between SUI and CON women

Assessment of upper extremity joint mobility: None of participants showed obvious upper extremity joint hypermobility; when joint mobility was tested for association with pelvic organ mobility, only elbow hyperextension correlated weakly but significantly with most measures of pelvic organ mobility; neither BMI nor age or any of the factors correlated with pelvic organ mobility; reliability: In a test-retest series (n=50) the ICC for BN descent was 0.77, implying excellent agreement

Wide variation in measurements observed in this study implies that there is likely to be a significant congenital contribution to the phenotype of female pelvic organ prolapse; correlations between joint mobility and pelvic organ mobility were significant but rather weak (r=0.27 to 0.29), making it unlikely that joint mobility scores could be useful in the context of clinical risk assessment.

El Sayed [15] 2008 Prospective study

N=59N=15 control

MRI, to determine whether SUI, POP, and anal incontinence are

1. Rest2. PFMC

Pelvic organ descent in sagittal plane at maximum straining (cm):

In sagittal plane the PCL, which extends from the inferior

Yes Levator plate angle (degrees); width of levator hiatus in

In patient group with SUI but without POP, level III fascial anatomic defects in the urethral supporting structures

Page 6: link.springer.com10.1007/s00192... · Web viewPTR: Pressure transmission ratio = (Δ urethral pressure/ Δ bladder pressure) x 100: significantly lower in the SUI group (p< 0,001)

Author Year Type of study

Subjects characteristics: sample size (n),age (yrs, mean, SD), BMI (mean), Parity (mean, SD)

Measurement method,test position,bladder filling

Tested activity

Direction, quantity of displacement

Measurement details

Comparison CON versus SUI

Secondaryoutcome(s)

Conclusion

(nulliparous, CON)Age: 25.6 (range 22-35)Subgroup A (n=9): no anatomical defect nor descentSubgroup B (n=6): anatomic defects and descentsN=44 patients, PF dysfunctionAge: 43.4 (range 18-62)Parity: 0-7 (range)Group A (n=10): POP without SUIGroup B (n=10): SUI without POPGroup C (n=16): SUI with POPGroup D (n=8): anal incontinenceOnly data of SUI subgroups without POP, anal incontinence have been extracted

associated with specific pelvic floor abnormalitiesSupineRectal enema with warm water the night before the MR imaging /voiding 2 hours before the examination

3. Mild straining

4. Moderate straining

5. Maximum straining

6. Repeated maximum straining to ensure maximal Valsalva

Control groupSubgroup A:Bladder neck: no descent below PCLBladder base: no descent below PCLUterus: no descent below PCLSubgroup B:Bladder neck: 0.8 ± 0.4Bladder base: 0.9 ± 0.5Uterus: 1.1 ± 0.2

Patient groupGroup B, SUI only:Bladder neck: 0.6 ± 0.3Bladder base: 0.7 ± 0.4Uterus: no descent

border of the symphysis pubis anteriorly to the tip of the coccyx posteriorly, was used as the reference line; other measurements in sagittal plane included the H-line, which extends from the inferior aspect of the pubic symphysis to the anorectal junction; the M-line, which drops as a perpendicular line from the PCL to the posterior aspect of the H-line; and the levator plate angle, which is enclosed between the levator plate and the PCL.

axial plane (cm); Iliococcygeus angle in coronal plane (degrees)

were detected in nine patients; dynamic sagittal images revealed a characteristic vertical direction of bladder neck movement; findings are in agreement with the ‘hammock hypothesis’ that suggests that loss of level III endopelvic fascial support at the vesical neck is one of the factors responsible for SUI;

Fielding [16] 1998 Observational study

N=16N=8 CONAge: 45 (range 36-59)N=8 SUIAge: 58 (range 45-69)

MRI Supine and sittingBladder filling: women were asked not to void 2 hr before imaging

1. Rest2. Valsalva

Maximum descent of BN (mean, cm below PCL)SUIsupine: 1.6 cmsitting: 2.2 cmCONsupine: 0.24 cmsitting: 0.8 cm

Rotation of the urethra (mean, degree) SUIsupine: 189°sitting: 208°CONsupine: 165°sitting: 179°

Descent of BN was measured with respect to PCL; urethrovesical angle was measured in the same fashion as that measured for voiding cystoure thrography

Descent of BN on straining and rotation of the urethra were greater in SUI than in CON in both supine and sitting positions

No difference in morphology of levator sling between the two groups

Pelvic floor laxity was more common in SUI than in CON; MR imaging performed in sitting position revealed ns. (p<0.1) greater degree of pelvic floor laxity compared to supine position

Hol [17] 1995 Prospective case-control study

N=160N=100 for displacement data extraction 50 CON:Age: 44.8 (range 30-59)

Vaginal ultrasound,to compare BN position and mobilityLithotomy position Standardised bladder volume: 250 ml

1. Rest2. Standar

dised Valsalva (straining): 30 cm H2O

Displacement with straining in x-axis (mean): CON: -7.4 SUI: -9.9 95%CI: -0.7 to 5.4/p: 0.09 n.s.Displacement with straining

BN position was plotted on a x, y-coordinate system and distances measured:R: distance of bladder neck at rest to inferior

Non-significant difference in displacement between CON and SUI; exception: change in angle with straining (Vα – Rα); significant

Q-tip test in 20 subjects

Vaginal US technique is feasible, acceptable and reproducible; assessment of BN position and mobility to predict SUI in an individual woman is not possible.

Page 7: link.springer.com10.1007/s00192... · Web viewPTR: Pressure transmission ratio = (Δ urethral pressure/ Δ bladder pressure) x 100: significantly lower in the SUI group (p< 0,001)

Author Year Type of study

Subjects characteristics: sample size (n),age (yrs, mean, SD), BMI (mean), Parity (mean, SD)

Measurement method,test position,bladder filling

Tested activity

Direction, quantity of displacement

Measurement details

Comparison CON versus SUI

Secondaryoutcome(s)

Conclusion

Parity: 2.4 (range: 1-5)50 SUI:Age: 46.3 (range 29-68)Parity: 2.5 (range 1-6)

3. Maximal PFMC

in y-axis (mean):CON: 2.6SUI: 3.595%CI: -1.9 to 0.3/p: 0.05 n.s.Change in angle with straining (Vα – Rα):CON: 15.6SUI: 26.495%CI: -15.9 to -5.2/p<0.001 Displacement with squeezing in x-axis (mean):CON: 2.5SUI: 1.695%CI: -0.2 to 3.5/p=0.06 n.s.Displacement with squeezing in y-axis (mean):CON: -3.5SUI: -3.795%CI:02.0 to1.6/p=0.4 n.s.Change in angle with squeezing (Sα – Rα):CON: -8.9SUI: -8.695%CI: -2.2 to 1.8/p=0.5 n.s.

border of symphysisRx: distance at rest along x-axis (cranial-caudal)Ry: distance at rest along y-axis (anterior-posterior)Rα: angle of R with the horizontal

Fluid level of balloon of the catheter was used as a reference of the horizontal (cranio-caudal) and vertical (anterior-posterior) axis of the woman.

differences in the position of BN

Howard [18] 2000 Observational study

N=58 (3 groups, white) :N=17 CON nulliparous

Age: 31.3 ± 5.6BMI: 23.5 ± 2.9

N=18 CON primiparous Age: 30.4 ± 4.3BMI: 24.9 ± 4.3

N=23 SUI primiparous

Age: 31.9 ± 3.9BMI: 25.8 ± 5.1

TPUS, to measure BN position Bladder was filled to a maximum of 300 mL or maximum bladder capacity if this was less than 300 mLstanding

1. Rest2. Cough3. Valsalva

BN descent (mm) with Valsalva, n.s. (p=0.42):CON nulliparous:12.4 ± 4.7CON primiparous:14.5 ± 7.0SUI primiparous:14.8 ± 6.4

BN mobility (mm) with cough, sign. (p = .001):CON nulliparous:8.2 ± 4.1CON primiparous:9.9 ± 4.0SUI primiparous SUI:3.8 ± 5.4

Resting position of BN is measured using X and Y coordinates; distance that the BN moves during a hard cough and maximal Valsalva maneuver is then measured directly Abdominal pressures were recorded simultaneously with an intravaginal catheter; to control for differing abdominal pressures, the stiffness of the BN support was calculated by dividing pressure exerted during a particular effort by urethral descent during that effort.

Nulliparas displayed greater pelvic floor stiffness during a cough compared with the CON and SUI primiparas (22.7, 15.5, 12.2 cm H2O/mm, respectively; p = .001).Valsalva stiffness was not significantly different among groups (10.6 ± 6.2 cm H2O/mm in the CON nulliparous compared with 9.3 ± 4.9 in the CON primiparous and 8.4 ± 4.9 in SUI primiparous; p = .47).

Cotton swab test (to measure urethral mobility during a Valsalva maneuver, degrees):CON nulliparous: 36.5 ± 17.9CON primiparous: 47.5 ± 11.7SUI primiparous: 54.6 ± 16.5

SUI primiparous women displayed similar BN mobility during a cough effort and during a Valsalva maneuver (13.8 mm compared with 14.8 mm; p = .49).CON nulliparous women (8.2 mm compared with 12.4 mm; p = .001) and the CON primiparous women (9.9 mm compared with 14.5 mm; p = .002) displayed less mobility during a cough than during a Valsalva maneuver despite greater abdominal pressure during cough. There are quantifiable differences in BN mobility during a cough and Valsalva maneuver in CON women; this difference is lost in SUI primiparous women.

Hu [19] 2009 Observational study

N=4020 CON20 SUI

MRI 1. Rest2. Valsalva

Mobility of BN (mm, mean, SD):SUI: 15.67 ± 2.36

MRI: three-dimensional virtual-reality model

Significant difference between the groups (p<0.05)

Vesicourethral angle; urethral tilt; comparison BN

Patients with SUI have urethral hypermobility; weakening of urethra supporting structures lead to

Page 8: link.springer.com10.1007/s00192... · Web viewPTR: Pressure transmission ratio = (Δ urethral pressure/ Δ bladder pressure) x 100: significantly lower in the SUI group (p< 0,001)

Author Year Type of study

Subjects characteristics: sample size (n),age (yrs, mean, SD), BMI (mean), Parity (mean, SD)

Measurement method,test position,bladder filling

Tested activity

Direction, quantity of displacement

Measurement details

Comparison CON versus SUI

Secondaryoutcome(s)

Conclusion

CON: 7.87 ± 1.33 mobility to levator ani volume

downward displacement and rotation of the urethra (greater vesicourethral angle); 3D-model MRI is an effective method to reveal morphologic alterations

Hung [20] 2011 Clinical trial, pretest-posttest design

N=23, incontinent (15 SUI and 8 MUI)Age: 51.9 ± 6.1BMI: 24.5 ± 3.2Parity: 2.4 ± 0.7

TPUS, to assess BN mobility (before and after a 4-month-PFM training programme)Lithotomy positionInfusion of 250ml into the bladder before US

1. Rest2. Voluntary

PFMC3. Maximal

cough4. Valsalva

Maximal Incursion (BN is elevated in the ventral-cranial direction):from rest to PFMCbefore training: 15° ± 15 after training: 27° ± 9(p 0.002, effect size 0.84)

Maximal Excursion (BN displaced in dorsocaudal direction):from rest to a coughbefore training: -27° ± -25after training: -25° ± -27(p 0.658, effect-size 0.09)from rest to Valsalvabefore training: -24° ± -20after training: -23° ± -19(p 0.843, effect size 0.03)

x-y coordinate system designed by Schaer et al. (1995); x-axis - central line of pubic symphysis; y-axis -inferior margin of pubic symphysis; the 2 coordinates then were converted to the angle of BN rotation as described by Balmforth et al.

-Pre-post comparison in symptomatic women

Severity Index score (was lowered (P=0.001) after the 4-month strengthening program); Self-reported improvement (1 cured, 22 improved); PFM strength (improved); Vaginal squeeze pressure (improved)

Position and mobility of BN during PFMC were elevated, with effect sizes of 0.48 and 0.84, respectively; BN position and mobility were not changed during cough and Valsalva manoeuvre; all participants reported diminution of SUI; PFM strength and maximal vaginal squeeze pressure were improved after the intervention;4 months of daily PFM strengthening can significantly improve the ability of the PFM to elevate the BN voluntarily, but may not improve its stiffness during cough and Valsalva for women with SUI and MUI.

Jones [21] 2009 Observational study

N=32N=23 CONAge: 41.1 ± 13.6Parity: 0.4 ± 0.9BMI: 22.4 ± 1.99N=9 SUIAge: 47.9 ± 13.2Parity: 1.6 ± 0.7BMI: 25.0 ± 4.11

TPUS, to measure displacement of ARA and urethrasupine

The Knack: squeeze, to prevent breaking wind and lift, while holding this contraction cough as hard as possible

Dorsal-ventral/caudal-cranial, in cmDisplacement of the urethra during coughingSUI: 1.10 ± 0.12CON: 0.51 ± 0.19p>0.0001Initial ventral displacement of posterior edge of the urethra during squeezing (while coughing)SUI: 0.26 ± 0.14CON: 0.42 ± 0.21p<0.05

Video recordings of US for offline-analysis

Significant differences in both the direction and magnitude of displacement of the ARA and the urethra during a knack between groups

Velocity and acceleration of ARA and urethra

There is less dorso-caudal displacement, velocity and acceleration of the ARA and urethra in CON than in SUI women consequent to “the Knack” which highlights the greater stiffness and control of PFM and urethra in CON

Jones [22] 2010 Feasibility study, observational

N=32 N=23 CONAge: 41.1 ± 13.6Parity: 0.5 ± 0.9BMI: 22.0 ± 2.0N=9 SUIAge: 47.9 ± 13.2Parity: 1.6 ± 0.7BMI: 23.9 ± 2.6

TPUS, motion tracking and digital vaginal examinationcrook-lying supine positionVolunteers were asked to void 1 h before testing, and then to drink 450 ml of water and to refrain from voiding until after the

Maximum cough (3 x) with 5 s rest between

ARA (cm) dorsal-ventralCON: 0.18 ± 0.36SUI: -0.20 ± 0.26p = 0.0038ARA (cm) cranial-caudalCON: -0.63 ± 0.37SUI: -1.01 ± 0.42p = 0.0084Anterior urethra dorsal-ventralCON: -0.43 ± 0.28

Displacements of urethra and ARAs were measured with respect to an orthogonal coordinate system fixed on the PS, parallel and vertical to the urethra at rest; when the tissues moved, the coordinate system maintained its original

YesCough in CON:ARA moved inventrocaudal direction towards the PS; cough in SUI: ARA and urethra moved in a dorsocaudal direction away from the PS

Velocity and acceleration of the PFM and the urethra during coughing

The urethras of SUI women were displaced more than twice as far (p = 0.0002), with almost twice the velocity (p = 0.0015) of the urethras of CON women; during a cough, normal PFM function produces timely compression of the PF and additional external support to urethra, reducing displacement, velocity, and acceleration; in SUI women who have weaker urethral attachments, this shortening contraction does not occur;

Page 9: link.springer.com10.1007/s00192... · Web viewPTR: Pressure transmission ratio = (Δ urethral pressure/ Δ bladder pressure) x 100: significantly lower in the SUI group (p< 0,001)

Author Year Type of study

Subjects characteristics: sample size (n),age (yrs, mean, SD), BMI (mean), Parity (mean, SD)

Measurement method,test position,bladder filling

Tested activity

Direction, quantity of displacement

Measurement details

Comparison CON versus SUI

Secondaryoutcome(s)

Conclusion

test sequences. SUI: -1.22 ± 0.48p < 0.0001Anterior urethra cranial-caudalCON: -0.66 ± 0.25SUI: -1.7 ± 0.51p = 0.0002Posterior urethra dorsal-ventralCON: -0.41 ± 0.21SUI : -1.1 ± 0.42p = 0.0009Posterior urethra cranial-caudalCON: -0.80 ± 0.27SUI : -1.7 ± 0.61p = 0.0014

position, and the subsequent trajectory of urogenital structures could then be measured relative to this fixed axis. To accurately map the trajectory of the ARA and the urethra, the apparent motion of the PS, created by movement of the transducer during the cough, was tracked and subtracted from the displacements of the ARA and the urethra.

consequently, the urethras of women with SUI move further and faster for a longer duration.

Junginger [23]

2010 Observational study

N=9,without PFM disorders (4 nulliparous)Age: 42 (32-59)

TPUS to measure BN-displacement, EMG, Rectal balloonSupine

1. Gentle PFMC

2. Moderate PFMC

3. Contraction of TrA

4. Brace contraction

5. Valsalva6. Head lift7. Maximu

m PFMC

Motion was primarily in ventral direction, no significant cranial motion of BN in any taskBN elevation (mm) during PFMC (gentle and moderate) and TrA range: 1.0 ± 0.3 to 3.3 ± 1.5(p<0.0001)No BN elevation with the brace, the Valsalva and the head lift of (p>0.56). BN elevation during the moderate PFMC was greater than during all other tasks (p<0.002). BN elevation during the gentle PFMC was greater than during all abdominal manoeuvres (p<0.04).Contraction of the TrA: greater BN elevation than in head lift or brace (p<0.03). No difference in BN elevation between head lift, brace and Valsalva task (p>0.33).

Position of BN was estimated using a coordinate system through the pubic symphysis (according to Schaer et al, 1995); displacement of the BN in anterior–posterior and caudal–cranial directions and a net displacement vector were calculated

- IAP increased in all tasks from 0.46 cmH2O (TrA) to 1.59 cmH2O (Valsalva; p<0.05); Brace and Valsalva increased the IAP more than TrA contraction (p<0.02); PFM EMG increased with all pelvic floor and abdominal tasks

BN elevation during a PFMC is influenced by the relationship between PFM activity and IAP; BN elevation occurred consistently only during PFM and gentle TrA contractions; abdominal tasks (gentle brace, gentle Valsalva and gentle head lift) increased IAP and prevented significant BN elevation; data imply that BN elevation occurs when PFMC is sufficient to counteract the BN descent caused by downward force of IAP

Kelly [24] 2007 Experimental study

N=65Age: 23 ± 3N=45 CON females (data are extracted in the review)(N=20 males, also

TAUS, to measure displacement of bladder base Standing and crook-lyingParticipants filled their

1. Rest2. PFMC

Elevation of bladder base in mm:Standing: 6.9 ± 4.8Crook-lying: 4.6 ± 4.5

Marker ‘X’ was placed on the central portion of the bladder base visualised during a pelvic floor muscle contraction

- Endurance (longer in standing than crook-lying); comparison male-female (no influence of sex on

Standing was found to be a more effective position for achieving and sustaining an elevation of the PF compared to crook-lying; this should be taken into account when assessing and training PFMC; patients who have

Page 10: link.springer.com10.1007/s00192... · Web viewPTR: Pressure transmission ratio = (Δ urethral pressure/ Δ bladder pressure) x 100: significantly lower in the SUI group (p< 0,001)

Author Year Type of study

Subjects characteristics: sample size (n),age (yrs, mean, SD), BMI (mean), Parity (mean, SD)

Measurement method,test position,bladder filling

Tested activity

Direction, quantity of displacement

Measurement details

Comparison CON versus SUI

Secondaryoutcome(s)

Conclusion

included in population, data not extracted here)

bladder by consuming 3 to 4 glasses (600–750 ml) of water in half an hour, one hour before the measurement without voiding to allow optimal imaging of the base of the bladder.

using the technique previously described by Sherburn et al (2005); displacement was measured as the distance between the two ‘X’ points

displacement or endurance of PF elevation (p = 0.18)); positive correlation between the displacement of PF elevation and the endurance of PF elevation in standing (Spearman’s rho = 0.71, 95% CI 0.60 to 1.00) and in crook-lying (Spearman’s rho = 0.71, 95% CI 0.60 to 1.00).

difficulty elevating their PF in crook-lying may be able to achieve this task more easily in standing

McLean [25] 2011 Intervention study

N=15, SUI TPUS, to determine the excursion of BN during coughing after a 12 week PFMTSupine and standing

Maximal coughs

Movement of BN in standing in cmBefore PFMT:1.843 ± 1.053 cmAfter PFMT:0.961 ± 0.656cm(p=0.0078)Movement of BN in supine in cmBefore PFMT:1.1701 ± 0.6494 cmAfter PFMT:0.876 ± 0.635 cm(p= 0.9967)

- -Pre/post comparison: there was significantly less BN movement seen during coughing in standing after the 12 week PFM training protocol as compared to before the protocol; no difference in BN motion during coughing performed in supine when before or after the PFM training protocol

Urogenital Distress Inventory (UDI) and Incontinence Impact Questionnaire (IIQ) before and after the training program; change in BN excursion was consistent with lower scores on the IIQ measured after compared to before the intervention (10.05±7.69 vs. 36.34±21.89 respectively; p=0.01), but not on the UDI (29.01±17.74 vs. 44.15± 21.49 respectively; p=0.356).

In women with SUI, performance of a 12 week PFMT program was associated with reduction in BN excursion during coughing in standing, but induced no difference in BN excursion during coughing in supine.

McLean [26] 2013 Intervention study

N=40, SUIN=20, treatment groupAge: 49.5 ± 8.2Parity: 2.6 ± 1.1BMI: 27.0 ± 3.8

N=20, control groupAge: 54.9 ± 8.4Parity: 2.2 ± 1.0BMI: 28.6 ± 11.3

TPUS, to determine the effect of a 12-week PFMT program on BN position and mobility Supine and standingBladder emptied

1. Rest2. Coughin

g3. Valsalva

BN displacement during Valsalva in caudal direction:Data for standing in cm (SD):Treatment groupbefore training:1.408 ± 0.789after training:1.597 ± 0.842Control groupbefore training:1.232 ± 0.744after training:1.584 ± 0.641Data for supine in cm (SD):

Maximal excursion of BN during Valsalva maneuver had a reference line drawn from the most caudal and posterior point of the PS to the posterior aspect of the apex of the ARA; the perpendicular distance from the BN to the reference line was measured for all conditions and

-Pre/post comparison: No main effect of group on the amount of BN descent during Valsalva (p=0.81); effect for session (p=0.003): both groups demonstrated more BN descent on Valsalva after 12 weeks than they did before; treatment group

3-day bladder diary, 30-min pad test, Incontinence Impact Questionnaire (IIQ-7) Urogenital Distress Inventory (UDI-6); women in treatment group demonstrated significant improvements in the 3-day bladder diary and IIQ-7

Women of treatment group demonstrated reduced BN mobility during coughing after as compared to before the training; these changes were not evident in the control group; no differences in the resting position of the BN or in BN excursion during Valsalva manoeuvre were noted in either group

Page 11: link.springer.com10.1007/s00192... · Web viewPTR: Pressure transmission ratio = (Δ urethral pressure/ Δ bladder pressure) x 100: significantly lower in the SUI group (p< 0,001)

Author Year Type of study

Subjects characteristics: sample size (n),age (yrs, mean, SD), BMI (mean), Parity (mean, SD)

Measurement method,test position,bladder filling

Tested activity

Direction, quantity of displacement

Measurement details

Comparison CON versus SUI

Secondaryoutcome(s)

Conclusion

Treatment groupbefore training:1.847 ± 1.033after training:2.015 ± 0.745Control groupbefore training:1.874 ± 1.118after training:2.236 ± 1.056

BN displacement during coughingData for standing in cm (SD):Treatment groupbefore training:1.170 ± 0.649after training:0.875 ± 0.634Control groupbefore training:1.266 ± 0.440after training:1.388 ± 0.595Data for supine in cm (SD):Treatment groupbefore training:1.842 ± 1.053after training:0.961 ± 0.656Control groupbefore training:2.106 ± 1.023after training:2.004 ± 0.755

positions; for Valsalva manoeuvre, BN excursion was calculated as the difference in position of the BN relative to the reference line

demonstrated a reduction in BN displacement during the cough between the pre- and post-test sessions (p < 0.0005)

after the PFMT and improved significantly more than the control group; urethral cross-sectional area was larger after the 12-week treatment session in women in the treatment group

Miller [27] 2001 Observational study

N=22N=11 CON, young, nulliparas Age: 24.8 ± 7.0N=11 SUI, older, parasAge: 66.9 ± 3.9

TPUS for BN displacementBladder not emptied for 2 hours before testing; instructed to drink 450 mL of water 1 hour before test.Standing

1. Rest2. Maximu

m PFMC3. Coughs,

with and without voluntary PFMC (the Knack)

BN displacement during coughs, median (range): without PFMC: 5.4 (20.0)with PFMC: 2.9 (18.3)(p < 0.001)

Median BN position at rest in the group of older SUI was significantly further dorsocaudal (p =0.001) than in the younger CON; The younger women demonstrated a median (range) decrease in excursion from 4.6 (19.5)

Measurement strategy described by Schaer et al., 1996 (X/Y coordinate system)

-Comparison young-old

Reproducibility of cough pressures: acceptably consistent; reproducibility of BN displacement measures: poor

PFMC in preparation for, and throughout a cough can augment proximal urethra support during stress, thereby reducing the amount of dorsocaudal displacement

Page 12: link.springer.com10.1007/s00192... · Web viewPTR: Pressure transmission ratio = (Δ urethral pressure/ Δ bladder pressure) x 100: significantly lower in the SUI group (p< 0,001)

Author Year Type of study

Subjects characteristics: sample size (n),age (yrs, mean, SD), BMI (mean), Parity (mean, SD)

Measurement method,test position,bladder filling

Tested activity

Direction, quantity of displacement

Measurement details

Comparison CON versus SUI

Secondaryoutcome(s)

Conclusion

(without) to 0.0 (17.0) (with) mm (p=0.007), and the older SUI women demonstrated a median (range) decrease from 6.2 (10.0) (without) to 3.5 (15.4) mm (with) (p= .003).

Peng [28] 2007 Observational study

N=31N=22 CON, asymptomaticAge: 39.0 ± 2.3Parity range: 0-3

N=9: SUIAge: 47.9 ± 4.4Parity range: 0-2

TPUS and motion tracking, to analyse dynamics of ARASupine and standingVolunteers were asked to void one hour before testing, then to drink 450 mL of water and refrain from voiding until after the test sequences

1. Rest2. Coughs

Displacement of ARA in supine (cm, mean ± SE)CON: Ventral-dorsal : 0.18 ± 0.05Cranial-caudal : -0.59 ± 0.04SUI:Ventral-dorsal : -0.21 ± 0.05Cranial-caudal : -1.00 ± 0.08P<0.0001

Displacement of ARA in standing (cm, mean ± SE)CON: Ventral-dorsal : 0.01 ± 0.04Cranial-caudal : -0.40 ± 0.05SUI:Ventral-dorsal : -0.88 ± 0.23Cranial-caudal : -1.17 ± 0.24P<0.0001

Video recordings of the imaging and audio signals were recorded on a personal computer and stored for off-line analysis; an orthogonal coordinate system fixed on a bony landmark, the SP, was established: the coordinate system was fixed during the manoeuvre, so, when the subject deformed the bladder, the coordinate system maintained its original position and the ensuing trajectory of urogenital structures could be measured relative to this fixed axis

YesSupine: During a cough, in CON the ARA moves ventrally toward the SP; in SUI the ARA moves dorsally away from the SP; the amplitude of the maximum caudal movement of the ARA in SUI is larger than that of CONStanding: SUI have significantly more dorsal and caudal displacement than CON women

Trajectories, velocity and acceleration of PFM dynamic responses

PFM responses of CON and SUI women are significantly different in both the supine and standing experiments; the method of motion tracking the ARA is able to quantify dynamic parameters of PFM function that have not been previously analysed using dynamic ultrasound imaging

Peschers [29] 2001 Observational study

N=39, CON, nulliparousAge: 24.2 ± 6-0

TPUS, to measure BN motion Bladder was filled with 200mL of sterile water using a catheterLithotomy position

1. Valsalva 2. PFMC3. Coughs

BN descent in mmDuring coughing: 8 ± 4During Valsalva: 15 ± 10 (p<0.005)

BN mobility in mm (range; mean, SD)During Valsalva (60 cm H2O ± 5):2 - 31 (14 ± 9)

BN mobility in mm (range; mean, SD)During coughing (110 cm H2O ± 5):4 - 32 (9 ± 6)

Position of BN was analysed according to a standardised and reproducible method described by Schaer et al. (1995); US was recorded on video tapes

- Test-retest-studies showed a maximum difference between tests during coughing of 4 mm (mean difference 1 ± 2; ICC 0.956) and during Valsalva of 5 mm (mean difference 1 ± 3; ICC 0.99).

BN is mobile in normal CON women; BN mobility is lower during coughing than during Valsalva

Pregazzi [30] 2002 Observational study

N=73N=23 SUIAge: 49.1 ± 6.7

TPUS, to assess urethral angle and BN mobility

1. Rest2. Valsalva

Alpha angle (° ± SD)SUIRest: 100 ± 5

Distance BN-PS: from the BN to the lowest point of the

Significant difference in all ultrasound variables between SUI

Determination of cutoff limits of urethral angle and

Urethral angulation plays a significant role in female continence: with SUI, urethral angle is lower at rest and

Page 13: link.springer.com10.1007/s00192... · Web viewPTR: Pressure transmission ratio = (Δ urethral pressure/ Δ bladder pressure) x 100: significantly lower in the SUI group (p< 0,001)

Author Year Type of study

Subjects characteristics: sample size (n),age (yrs, mean, SD), BMI (mean), Parity (mean, SD)

Measurement method,test position,bladder filling

Tested activity

Direction, quantity of displacement

Measurement details

Comparison CON versus SUI

Secondaryoutcome(s)

Conclusion

Nulliparae: 5Multiparae: 18BMI: 24.8 ± 1.8N=50 control (other urological disorder but proven sphincter competenceAge: 49.7 ± 6.5Nulliparae: 6Multiparae: 44BMI: 24.6 ± 1.4

Lithotomy positionBefore and after micturition

3. Maximal PFMC

Valsalva: 120 ± 8Contraction: 90 ± 9CONRest: 92 ± 6Valsalva: 100 ± 8Contraction: 80 ± 8p<0.001

Beta angle (° ± SD)SUIRest: 12 ± 2Valsalva: 5 ± 2CONRest: 20 ± 4Valsalva: 21 ± 5p<0.001

BN–S distance (mm ± SD)SUIRest: 21 ± 2Valsalva: 18 ± 2Contraction: 17 ± 2CONRest: 25 ± 3Valsalva: 23 ± 3Contraction: 24 ± 4p<0.001

PS; angle between the BN-PS line and the midline of the symphysis (alpha angle) and the urethral knee (beta angle);

and CON; SUI women demonstrated significantly lower values of the beta angle; beta angle lowers with straining in SUI while it increases with straining in CON

BN mobility discriminating between CON and SUI women (ROC curves): 14° for urethral angle and 26 mm for BN mobility;association between BN mobility and urethral angle: regression coefficient is -0.375 (95% CI: -0.486 to-0.264)

lowers with straining

Rahmanian [31]

2008 Observational study

N=31N=22 CONAge: 39 ± 2N=9 SUIAge: 48 ± 4

Approximately same parity

TPUS, motion trackingSupine and standing

Coughs From the displacement measurements, muscle strain ε was calculated:CON, max ε: supine: -0.088 ± 0.007standing: -0.045 ± 0.003SUI, max ε: supine: -0.041 ± 0.002standing: 0.10 ± 0.04

Images were captured by a video and stored for off-line analysis; to analyse and segment the images the software MATLAB was used

Strain is significantly different in standing and supine and also between the groups

Strain rate To previously defined parameters (velocity, acceleration, trajectory of the bladder, ARA) the biomechanical quantity of strain has been included; muscle strain can measure the elastic properties of urogynecological tissues

Raizada [32] 2010 Observational study

N=16 CON, nulliparaAge: 37.4 (range: 21-61)

TPUS, dynamic MRI; high definition manometryLithotomy position

1. Rest2. PFMC

(squeeze)

ARA moves in cranial and ventral direction during PFMC, in cm:cranialUS: 0.5MRI: 0.7ventralUS: 1.1MRI: 1.1

TPUS/MRI: x-axis was drawn parallel to the transducer surface; y-axis was drawn tangential to the inferior and posterior point of PS and perpendicular to the first line

- High definition manometry: plots reveal that in the vaginal High Pressure Zone, the contact pressures are distributed asymmetrically

The vaginal high-pressure zone represents the constrictor function and cranial movement represents the elevator function of PFM; cranial movement of ARA is related to the lifting action of pubococcygeus and ileococcygeus

Page 14: link.springer.com10.1007/s00192... · Web viewPTR: Pressure transmission ratio = (Δ urethral pressure/ Δ bladder pressure) x 100: significantly lower in the SUI group (p< 0,001)

Author Year Type of study

Subjects characteristics: sample size (n),age (yrs, mean, SD), BMI (mean), Parity (mean, SD)

Measurement method,test position,bladder filling

Tested activity

Direction, quantity of displacement

Measurement details

Comparison CON versus SUI

Secondaryoutcome(s)

Conclusion

Reddy [33] 2001 Observational study

N=30N=10 CON, nulliparousAge: 27.9 ± 4.3BMI: 27.6 ± 6.6N=10 CON, primiparous Age: 27.4 ± 4.5BMI: 23.8 ± 3.7N=10 SUI, primiparousAge: 28.0 ± 8.1BMI: 25.8 ± 6.2

TPUS,for analysis of BN movement and to quantify amount of probe-transducer displacementStanding

1. Rest2. Valsalva3. Coughs4. Maximal

PFMC

Corrected values of BN motion (mean ± SD):Distance (mm)Valsalva: 15.0 ± 6.9Cough: 10.2 ± 7.1PFMC: 6.6 ± 4.1Direction of vector (degrees)Valsalva: 204.4 ± 15.0Cough: 209.8 ± 19.8PFMC: 3.3 ± 41.8

Central axis and inferior border of PS acted as a reference for BN position; a midpubic axis was drawn through the inferior and superior borders of the PS; resting BN position was determined relative to the pubic bone with the included angle between the midpubic axis and the line joining the BN to the pubic point; Transducer motion relative to the pubic axis was measured by determining the distance and direction of apparent pubic point movement; BN movement made on screen was called uncorrected vector vesical neck; the vector of pubic point movement was similarly tracked; difference between these vectors gave the final real motion (corrected) of the BN having compensated for the transducer movement

- Transducer movement was assessed by measuring the displacement of the pubic bone; the percentage errors between corrected and uncorrected measurement were considerable: ranging from 18% to 87%; the pubic bone, which indirectly reflected transducer movement, shifted in 70% of the time during strain, 53.3% of the time during coughing, and 20% of the time during PFMC;Test-retest reliability correlations were more than an r value of 0.7.

BN showed maximum movement during strain and moved least during PFMC; In terms of direction, the BN moved along the same direction during the efforts of coughing and straining; during PFMC the BN moved in the opposite direction;the vector-based system provides a simple method for quantifying distance and direction of BN motion, as well as localizing the resting BN position

Rizk [34] 2004 Observational study

N= 55CON, nulliparous, multiethnic 5 ethnic groups à 11 womenAge: 25.5 ± 4.2 (range 18-29)

MRI, for PF anthropometry and pelvimetrySupineModerately filled urinary bladder

1. Rest2. Valsalva

BN descent at straining (mm, mean, SD):European/white: 7 ± 0.7Emirati: 6 ± 0.6Other Arab: 7 ± 0.8Indian/Pakistani: 5 ± 0.5Filipino: 4 ± 0.3

PCL extended from the inferior border of the pubic symphysis to the last joint of the coccyx; the distance from this line to the BN and cervix was measured at rest and at maximal strain

-Comparison between ethnic groups: statistically significant differences in all PF measurements between the white group and other groups, (except anteroposterior diameter of the genital hiatus)

Sociodemographic characteristics; anthropometric dimensions of the bony pelvis and the PF

BN descent was significantly greater in the white group than in other subgroups; this finding indicates a differential response of the PF to straining in white and non-white women with relatively weaker BN supports; white women were significantly taller (p<0.001) than the other women; results indicate that the size of the female PF and bony pelvis may be related to anthropometric measurements such as height or

Page 15: link.springer.com10.1007/s00192... · Web viewPTR: Pressure transmission ratio = (Δ urethral pressure/ Δ bladder pressure) x 100: significantly lower in the SUI group (p< 0,001)

Author Year Type of study

Subjects characteristics: sample size (n),age (yrs, mean, SD), BMI (mean), Parity (mean, SD)

Measurement method,test position,bladder filling

Tested activity

Direction, quantity of displacement

Measurement details

Comparison CON versus SUI

Secondaryoutcome(s)

Conclusion

weight, which could be responsible for the observed ethnic differences

Saleme [35] 2009 Observational comparative study

N=1, SUIAge: 33

MRI, to compare PFM displacement in MRI and Finite Element Analysis (FEA)Supine

1. Rest2. Maximal

PFMC

Range of displacement (between rest and PFMC, mm): 5.75 - 5.58

20 consecutive images were used to construct a 3D model from a pubovisceral muscle; the model was meshed with tetrahedral elements

- Comparing the displacement from 100% contraction to the real value obtained by overlapping the MRI images, an error of 2.8% is obtained

The finite elements methodology of the active contraction behaviour proposed in this study is adequate to simulate PFMC

Sherburn [36] 2005 Observational study

N=30N=10 for validity studyAge: 41.8 ± 11.0

N=20 for reliability studyAge: 39.3 ± 10.4Parity was similar for both groupsContinence status not reported.

TAUS, to measure displacement of the posterior bladder SupineBladder filling protocol: subjects consuming 600–750 ml of water in a one-hour period, completed half an hour prior to testing, without voiding during this period.

PFMC Bladder wall displacement in anterocephalic (sagittal plane) and cephalic direction (horizontal plane, ‘lift’ component of PFMC)

Intra-rater reliability, displacement in mm (mean; SEM)Sagittal planesession 1: 9.31; 0.22session 2: 8.96; 0.57Transverse planesession 1: 8.43; 0.28session 2: 7.51; 0.44

Inter-rater reliability, displacement in mm (mean; SEM)Sagittal planerater 1: 9.89; 0.22rater 2: 10.33; 0.46Transverse planerater 1: 8.53; 0.10rater 2: 8.70; 0.42

Point of greatest observed displacement clearly visible throughout the movement was selected for measurement; the position of this point at rest was marked electronically with an ‘X’; the subject performed a maximum PFMC and image was captured at moment of maximum displacement

- Validity and reliability of TAUS measurements: validation study included digital vaginal examination; digital strength grading did not correlate with ultrasound measures (r = 0.21 and -0.13); for the reliability study subjects were tested on two occasions up to five days apart; average intra-class correlation coefficients for within session inter-rater reliability ranged between 0.86 and 0.88 (95% CI 0.68 to 0.97), and for inter session intra-rater reliability between 0.81 and 0.89 (95% CI 0.51 to 0.96

Transabdominal application of diagnostic ultrasound as non-invasive method for imaging and assessing PFM activity is both valid and reliable

Strauss [37] 2012 Prospective cohort study

N=134N=117 CON N=20 nulliparousAge: 30N= 97 primiparousAge: 32

N=17symptomatic, parous prolapse patientsAge: 62

MRI, to measure pelvic organ displacement as force-displacement vectorSupineMeasurements performed after voiding

Valsalva Direction of force–displacement-vector and frequency (%) of angular deviation based on PCL:Nulliparousventral: 60%mid: 20%dorsal: 20%Primiparous (vaginal delivery)ventral: 17%

To evaluate pelvic organ shift, the center of area of the urinary bladder at rest and during contraction was compared; from displacement of these areas, the direction of forces was calculated, specified as angle between PCL and the

-Comparison between parous and nulliparous women

Force vector direction differed regarding the mode of delivery (P<0,001)

There was no correlation between patient’s body weight and the degree of vector displacement; women’s body height (r = 0.27, P = 0.003) and age (r = -0.22, P = 0.009), did influence the vector direction; increasing pelvic compressive load (e.g. deliveries, age) causes a consecutive ventral to dorsal vector-shift

Page 16: link.springer.com10.1007/s00192... · Web viewPTR: Pressure transmission ratio = (Δ urethral pressure/ Δ bladder pressure) x 100: significantly lower in the SUI group (p< 0,001)

Author Year Type of study

Subjects characteristics: sample size (n),age (yrs, mean, SD), BMI (mean), Parity (mean, SD)

Measurement method,test position,bladder filling

Tested activity

Direction, quantity of displacement

Measurement details

Comparison CON versus SUI

Secondaryoutcome(s)

Conclusion

Only data for patients without POP have been extracted in this SR

mid: 46%dorsal: 37%Amplitude of organ descent during Valsalva (in cm):NulliparousBN: 1.6 Bottom of bladder: 1.5 PrimiparousBN: 2.8Bottom of bladder: 2.9 r = -0.21, p = 0.02

perpendicular to this reference axis; three directions for the force–displacement-vectors were defined: Ventral direction (>30°, vectors point to the ventral edge of the pubic bone); Mid direction (≥ 0° and ≤30°, vectors act towards the rear edge of the pubic bone); Posterior direction (<0°)

Talasz [38] 2011 Observational study

N=8, CON, nulliparous

Age: 25 ± 6BMI: 21 ± 2

MRI to measure movement of diaphragm and PFSupineMeasurements performed after voiding

1. Quiet breathing

2. Forceful breathing

3. Coughing

Respiratory-related cranio-caudal movement of diaphragm and PF:Maximum inspiration phases, defined as maximum inferior diaphragmatic positions, were used as starting points (0 mm) for measurements.Movement amplitudes in mm (mean, SD):Quit breathingL4/5-PF: 4.8 ± 3.2PRS-PCL: 2.1 ± 2.5Forceful breathingL4/5-PF: 5.1 ± 4.7PRS-PCL: 7.0 ± 4.1CoughingL4/5-PF: 7.4 ± 5.8PRS-PCL: 3.8 ± 3.0

Coronal plane (PF movement) relative to defined horizontal lines: one line transecting the basis of intervertebral disc L4/5, the second line transecting the PF region; differences represent vertical movement; M-line is defined as a line perpendicular to the PCL that crosses the PRS; M-line, measured in inspiration and expiration was used to determine displacements of the PRS

- Movement of diaphragm; waist diameter

In healthy women, real-time dynamic MRI demonstrates parallel cranio-caudal movement of the diaphragm and the PF during breathing and coughing and synchronous changes in abdominal wall diameter; PF displacement in a cranial direction was consistently found in all subjects during exspiration

Talasz [39] 2012 Observational study

N=4, CON Subject 1Age: 50BMI: 21Parity: 0Subject 2Age: 50BMI: 24Parity: 2Subject 3Age: 25BMI: 22Parity: 0Subject 4Age: 25

Dynamic MRI, to measure different movement patterns of the diaphragm and PFSupine

1. Forceful breathing

2. Valsava maneuver (VM)

3. Straining maneuver (SM)

During the VM the PF moved cranially parallel to the diaphragm, whereas during the SM the PF was markedly displaced caudally.Vertical movement amplitude of the puborectalis muscle sling (PRS) in mm (mean, SD):cranial direction: positive value, caudal direction: negative valueForceful expiration: 9.1 ± 3.2Valsalva: 14.6 ± 8.9Straining: -14.9 ± 1.3

See Talasz et al., 2011

- Measurement of changes in anterolateral abdominal muscle thickness and abdominal diameter at the umbilical level during a VM as opposed to SM

The study demonstrates that the VM and SM are different tasks, based on two disparate respiratory patterns, leading to different positions and performances of the diaphragm and the muscular PF; the VM reflects an expiratory pattern with diaphragm and PF elevation, whereas during SM the PF descends;

Page 17: link.springer.com10.1007/s00192... · Web viewPTR: Pressure transmission ratio = (Δ urethral pressure/ Δ bladder pressure) x 100: significantly lower in the SUI group (p< 0,001)

Author Year Type of study

Subjects characteristics: sample size (n),age (yrs, mean, SD), BMI (mean), Parity (mean, SD)

Measurement method,test position,bladder filling

Tested activity

Direction, quantity of displacement

Measurement details

Comparison CON versus SUI

Secondaryoutcome(s)

Conclusion

BMI: 23Parity: 0

Thompson [40]

2007 Cross-sectional observational study

N=120, 4 groupsAge: 43 ± 7BMI: 24 ± 4Median Parity: 2 (range 0-5)

N=60 CON30 nulliparous, 30 parousN=60 UI30 SUI, 30 UUIOnly data for continent and SUI (no UUI) have been extracted in this SR.

Comparison of TAUS and TPUS

1. PFMC 2. Valsalva 3. Abdomin

al curl up

TPUS BN movement (cm; mean ± SD):Elevation during PFMC:Nulliparous: 0.57 ± 0.59Parous: 0.59 ± 0.54SUI: 0.50 ± 0.50Descent during Valsalva:Nulliparous: 0.92 ± 0.69Parous: 0.97 ± 0.47SUI: 1.76 ± 0.88Desent during Abd. Curl:Nulliparous: 0.44 ± 0.59Parous: 0.54 ± 0.32SUI: 0.87 ± 0.48

TAUS bladder base movement (cm; mean ± SD):Elevation during PFMC:Nulliparous: 0.50 ± 0.49Parous: 0.49 ± 0.50SUI: 0.55 ± 0.51Descent during Valsalva:Nulliparous: 1.64 ± 0.90Parous: 1.90 ± 0.83SUI: 2.27 ± 1.00Descent during Abd. Curl:Nulliparous: 1.48 ± 0.68Parous: 1.74 ± 0.67SUI: 1.96 ± 0.71

TPUS: Measure of the position of BN was taken at rest, and the change from the resting position was measured using the standardised method described by Schaer et al. (1995); descent was calculated using the method described by Dietz et al. (2001);TAUS: marker was placed at rest and at the end of PFMC to mark the point of maximal displacement of bladder base from resting position; difference was measured using the on-screen callipers

PFMC: BN elevation in TPUS showed no significant difference between the groups, but strong trend (p=0.051) towards greater BN elevation in CON compared to incontinent women;TAUS: no significant difference (p=0.112) in bladder base movement between groupsValsalva: BN descent (TPUS): comparisons showed that the SUI group had increased BN descent compared with CON group (p<0.001); TAUS: SUI displayed a greater amount of bladder base descent compared with CON (p=0.021);Abdominal curl:TPUS: SUI displayed greater BN descent than CON during abdominal curl (p<0.001); TAUS: strong trend towards SUI having greater amount of bladder base descent compared with CON (p=0.056)

Reliability: TPUS more reliable compared to TAUS

There were no differences between the four groups in the amount of BN and bladder base movement during voluntary PFMC

Wise [41] 1992 Observational study

N=23 CON, primiparous women, 4-6 weeks following a normal vaginal delivery; no UI prior to pregnancy

TPUS, to measure BN movementSemi-recumbent positionFoley catheter was inserted into the bladder, 250 ml saline was instilled into the bladder

1. Rest2. PFMC3. Valsalva

y-axis = vertical movement:significant descent of the BN on Valsalva (p< 0.0001) in mm, median (IQR):30.6 (18.9 -43.4)significant elevation of the BN during PFMC (p< 0.001) in mm, median (IQR): -9.52 (0 - -18.9)The distance moved on Valsalva is given a positive

BN was defined by the presence of the catheter; position described according the x,y coordinate system devised by Clark et al.

- Angle A: between BN and y-axis; distance B from BN to the intercept of the x and y axes

One third of postnatal women were unable to elevate their BN during PFMC; direction of movement on Valsalva is opposite to that of PFMC; BN moved in an arc of a circle

Page 18: link.springer.com10.1007/s00192... · Web viewPTR: Pressure transmission ratio = (Δ urethral pressure/ Δ bladder pressure) x 100: significantly lower in the SUI group (p< 0,001)

Author Year Type of study

Subjects characteristics: sample size (n),age (yrs, mean, SD), BMI (mean), Parity (mean, SD)

Measurement method,test position,bladder filling

Tested activity

Direction, quantity of displacement

Measurement details

Comparison CON versus SUI

Secondaryoutcome(s)

Conclusion

value whereas movement on PFMC is negative.x-axis = horizontal movement: on Valsalva significant movement towards the symphysis (p<0.005)

Yousuf [42] 2009 Longitudinal study

N=13 primiparous women, with obstetric factors (levator ani injury)Age: 28.6 ± 3.6BMI: 25.6 ± 4.0Racial distribution: 83.3% white, 11% Asian, 5.6% other raceSUI-complaints: 61.5% of the sample

Dynamic MRI, to determine changes in location and movement of PF at 1 (early) and 7 (late) months postpartum.Supine

1. Rest2. Maximu

m PFMC3. Valsalva

Displacement of BN in mm (mean, IQR):MVC (lift)Early postpartum: 3.4 (2.1-5.4)Late postpartum: 1.9 (1.1-3.0)p=0.10

Valsalva (descent)Early postpartum: 18.1 (8.4-23.8)Late postpartum: 19.1 (12.7-22.4)p=0.35

Mid-sagittal MRI scans were converted into JPEG format and analysed with diagrams; the sacro-coccygeal inferior pubic point (SCIPP) line, the levator hiatus, the levator plate angle, the perineal body, the anal verge, the BN, and the cervix were drawn; for measurement purposes, the SCIPP line was considered as the x axis, and a line was drawn perpendicular to it (y axis); the angle of the levator plate was measured relative to the SCIPP line

-Comparison1 and 7 months postpartum

Displacement during PFMC and Valsalva were similar when late measures were compared to early postpartum measures for all of the measured pelvic structures; both the urogenital and levator hiatus diameters were smaller at 7 months (P<0.5)

The perineal body was 7.1 mm and anal verge 7.9 mm higher at 7 months postpartum (P=0.003); displacement during PFMC and Valsalva was similar between the 2 time points

1. Arab AM, Behbahani RB, Lorestani L, Azari A (2009) Correlation of digital palpation and transabdominal ultrasound for assessment of pelvic floor muscle contraction. Journal of Manual & Manipulative Therapy 17 (3):75E-79E2. Baessler K, Junginger B Bladder neck elevation with different levels of effort of pelvic floor muscle contraction. In: ICS 2008 Annual Meeting of the International Continence Society (ICS), 2008. 3. Balmforth JR, Mantle J, Bidmead J, Cardozo L (2006) A prospective observational trial of pelvic floor muscle training for female stress urinary incontinence. Bju Int 98 (4):811-817

Page 19: link.springer.com10.1007/s00192... · Web viewPTR: Pressure transmission ratio = (Δ urethral pressure/ Δ bladder pressure) x 100: significantly lower in the SUI group (p< 0,001)

4. Barbič M, Kralj B, Cör A (2003) Compliance of the bladder neck supporting structures: importance of activity pattern of levator ani muscle and content of elastic fibers of endopelvic fascia. Neurourology and urodynamics 22 (4):269-2765. Bo K, Lilleas F, Talseth T, Hedland H (2001) Dynamic MRI of the pelvic floor muscles in an upright sitting position. Neurourology and urodynamics 20 (2):167-1746. Brækken IH, Majida M, Engh ME, Bø K Functional aspects of pelvic floor muscle contraction using 4D real time ultrasound. A test-retest study. In: ICS 2008 Annual Meeting of the International Continence Society (ICS), 2008. 7. Chehrehrazi M, Arab AM, Karimi N, Zargham M (2009) Assessment of pelvic floor muscle contraction in stress urinary incontinent women: comparison between transabdominal ultrasound and perineometry. International Urogynecology Journal 20 (12):1491-14968. Chen R, Song Y, Jiang L, Hong X, Ye P (2011) The assessment of voluntary pelvic floor muscle contraction by three-dimensional transperineal ultrasonography. Archives of gynecology and obstetrics 284 (4):931-9369. Christensen L, Djurhuus J, Constantinou C (1995) Imaging of pelvic floor contractions using MRI. Neurourology and urodynamics 14 (3):209-21610. Constantinou C, Hvistendahl G, Ryhammer A, Nagel LL, Djurhuus J (2002) Determining the displacement of the pelvic floor and pelvic organs during voluntary contractions using magnetic resonance imaging in younger and older women. Bju Int 90 (4):408-41411. Crotty K, Bartram CI, Pitkin J, Cairns MC, Taylor PC, Dorey G, Chatoor D (2011) Investigation of optimal cues to instruction for pelvic floor muscle contraction: A pilot study using 2D ultrasound imaging in pre menopausal, nulliparous, continent women. Neurourology and urodynamics 30 (8):1620-1626‐12. Da Roza T, Mascarenhas T, De Araujo M, Parente M, Duarte S, Loureiro J, Natal Jorge R Displacement of the levator ani muscle in continent and incontinent female athlete. In: ICS 2011 Annual Meeting of the International Continence Society (ICS), 2011. 13. Delmas V, Ami O, Iba-Zizen M-T (2010) Examen dynamique du muscle élévateur de l'anus de la femme par modélisation vectorielle 3D IRM: étude préliminaire. Bulletin de l'Académie nationale de médecine 194 (6):969-98014. Dietz H, Eldridge A, Grace M, Clarke B (2004) Pelvic organ descent in young nulligravid women. American journal of obstetrics and gynecology 191 (1):95-9915. El Sayed RF, El Mashed S, Farag A, Morsy MM, Abdel Azim MS (2008) Pelvic Floor Dysfunction: Assessment with Combined Analysis of Static and Dynamic MR Imaging Findings 1. Radiology 248 (2):518-53016. Fielding JR, Griffiths D, Versi E, Mulkern R, Lee M, Jolesz F (1998) MR imaging of pelvic floor continence mechanisms in the supine and sitting positions. AJR American journal of roentgenology 171 (6):1607-161017. Hol M, Bolhuis CV, Vierhout M (1995) Vaginal ultrasound studies of bladder neck mobility. BJOG: An International Journal of Obstetrics & Gynaecology 102 (1):47-5318. Howard D, Miller JM, Delancey JO, Ashton-Miller JA (2000) Differential effects of cough, valsalva, and continence status on vesical neck movement. Obstetrics and gynecology 95 (4):53519. Hu L, Song Y Three-dimensional Virtual-reality reconstruction of pelvic floor structure for patients with female stress Urinary incontinence. In: ICS 2009 Annual Meeting of the International Continence Society (ICS), 2009. 20. Hung H-C, Hsiao S-M, Chih S-Y, Lin H-H, Tsauo J-Y (2011) Effect of pelvic-floor muscle strengthening on bladder neck mobility: a clinical trial. Physical therapy 91 (7):1030-1038

Page 20: link.springer.com10.1007/s00192... · Web viewPTR: Pressure transmission ratio = (Δ urethral pressure/ Δ bladder pressure) x 100: significantly lower in the SUI group (p< 0,001)

21. Jones LR, Peng Q, Humphrey V, Stokes M, Payne C, Constantinou C Effect of the knack on the pelvic floor: evaluated by 2d real time ultrasound and image processing methods. In: ICS Annual Meeting of the International Continence Society, 2009. ICS, 22. Lovegrove Jones RC, Peng Q, Stokes M, Humphrey VF, Payne C, Constantinou CE (2010) Mechanisms of pelvic floor muscle function and the effect on the urethra during a cough. European urology 57 (6):1101-111023. Junginger B, Baessler K, Sapsford R, Hodges PW (2010) Effect of abdominal and pelvic floor tasks on muscle activity, abdominal pressure and bladder neck. International urogynecology journal 21 (1):69-7724. Kelly M, Tan B, Thompson J, Carroll S, Follington M, Arndt A, Seet M (2007) Healthy adults can more easily elevate the pelvic floor in standing than in crook-lying: an experimental study. Australian Journal of Physiotherapy 53 (3):187-19125. McLean L, Gentilcore-Saulnier E, Baker K, Harvey M-A, Sauerbrei E Pelvic floor muscle training reduces bladder neck mobility during coughing in women with stress urinary incontinence. In: 2011 International World Physical Therapy Congress 2011, 2011. 26. McLean L, Varette K, Gentilcore-Saulnier E, Harvey MA, Baker K, Sauerbrei E (2013) Pelvic floor muscle training in women with stress urinary incontinence causes hypertrophy of the urethral sphincters and reduces bladder neck mobility during coughing. Neurourology and urodynamics 32 (8):1096-1102. doi:10.1002/nau.2234327. Miller JM, Perucchini D, Carchidi LT, DeLancey JO, Ashton-Miller J (2001) Pelvic floor muscle contraction during a cough and decreased vesical neck mobility. Obstetrics and gynecology 97 (2):255-26028. Peng Q, Jones R, Shishido K, Constantinou CE (2007) Ultrasound evaluation of dynamic responses of female pelvic floor muscles. Ultrasound in medicine & biology 33 (3):342-35229. Peschers UM, Fanger G, Schaer GN, Vodusek DB, DeLancey JO, Schuessler B (2001) Bladder neck mobility in continent nulliparous women. Brit J Obstet Gynaec 108 (3):320-32430. Pregazzi R, Sartore A, Bortoli P, Grimaldi E, Troiano L, Guaschino S (2002) Perineal ultrasound evaluation of urethral angle and bladder neck mobility in women with stress urinary incontinence. BJOG: An International Journal of Obstetrics & Gynaecology 109 (7):821-82731. Rahmanian S, Jones R, Peng Q, Constantinou CE (2008) Visualization of biomechanical properties of female pelvic floor function using video motion tracking of ultrasound imaging. Studies in health technology and informatics 132:390-39532. Raizada V, Bhargava V, Jung S, Karstens A, Pretorius D, Krysl P, Mittal RK (2010) Dynamic assessment of the vaginal high-pressure zone using high-definition manometery, 3-dimensional ultrasound, and magnetic resonance imaging of the pelvic floor muscles. American journal of obstetrics and gynecology 203 (2):172. e171-172. e17833. Reddy AP, DeLancey JO, Zwica LM, Ashton-Miller JA (2001) On-screen vector-based ultrasound assessment of vesical neck movement. American journal of obstetrics and gynecology 185 (1):65-7034. Rizk DE, Czechowski J, Ekelund L (2004) Dynamic assessment of pelvic floor and bony pelvis morphologic condition with the use of magnetic resonance imaging in a multiethnic, nulliparous, and healthy female population. Am J Obstet Gynecol 191 (1):83-89. doi:10.1016/j.ajog.2003.12.04135. Saleme C, Roza T, Mascarenhas T, Loureiro J, Parente MPL, Jorge RMN, Pinotti M, da Silva Tavares JMR Comparative study of pelvic floor displacement in a woman with stress urinary incontinence using finite element method and magnetic resonance imaging. In: ICS 2009-39th Annual Meeting of the International Continence Society (ICS), 2009.

Page 21: link.springer.com10.1007/s00192... · Web viewPTR: Pressure transmission ratio = (Δ urethral pressure/ Δ bladder pressure) x 100: significantly lower in the SUI group (p< 0,001)

36. Sherburn M, Murphy CA, Carroll S, Allen TJ, Galea MP (2005) Investigation of transabdominal real-time ultrasound to visualise the muscles of the pelvic floor. Australian Journal of Physiotherapy 51 (3):167-17037. Strauss C, Lienemann A, Spelsberg F, Bauer M, Jonat W, Strauss A (2012) Biomechanics of the female pelvic floor: a prospective trail of the alteration of force–displacement-vectors in parous and nulliparous women. Archives of gynecology and obstetrics 285 (3):741-74738. Talasz H, Kremser C, Kofler M, Kalchschmid E, Lechleitner M, Rudisch A (2011) Phase-locked parallel movement of diaphragm and pelvic floor during breathing and coughing—a dynamic MRI investigation in healthy females. International urogynecology journal 22 (1):61-6839. Talasz H, Kremser C, Kofler M, Kalchschmid E, Lechleitner M, Rudisch A (2012) Proof of concept: differential effects of Valsalva and straining maneuvers on the pelvic floor. European Journal of Obstetrics & Gynecology and Reproductive Biology 164 (2):227-23340. Thompson JA, O’Sullivan PB, Briffa NK, Neumann P (2007) Comparison of transperineal and transabdominal ultrasound in the assessment of voluntary pelvic floor muscle contractions and functional manoeuvres in continent and incontinent women. International Urogynecology Journal 18 (7):779-78641. Wise B, Cutner A, Cardozo L, Abbott D, Burton G (1992) The assessment of bladder neck movement in postpartum women using perineal ultrasonography. Ultrasound in obstetrics & gynecology : the official journal of the International Society of Ultrasound in Obstetrics and Gynecology 2 (2):116-120. doi:10.1046/j.1469-0705.1992.02020116.x42. Yousuf AA, DeLancey JO, Brandon CJ, Miller JM (2009) Pelvic structure and function at 1 month compared to 7 months by dynamic magnetic resonance after vaginal birth. American journal of obstetrics and gynecology 201 (5):514. e511-514. e517