__Pelvic_Floor_Re_education__Principles_and_Practice__Second_Edition

92 D.K. Newman and J. Laycock examination. Ideally, the legs should be sup- Palpation ported, with one leg against the examiner and the other leg supported on a pillow, or in stirrups. If Manual evaluation of the PFM provides informa- appropriate and acceptable, the examiner should tion about the woman's ability to relax and the consider the use of a mirror to demonstrate the duration and symmetry of contractions. This is findings to the patient. an important part of the pelvic examination in patients with pelvic floor disorders, because in The vulva and vagina may be examined for addition to evaluating the woman's ability to irritation from urine or perineal pads, urethral produce a voluntary contraction, it also provides caruncle, atrophic vaginitis, and pelvic organ information about the ability of the woman to prolapse (POP). Excuses for not performing the maintain that contraction during stressful situa- examination include discomfort associated with tions.' Palpat ion of the PFM can be performed atrophic vaginitis, patient and clinician embar- per vagina or per rectum. rassment with the examination, and procedural difficulty because of the need for assistance with Transvaginal (per vagina) palpation, with the confused or elderly patients. A speculum exam is woman initially positioned supine (as previously optimal, but in older frail women, a digital exam described) is the preferred route for assessing may be more feasible, especially in those women women. This technique allows the examiner to residing in a nursing home. evaluate muscle bulk, resting tone, contractile strength, and reflex response to cough or val- Introital laxity is usually obstetrical in origin, salva. In addition, reduced sensation, tenderness, and is accompanied by disturbed architecture of and/or pain should be identified. the musculature responsible for an enlarged vagina . This defect is common after childbirth. Transvaginal assessment can be performed The vagina may be torn away from its intrapelvic using either one or two digits (Fig. 2.1.2). The attachments, with subsequent loss of the superior PFM of a parous woman is usually assessed using vaginal sulcus. There may also be direct attenu- two fingers (Fig. 2.1.3), but this technique may be ation of the vaginal wall itself, which is mani- unsuitable for nulliparous women because of fested by loss of vaginal rugae and a thin their narrower vaginas, or for elderly women appearance. Stretching and tearing of the levator with atrophic vaginitis and vaginal stenosis. The ani (LA)muscles results in a longer, wider levator index finger is placed over the middle finger and hiatus. inserted into the vagina. Normally, the pubococ - cygeus muscle (PCM) is felt as a distinct 1- to Pelvic Floor Muscle Assessment 2-cm band that can be palpated on the lateral vaginal wall when the examiner's finger is intro- The PFM is a group of muscles that extend from duced to a depth of 3 to 5cm beyond the vaginal the front (anterior) to the back (posterior) of the introitus and rotated 360 degrees while palpating pelvis, forming a sling that supports the pelvic the perivaginal muscles (Fig. 2.1.4). A weak or organs (Fig. 2.1.1). Normal function of the PFM is attenuated PCM may be indistinguishable from essential in maintaining appropriate function of the surrounding tissues. The woman is asked to the pelvic viscera. The PFM (or circumvaginal contract her PFMs as hard as possible, and then muscle [CVM]) made up of the levator ani group to squeeze the examining fingers together and and include the pubococcygeus, puborectalis, draw them into the vagina .' This test can then be and ileococcygeus (Table 2.1.1). The PFMnot only repeated with the index and middle fingers spread provides support for all the organs of the pelvis, laterally, thus, palpating the right and left LA but because it is a postural muscle, it differs from simultaneously; it is not uncommon to find asym- other skeletal muscles in that it has a higher metry in a parous woman. resting tone. Evaluation of the PFM is made through manual intravaginal (or transrectal) The strong LA muscles of a young woman will examination and may include the use of measur- be felt as a thick, firm band of muscle, compared ing devices for complementary assessment. with the weak LA muscles of an elderly woman, which may feel thin and may have reduced tone that renders them indistinguishable from the

2.1. Clinical Evaluation ofthe Pelvic Floor Muscles 93 Bladder wall --+--'~ lIIlfl;i;;.-- -r- -:'7-.-::;-- --T- Region 1 Vagina --+~:---- I ,h.='=--:-=-r=-.:....-'-~=--- Region 2 Vi~~,...,,,£----I---- Region 3 fiI:IJI\"-.....~~---I---- Region 4 -==-::--- Bladder wall 1..,-- -;-- - - - Pubic bone Extemal urethral meatus Vaginal opening FIGURE 2.1.1. Pelvic floormuscle. (Source: reproduced from Newman DK, 2003.)

94 D.K. Newman and J.Laycock TABLE 2.1.1. The pelvic floor musculature (PFM)26.28.29 The PFM can beviewed in three layers: First Layer (Endopelvic Fascial The first layer iscalled theendopelvic fascia. Itisa lining made ofa mesh ofsmooth fibers, ligaments, nerves, blood vessels,and connective tissue. Itsupports and cors thebladder, theinner organs such astheintestine, and theuterus and upper vagina in women. Some oftheligaments oftheendopelvic fascia connect tothelumbar spine and thesymphysis pubis. Even though this layer cannot be exercised, training thepelvic floor muscles ofthesecond layer (pelvic diaphragm) can improve back painby increasingsupport ofthebladder and uterus from below and decreasing thestrain ontheligaments upon which thesupport otherwise depends. Strong pelvic floor muscles can help support thebladder, uterus, and rectum ifa woman has sustained tears oftheendopelvic fascia through difficult childbirth orother injury. Second Layer (Pelvic Diaphragm) The pelvicdiaphragm consists oftheLA, themost important muscle forming thepelvic floor. Itisthemain muscular support for thepelvic organs and is ofcrucial importance for pelvic floor muscle rehabilitation ortraining. The LAisa paired muscle thatstretches hammock-like between thepubic bones inthefront and coccyx behind. Itis attached along thelateral pelvic wall toa thickened band in theobturator fascia, thearcus tendineus. The LA muscle has three principal parts: 1. The puboreetalis muscle arises from theinner surface ofthepubic bones, proceeds backward along theedge ofthegenital hiatus in contact withtheside ofthevagina and loops around therectum, pulling itforward during contraction and assisting withproviding continence. 2. The PCM lies in themiddleofthevagina and feels like a ridge above thehymeneal ring and can befelt during a pelvic examination.The muscle originates intheinnersurface ofthepubic bones, passes backwardalong thepuborectalis muscle and inserts into theanococcygeal and thesuperior surface ofthecoccyx. Its fibers create a slinglike band (often referred toasa hammock).Thismuscle provides essential support totheproximal bladder neck and urethra. The pubovaginalis muscle (in women only) loops around thevagina. These fibers run in the direction offront toback. 3. The iIiococcygeus muscle arises from thearcus tendineus LA, running posteromedially toinsert onthecoccyx (tail bone) and theanococcygeal raphe, which isclinically called thelevator plate. Some ofthese muscle fibers run from one side totheother; some ina more diagonal direction. This muscle does not participate inlifting theanus.The coccygeus muscle lies adjacent totheiIiococcygeus muscle and arisesfrom theischialspine and thesacrospinous ligament. Itpasses backward against theposterior border oftheiIiococcygeus muscle and inserts into thecoccygeus and lower segment ofthesacrum. Itcan influence stability ofthesacroiliac joint. Third Layer (Urogenital Diaphragm) The outer layer ofthepelvic floor consists ofseveral muscles.The urethra, vagina and rectum pass within this area. Sometimes thethird layer is described astwo different layers because thedeep transverse perineal muscle lies deeper than theother muscles oftheurogenital diaphragm. The deep transverse perineal muscle (sometimes referred toastheperineal membrane) isvery important for continence and supports thefunction oftheLA. The other muscles ofthis layer are important for sexual function.The muscles ofthethird layer donot support theorgans ofthepelvis. 4. The deep transverse perineal muscle provides additionalfibers, such asthesphincter, loopsaround theurethra in men and women, and assists with continence. Itis under voluntary control. 5. The superficial transverse perineal muscle reinforces theaction ofthedeep transverse perineus. 6. The bulbocavernosus muscle connects contracts during orgasm, erecting theclitoris. 7. The ischiocovernosusmuscle has little function inwomen.The muscle fibers run ina diagonal direction. 8. The anal sphincter muscle loops around theanus like a ring and provides continence. Itcomprises theinternaland external analsphincters and thepuborectalis muscle. FIGURE 2.1.2. Lateral view of digital palpation of the pelvic floor muscles using one finger. (Source: modified from Laycock J, 1994.)

2.1. Clinical Evaluation ofthe Pelvic Floor Muscles Pubic symphysis 95 FIGURE 2.1.3. PFM measurement using 2 I - Rectum digits.(Source:reproduced from Laycock J, 1994.) I surrounding tissues. Many patients with pelvic also be assessed while standing, since women floor disorders exhibit low tone muscle dysfunc- will perform their PFM exercises in standing, tion (Table 2.1.2). during activities of daily living. Posterior pressure palpates the rectum, and Transrectal (per rectum) palpation of the rectal contents can be detected. An active volun- puborectalis and external anal sphincter at rest tary PFM contraction is felt as a tightening, and during a muscle contraction is best carried lifting, and squeezing action around the exami- out with the patient in the left-lateral position. nation finger. If possible, this muscle test should The puborectalis swings around the anorectal junction, and at rest, it pulls the junction forward ) to create an acute angle between the anal canal and the rectal ampulla. The well-lubricated index FIGURE 2.1.4. Transvaginal palpation of theperivaginal muscles finger is introduced 3 to 4 ern through the anus to from above, noting rotation of assessment. (Source: reproduced the rectum, and the puborectalis muscle is pal- from Laycock J, 1994.) pated with the distal pad of the index finger; the effect of a PFM contraction is felt as tension on the examining finger as the sling-like puborecta- lis pulls the anorectal junction anteriorly. A con- traction of the external anal sphincter is detected on withdrawing the finger to a position 2em inside the anal canal. Both the puborectalis and external anal sphincter should relax during def- ecation, and this is evaluated by instructing the patient to bear down, as if emptying the bowels. Either assessment should note any discomfort or pain that can occur in patients with chronic pelvic pain, interstitial cystitis/painful bladder syndrome, orvulvodynia, as many ofthese patients have high tone muscle dysfunction as described in Table 2.1.2.3 Pain should be graded using a scale similar to the one shown in Table 2.1.3. Elevation of the urethrovesical junction during a PFM contraction should be evaluated (Fig. 2.1.5). In addition, palpation of the periurethral

96 D.K. Newman and J. Laycock TABLE 2.1.2. Identification ofpelvic floor dysfunction\" • low-tone pelvic floor dysfunction (LTPFDj refers totheexamination findings ofanimpaired ability toisolate and contract thePFM in the presence ofweak and atrophic musculature and isseen inwomen withtoPOP, UI, vaginal laxity, orfecal incontinence.lTPFD may beencountered inpatients withpartial pelvic floor denervation asa result ofparturition, ageing, orsome comblnatlon's\" • High-tone pelvic floor dysfunction (HTPFD) refers totheclinical condition ofhypertonic, spastic PFM with resultant impairment ofmuscle isolation, contraction, and relaxation\". Urological and gynecological disorders include interstitial cystitis, voiding dysfunction, overactive bladder symptoms ofurinary frequency and urgency, and pelvic pain, sexual dysfunction with dyspareunia. All ofthesyndromes contributing toHTPFD arecharacterized by tender, spastic PFM manifesting aspain localized tothesuprapubic area, coccyx and lower sacrum, rectal pain, orgeneralized pelvic discomfort. Amusculosketal etiology for HTPFD has been suggested asPFM spasm with poor posture and prolonged sitting which can lead tooverflexion ofthecoccyx. Some have described a\"typical pelvic painposture: which ischaracterized by exaggerated lumbar lordosis, anterior pelvic tilt, and thoracic kyphosis, causing sacroiliac pathology.The lumbar and pelvic changes cause thePFM tobestretched orcompressed thus preventing themaintenance ofnormal resting tone, Thiscan lead totrigger point formation and hypertonicity (lukban, 2002).The presence of sacroiliac dysfunction with orwithout thecontribution ofpoor posture may reasonably serve asa trigger for thedevelopment ofHTPFIY Specific presentations ofHTPFD include: i. Coccydynia which ischaracterized by pain localized tothecoccyx, but can include lAand coccygeus muscle spasm. Symptoms include pain localized tothelower sacrum and coccyx. ii. Tension myalgia ofthepelvic floor can cause low back pain and heaviness in theperineum orpelvis aggravated. Prolonged sittingwill aggravate this condition. iii. Coccygeus-levator spasm syndrome has been seen in patients with pelvic floor spasm and \"rectal\" pain with complaints oftenderness at muscular sites adjacent totheischial spines and coccyx, which can include involvement ofmusculofascial, ligamentous, and tendinous structures. iv. levator ani spasm isused todescribe patients exhibiting PFM spasm and tenderness.\" Apredominant symptom isdiscomfort. In patients with interstitial cystitis, levator ani syndrome isreported aspaininthearea ofthebladder and also intheregions ofthesacrum, coccyx, and anus. Itis felt thatthese muscle spasms aretheresult ofbladder pathology, withincreased PFM tone appearing inresponse toafferent autonomic impulses emanating from thebladder wall. muscles centrally (12 o'clock) and each side of the and specific training. Without adequate instruc- urethra (11 o'clock and 1 o'clock), will determine tion, 30% to 50% of women perform them incor- their contractility and symmetry. rectly, potentially worsening the very condition they are intending to prevent or treat/ Assessment ofa PFM Contraction Instruct the woman on how to contract the It is important to realize that when asked to con- PFM by asking her to \"pull in\" or \"lift up\" the tract the PFMs, a woman may use the wrong floor of her vagina or to imagine that she is trying muscles, strain down, or perform a Valsalva to control passing wind or pinching off a stool. maneuver, or fail to activate all layers of the pelvic Confirm by digital palpation that she's perform- musculature. It is known that most women are ing the contraction correctly and can maintain it largely unaware that the PFM exist, and simple while breathing in and out. The same protocol is instruction in technique may not be adequate performed for both the right and left PFM.A very preparation. To be effective, PFM exercises must important part of the physical examination in be performed correctly, which requires careful women is to determine the strength of the PFM. The woman is asked to contract the PFM around TABLE 2.1.3. Pelvic floor muscle tenderness (hypertonus) scale the examiner's fingers with as much force and for as long as she is able. Women are taught the fol- o- nopressure orpain associated with exam lowingthree different types of muscle contrac- tions: (l) Strong maximal contractions, (2) short, 1- comfortable pressureassociated with exam one-second maximum contractions (sometimes 2- uncomfortable pressure associated withexam referred to as \"quick flicks\"), and (3) submaxi- 3- moderate painassociated with exam, intensifieswith contraction mal contractions, which may be sustained for 4- severe pain associated with exam; patient is unable toperform 5 to 10 seconds . It is recommended that both maximal and submaximal PFM contractions contraction maneuver because ofpain should be practiced as part of a home exercise program.16.25.26 Source: Whitmore Ket al.,1998.

2.1. Clinical Evaluation ofthe Pelvic Floor Muscles 97 B FIGURE 2.1.5. (A) Palpation oftheurethra.(8)Assessing elevation oftheurethra during a pelvic floor contraction. (Source: Reproduced from Laycock J,1994.) Observations During a PFM Contraction repeated coughing may cause. At this time, the women should be instructed to contract the PFM Educating women regarding the anatomy and and repeat the cough, to test whether she can workings of the lower urinary and lower gastro- minimize the perineal descent and urine loss. intestinal tracts, including the PFM and sphinc- ters, is important. This is followed by a brief Observations ofExtraneous lesson in contracting the PFMbefore muscle con- Muscle Activity tractility is assessed. During a strong con- tra ction, the main observation is a puckering Muscles rarely work in isolation, and the PFMs and cephalad drawing-in of the vaginal intro- are no exception. Research has shown that the itus, anus, and perineum; a weak contraction abdominal muscles, in particular the transversus may only demonstrate a slight puckering, and abdominis (TrA) muscles, are always recruited some women are unable to produce any move- (contracted in unison) during a PFM maximum ment of the perineum. Observat ion of a down- voluntary contraction (MVC).6 These muscles ward movement suggests that the woman is (PFM and TrA) work in conjunction with the straining and not producing a correct PFM lumbar multifidi muscles and the respiratory dia- contraction. phragm to stabilize the lumbar spine . The impact of a cough on a healthy, strong In light of the difficulty some patients have PFM produces little or no movement, either at the initiating a voluntary PFM contraction,' and the vaginal introitus or the perineum as a whole. In fact that when TrA is contracted the PFMs are some cases, an anticipatory precough PFM con- recruited,\" it has been suggested that patients can traction is noted. On the other hand, a woman be taught to contract the TrA so as to recruit the with a very weak pelvic floor may demonstrate PFMs.9 However, more research is needed before perineal descent, possibly below the level of the traditional PFM exercises are discontinued. \" ischial spines,' and the vaginal introitus may Furthermore, muscles are not recruited if their bulge and gape. There may also be caudal move- activation causes pain, or there is pain in the ment of any prolapse, and urine loss may be region.\" Consequently, pain in the pelvis, pelvic observed. These observations should be relayed floor, pelvic joints, or abdomen may inhibit PFM to the woman so that she is aware of the bulging activity. perineum on coughing and the possible damage

98 D.K. Newman and J. Laycock Contraction of TrA is characterized by a When contracting the PFMs, three criteria of drawing-in of the lower abdomen. When learning muscle strength should be noted: strength, dura- this technique, patients are instructed to avoid tion, and alteration in position. The amount of using other abdominal muscles. Many women pressure or strength of the muscle contraction may have difficulty coordinating the TrAwithout can range from imperceptible to a firm squeeze. contracting the entire abdomen. To avoid holding Duration involves the number of seconds that the the breath while learning this technique, TrA examiner feels the muscle contraction. In a and PFM contraction is initially taught on woman with a well-supported pelvic muscle, the expiration. muscle contraction can lift the base of the exam- iner's fingers. Observations inStanding Assessment ofMuscle Coordination The postural role of the PFM to counteract the pull of gravity and the increase in intraabdomi- Coordination is ascertained by monitoring the nal pressure is often overlooked, and weak ability to contract and relax quickly and slowly; muscles may be unable to give adequate support special attention is paid to the ability to relax in the upright position over a period of time. quickly and completely. Asluggish response indi- Consequently, because stress urinary inconti- cates poor coordination, and this test completes nence (SUI) and POP are more likely to be pro- the digital assessment. The time to maximum voked in the standing position, it is recommended contraction, which can be described as brisk, fair, that the vulva is observed and palpated at rest or sluggish, not only gives a measure of PFM during a PFM contraction and in supine and coordination, it also provides further informa- standing positions on coughing. tion on the fast-twitch fiber capability. This is important because it is thought that the reflex Digital Self-Assessment response of the fast fibers to coughing is the mechanism that maintains continence, by lifting Digital self-assessment is an important part of a the proximal urethra and increasing the urethral pelvic floor re-education regimen and should be occlusive pressure. taught to any woman who is willing and able to perform it, as it can be a useful feedback tech- Use ofScales or Assessment Tools nique for women who are unsure of the correct muscle action. The woman can be taught trans- Digital evaluation of the PFM has been described vaginal palpation with one or two fingers while by several authors, and many have attempted to sitting or standing in the bath or shower, with quantify this assessment through the use of water as a lubricant (gloves are not needed) . Some grading scales or assessment tools. The early women find it easier if the thumb is used; the ones are from nurse researchers in the U.S. distal pad of the thumb is placed over the poste - Worth and colleagues\" described the \"CVM rior vaginal wall, just inside the vagina . Further- Rating Scale,\" a one-to-three scale using a one- more, this technique may help in understanding finger assessment of pressure, duration, muscle pelvic floor activity, as well as in monitoring the \"ribbing\" (tone during contraction), and position progress of a treatment program. (degree of displacement) of the examiner's finger during examination. This scale was adapted from Measurement ofPFM Strength scales to assess orgasmic dysfunction and was tested on 25 women (Table 2.1.4). Interobserver Appropriate training includes the initial exami- and test-retest reliability for this technique was nation, to determine muscle strength and place proved. Brink and colleagues' reported on the the woman at an appropriate level of exercise, \"Pelvic Muscle Rating Scale,\" which is a 1-4 scale and a graduated strength-training protocol using a two-finger assessment of lateral and supported by periodic assessment of muscle anteroposterior pressure, time or duration, and strength.' vertical displacement. This scale was tested in

2.1. Clinical Evaluation ofthe Pelvic Floor Muscles 99 TABLE 2.1.4. The circumvaginal musculature rating scale Pressure Slight Moderate 3 Duration None 3seconds orless Ribbing Muscle feels soft; Muscle feels Firm 4seconds ormore no ribbing different from Muscle feels distinct. Like surrounding tissue Position of Can easily slip out but not very rings ofribbing orribbed examiner's ribbed muscle tissue fingers Remains inthe same position Forcibly gripped orexpelled, finger in upward position Source: Worth AM et al, 1986. 338 noninstitutionalized women with VI. Inter- which is an internationally accepted muscle rater and test-retest reliability for this scale was grading method. However, none of the above also proved. (Table 2.1.5). Confirmation of PFM grading systems is recognized by the Interna- strength was also measured using a vaginal EMG tional Continence Society document on stan- perineometer. There were significant positive dardization of terminology of the PFM, which correlations between the perineometer and recommends the followinglesssubjective grading: digital scores of PFM strength, but also signifi- absent, weak, normal, strong.\" cant relationships with such variables as ability to control urine stream and age. Table 2.1.6 is a Laycock\" developed a notable PFM digital scale modified from the Oxford grading system, assessment tool that uses a 0-5 scale that is repro- ducible and assesses pressure and displacement TABLE 2.1.5. Pelvic Muscle rating scale Dimensions 1 2 3 4 Pressure No response; cannot Weak squeeze felt Moderate squeeze; Strong squeeze; full perceive onfinger asflick at various felt all theway circumference of surface points along finger around finger fingers compressed; surface, not all surface override Duration None theway around Duration None >1 but<3 seconds >3 seconds <1 second Whole length of Whole fingers move Fingertips may move fingered move anteriorly, are anteriorly (pulled up anteriorly gripped and pulled in by muscle bulk) <1second Source: 8rink et al, 1989. TABLE 2.1.6. Pelvic floor muscle assessment ofstrength; the modified \"Oxford Scale\" Grade Description o NiI- lackofany discernible response in theperi-vaginal muscles. 1 Flicker - \"flicker\" describes a fluttering/quivering ofthemuscle. 2 Weak - contraction which isnot fluttering. J Moderate - increase in pressure, compressing the examiner's fingers and incorporating a small degree oflift, asthefingers aremoved ina cranial direction. 4 Good - contraction isfirm causing lifting ofthePFM up and in against resistance. S Strong - impliesa very strong grip oftheexaminer'sfinger and positive movement in a cranial direction againststrong resistance.

100 D.K. Newman and J.Laycock TABLE 2.1.7. The \"P.E.R.F.E.C.T\" Description Scale Measurement P Power (measurement ofstrength) Graded from 0 (no movement) to5 (strong movement) and isbased onthe Oxford grading system. Both slow and fast twitch muscle fibres E Endurance measured in seconds contribute topower. R Number ofRepetitions thata woman Duration oftime (in seconds) thata maximum vaginal contraction can be isable toachieve maintained before a drop of50% ofthestrength (up to lOs) and reflects theactivity oftheslow-twitch muscle fibres. F Number ofFast - 1to2second contractions thatcan beperformed Another way todetermine endurance ofthemuscle istoassess the repetitions ofthemuscle contractions.This isdone by instructing the E Every patient tocontract themuscle for aslong aspossible - say 5seconds, C Contraction then repeat thecontraction asmany times aspossible with 4seconds T Timed rest in between each contraction. Ifthepower ofthecontraction is reduced by 50% ortheholding time decreases, theassessment stops and thenumber ofrepetitions is recorded. Ideally, theprescription for the home exercise program would bebased onthenumber ofrepetitions thatareperformed during thePFMassessment. The contractility ofthefast-twitch fibres isdetermined after two minutes rest, by recording thenumber offast orquick MVCs (1 to2seconds in length) thatthewoman can perform. Thisreminds theexaminer tomonitor progress by timing all contractions. Thismethod equates with general muscle assessment and re-education; for example, after knee surgery, a woman is encouraged tostrengthen her quadriceps muscles, being taught toincrease thehold-time and number ofrepetitions ofa\"straight-leg raise.\" The P.E.R.F.E.C.T. isa mnemonic ofanassessment technique thatcan beused when performing a PFM examination asit supplies data regarding muscle contractility and coordination which can beused when planning a patient-specific exercise programme.\" Source: Adapted from Laycock and Jerwood, 2001.'5 (Table 2.1.7). The P.E.R.F.E.C.T. scheme of PFM methodology may be criticized for its complex- assessment has been validated to verify that the ity, but it is the only reported method of PFM increase in vaginal pressure is caused by contrac- assessment that enables the planning of a patient- tion of the perivaginal muscles, and not a mani- specific exercise program. In its favor, this festation of transmitted abdominal pressure method requires no expensive equipment and is caused by concomitant abdominal muscle con- quick and easy to perform. Table 2.1.8 shows traction. Furthermore, interexaminer and test- examples. retest studies have shown that this digital technique is reliable and reproducible.IS This The use of an assessment tool for documenta- tion on the patient's medical record is advised, TABLE 2.1.8. Examples oftheP.E.R.F.E.C.T. assessment techniques Example Assessment Explanation Comment P/E/R//F P= 4, good contraction This woman can perform five (good) contractions 4/7/5//6 - brisk E= 7, held for 7s lasting 7s,followed by six fast contractions. Every response R= 5, repeated 5times contraction istimed (E.C.T.)and this will beher F= 6,6fast contractions exercise regimen. \"Brisk response\" describes the level ofcoordination. 2 P/E/R/F P= 2, weak contraction This woman can perform two contractions lasting 5s, 2/5/2//3 - sluggish E= 5,held for 5s followed by three fast contractions. Every contraction istimed (E.C.T.)and this isher initial response R= 2,repeated 2times exercise regimen. \"Sluggish response\"describes thepoor coordination when asked tocontract F= 3, 3fast contractions quickly.

2.1. Clinical Evaluation ofthePelvic Floor Muscles 101 TABLE 2.1.9. Clinical scale for grading digital evaluation ofmuscle strength Patient Name Date (CHECK ONE) o VAGINAL EXAM o RECTAL EXAM Scale Grade Description NONE 0 No DURATION OF MUSCLE CONTRACTION, PRESSURE, DISPLACEMENT TRACE RECRUITMENT OF LARGE MUSCLE GROUP (E.G. GLUTEALS, ADDUCTORS, ABDOMINALS WEAK MODERATE 1/5 SLIGHT BUT INSTANT CONTRACTION: <1 SECOND GOOD RECRUITMENT OF LARGE MUSCLE GROUP (E.G. GLUTEALS, ADDUCTORS, ABDOMINALS STRONG 2/5 WEAK CONTRACTION : WITH OR WITHOUT POSTERIOR ELEVATION OF FINGERS, HElD FOR>1 SECOND BUT ~3 SECONDS 3/5 MODERATE CONTRACTION: WITH OR WITHOUT POSTERIOR ElEVATION OF FINGERS, HELD FOR AT LEAST 4-6 SECONDS, REPEATED 3 TIMES 4/5 STRONG CONTRACTION : WITH POSTERIOR ELEVATION OF FINGERS, HElD FOR AT LEAST 7-9 SECONDS, REPEATED 4-5 TIMES 5/5 UNMISTAKABLY STRONG CONTRACTION WITH POSTERIOR ElEVATION OF FINGERS, HELD FOR AT LEAST 10SECONDS, REPEATED >5 TIMES Evaluation - muscle hypertonus/spasm CIRClE ONE: o No PRESSURE, TENDERNESS OR PAIN COMFORTABLE PRESSURE, SLIGHT TENDERNESS BUT BEARABLE 1 UNCOMFORTABLE PRESSURE, SLIGHT PAIN 2 MODERATE PAIN THAT INTENSIFIES WITH MUSCLE CONTRACTION 3 SEVERE PAIN, WOMAN UNABLE TO PERFORM MUSCLE CONTRACTION DUE TO PAIN 4 Comments _ Adapted withpermission from Newman,\" especially in the U.S. Table 2.1.9 is a Clinical Scale 1. Are the muscles morphologically symmetric? for Grading Digital Evaluation of PFM Strength 2. Are there any defects in the muscles, such as that has been used in clinical practice by this author.\" It was developed by combining scales hernias or tears from obstetrical trauma? used in clinical research . It also allows the grading 3. Is there any scarring? of women with pelvic pain and possible muscle 4. What is the strength and bulk (volume) of the spasms, and it is easy to use in a busy clinical practice. muscles? 5. Is there voluntary symmetric contraction? There is a relative paucity of data regarding 6. Does contraction evaluate the bladder neck digital scoring systems in the evaluation of high- tone pelvic floor dysfunction. Most scales seem and anorectal angle? to address a woman's ability to contract her PFM 7. Is there tenderness and pain during the exam- without an assessment of tenderness or impaired relaxation. ination? With a contraction? Initiating a PFM Exercise Program The examiner uses both inspection and palpation to answer these questions. During inspection, Before initiating a course of PFM exercises, clini- when the LA muscle group is healthy, voluntary cal evaluation should be designed to assess the contraction of these muscles results in a pucker- integrity of the PFMand their contractility. Ques- ing and drawing-in of the vaginal introitus, anal tions the examiner should consider during the sphincter, and perineal body. Coughing should examination involve the functional integrity of produce little or no descent of the perineum, in the PFM and include the following: either the supine or standing position. In the woman whose LA muscle function is com- promised, voluntary contraction may produce minimal puckering or no movement at all. Coughing when levator muscle function is

102 O.K. Newman and J.Laycock compromised produces perineal descent and terbalancing upward (cephalic) force by lifting gaping of the vaginal introitus with accompany- the endopelvic fascia, on which the urethra rests , ing POP.The standing position may be necessary and pressing it upward toward the pubic symphy- to demonstrate the full extent of prolapse and sis, creating a mechanical pressure rise. perineal descent. 3. Muscle contraction causes a pelvic muscle Other aspects of PFM function that can be \"reflex\" contraction that precedes increased evaluated include coordination and reflex bladder pressure and may inhibit bladder overac- response. A woman with a healthy functioning tivity. The aim is to acquire learned reflex pelvic floor should be able to contract and relax activity. the pelvic floor both quickly and slowly on command. An increase in intraabdominal pres- Use ofInstrumentation sure should result in a reflex contraction of the PFM that can be observed at the introitus and In order to re-educate a muscle or muscle group, palpated digitally,\" it is first necessary to evaluate the state of the muscle at rest and during a maximum voluntary PFM Rehabilitation or Training contraction (MVC). Generally, muscle evaluation involves (1) inspection, (2) palpation and then (3) The actual effects of PMEs on lower urinary tract testing the muscles, with some method of stan- function are not completely understood. Some dardized recording to allow comparison of studies show a relationship between changes in clinical data before and after treatment; this various measures of pelvic floor strength, such as methodology also applies to the PFM. anal sphincter strength or increased urethral closure pressure and resistance, all of which will Instrumentation that objectively measures the prevent urine leakage. Kegel introduced PFM PFM can be used to validate the digital examina- exercises through the implementation of a com- tion and was first described by Kegel, who devel- prehensive program of progressive or maximal oped and used a vaginal perineonmeter that contractions of the LA muscle that incorporated utilized pressure (manometry) for measurement. biofeedback technology and was under direct Traditionally, this device consisted of an air- supervision of a trained nurse. \" The proposed filled vaginal pressure probe connected to a mechanisms of action for PMEs are that: manometer that registered changes in pressure caused by a contraction of the perivaginal 1. A strong and fast pelvic muscle contraction muscles.F'\" and it is used to measure the strength closes the urethra and increases urethral pres - of the PFM, as well as for biofeedback. The peri- sure to prevent leakage during sudden increase neometer can, thus, provide objective informa- in intraabdominal pressure (e.g., during a tion regarding the strength of the PFM. However, cough).\" :\" Urethral compression can be maxi- care must be taken to ensure that the pressure mized by timing the muscle contraction at the increase is caused by a PFM contraction and not exact moment of intraabdominal force (called the transmitted abdominal pressure. This is most \"Knack,,).20-22 It refers to the skill of consciously easily done by observing a drawing-in of the peri- timing a PFM contraction just before and during neometer during a PFM contraction and palpat- the intraabdominal pressure rise associated with ing the abdominal muscles. a predictable stressful activity, such as a cough . A woman should practice the Knack by contract- Most clinicians who specialize in this field ing her PFM about 1 second before a hard cough prefer EMG measurements.\" Electromyography and maintaining the contraction throughout the is the recording of the electrical activity of a cough . muscle and is a practical indicator of muscle activity which has been defined as: 2. Rising intraabdominal pressure (e.g, during coughing, laughing, or sneezing) exerts a down- • The study of electrical potentials generated by ward (caudal) pressure or force on the bladder the depolarization of muscle. and urethra. Contraction of the LAexerts a coun- • A monitor of bioelectrical activity correlating to motor unit activity; it does not measure the

2.1. Clinical Evaluation ofthe Pelvic Floor Muscles 103 muscle contractility itself, but the electrical Monitoring Therapy correlate of the muscle contraction. • An indicator of the physiological activity. As a pelvic floor re-education program may last up to six months, it is important to monitor the The advantage ofEMG over manometric pressure effect of therapy by regular reassessment of both is that, provided the machinery is of sufficient the PFM and the severity and frequency of pelvic sophistication with adequate filtering, the EMG floor symptoms. However, many patients are apparatus can engage the use of the newer types unable to attend a hospital/clinic on a regular of electrodes that are lightweight and designed to basis because of work and family commitments. stay in place, hence, allowing more functional Monthly completion of a bladder diary (fre- positions during assessment and treatment.\" quency/volume chart) and encouragement to continue with the exercise regimen should be tai- Weighted cones may also be used as an adjunct lored to resources and patient's needs . assessment tool, being the measure of the weight a subject can retain in the vagina while standing. References It is generally accepted that as the muscle strength increases, heavier cones can be retained, thus 1. Bourcier AP, Juras JC, Villet RM. Office evalua- improving the symptoms ofSUI. 27 The disadvan- tion and physical examination. In: Bourcier AP, tage of this method lies in the varying vaginal McGuire EJ, and Abrams P, editors. Pelvic Floor diameters and amount of mucous present, which Disorders. Philadelphia: Elsevier Saunders, 2004; will influence the initial cone assessment. 133-148. Other Assessment Methods 2. Brink C, Sampselle C, Wells T, et al. A digital test for pelvic muscle strength in older women with Further methods of assessment of incontinence urinary incontinence. Nurs Res. 1989;38(4):196- and pelvic floor strength include the stress test; 199. SUI is a condition in which increased intra- abdominal pressure transmitted to the bladder 3. Lukban JC, Whitmore KE. Pelvic floor muscle re- (e.g., during coughing or jumping) exceeds intra- education treatment of the overactive bladder and urethral pressure, resulting in urine loss. It is painful bladder syndrome. Clin Obstet Gynecol. generally accepted that urinary leakage is more 2002;45:273-285. likely to occur with increasing volumes of urine in the bladder. The stress test is devised as a self- 4. Miller J, Kasper C, Sampselle C. Review of muscle test for patients to monitor their own progress physiology with application to pelvic muscle exer- and to set targets for improvement. An example cise. Urol Nurs. 1994;14(3):92-97. would be to aim to perform five coughs or five jumping jacks (jumping and landing with the 5. Parks AG, Porter NM, Hardcastle JD. The syn- arms and legs apart) with a full bladder (assum- drome of the descend ing perineum. Proc Royal ing this to be impossible at the beginning of Soc Med. 1966;59:477-482. treatment). The patient starts by carrying out five coughs (or jumping jacks) 10 minutes after emp- 6. Neumann P, Gill V. Pelvic floor and abdominal tying the bladder, and gradually (over several muscle interaction: EMG activity and intra- weeks) increases the time between voiding and abdominal pressure. Int Urogynecol J. 2002;13: coughing (or jumping jacks), providing there is 125-132. no urine loss, until she can reach her target. The numbers/activities will need modification for 7. Bump RC, Hurt WG, Fantl A, et al. Assessment of individual patients, to provide a challenge with- Kegel pelvic muscle exercise performance after out setting impossible goals. The \"Stop Test,\" brie f verbal instruction. Am J Obstet Gynecol. instructing patients to stop and start the flow of 1999;165:322-329. urine, is discouraged because of possible harmful effects / 8. Hulme , JA. Research in geriatric urinary inconti- nence: Pelvic muscle force field. Top Geriatric Rehabil. 2000;16(1):10-21. 9. Sapsford R. The pelvic floor. A clinical model for function and rehabilitation. Physiotherapy. 2001; 87:620 - 6 3 0 . 10. Bo K. Pelvic floor muscle training is effective in treatment of stress urinary incontinence, but how does it work? Int Urogynecol J. 2004;15(2):76-84.

104 D.K. Newman and J.Laycock 11. Hodges PW, Richardson CA. Inefficient muscular incontinence. Am I Obstet Gynaecol. 177:536- stabilization of the lumbar spine associated with low back pain. Spine. 21;22:2640-2650. 540. 24. Shepherd AM, Montgomery E, Anderson RS. 12. Worth AM, Dougherty MC, McKey PL. Develop- ment and testing of the circumvaginal muscles Treatment of genuine stress incontinence with a rating scale. Nurs Res. 1986;35(3):166-168. new perineometer. Physiotherapy. 1983;69:13. 25. Newman DK. Behavioral treatments. In: Vasavada 13. Messelink B, et al. The standardisation of termi- SP, Appell RA, Sand PK, et al., editors. Female nology of pelvic floor muscle function and dys- urology. Urogynecology and voiding dysfunction. function. Report from the pelvic floor clinical New York: Marcel Dekker; 233-266. assessment group of the International Continence 26. Newman DK. Clinical Manual for Pelvic Muscle Society (ICS). Neurourol Urodyn 2005:24;374-380. Rehabilitation. Dover, NH. Prometheus, Inc; 2003: 89-98. 14. Laycock J. Pelvic muscles exercises: physiotherapy for the pelvic floor. Urol Nurs. 14(3);136-140. 27. Peattie AE, Plevnik S, and Stanton SL. Vaginal cones; a conservative method of treating genuine 15. Laycock J, Jerwood D. Pelvic floor assessment; the PERFECT scheme. Physiotherapy. 2001;87(12): stress incontinence. Br I Obstet Gynaecol. 1988; 631-642. 95:1049-1053. 16. Newman DK. Managing and treating urinary 28. Peschers UM,DeLanceyIOL. Anatomy. In: Laycock incontinence. Baltimore: Health Professions Press; 2002. I, Haslam I, editors. Therapeutic management of 17. Kegel AH. Physiologic therapy for urinary incon- incontinence and pelvic pain. London: Springer- tinence. JAMA. 1951;146:915-917. Verlag; 2002:7-16. 29. Ashton-Miller lA, Howard D, DeLancey IOL. The 18. Theofrastous JP, Wyman JF, Bump RC, et al. functional anatomy of the female pelvic floor and Effects of pelvic floor muscle training on strength and predictors of response in the treatment of stress continence control system . Scand I Urol urinary incontinence in women. Neurourol Urodyn . 2002;21:486-490. NephroI2001;207:1-7. 30. Allen RE, Hosker GL, Smith ARB, Warrel DW. 19. Bo K, Talseth T. Change in urethral pressure during voluntary pelvic floor muscle contraction Pelvic floor damage and childbirth: A neurophysi- and vaginal electrical stimulation. Int Urogynecol J. 1997;8:3-7. ological study. Br I Obstet Gynaecol. 1990;97:770- 20. Miller JM. Criteria for therapeutic use of pelvic 779. floor muscle training in women. IWOCN. 2002; 31. Smith ARB, Hosker GL, Warrell DW. The role of 29(6):301-31l. partial denervation of the pelvic floor in the aetiol- 21. Miller JM, Perucchini D, Carchidi L, DeLancey ogy of genitourinary prolapse and stress inconti- JOL, Ashton-Miller JA. (2001) Pelvic floor muscle contraction during a cough and decreased vesical nence of urine. A neurophysiological study. Br I neck mobility. Obstet Gynecol. 97(2):255-260. Obstet Gynaecol. 1989;96(l):24-28. 22. Miller J, Aston-Miller J, DeLancey J. (1996) The 32. Oyama lA, RejbaA,Lukban IC, et al. Modified thiele Knack: Use of precisely-timed pelvic muscle con- traction can reduce leakage in SUI.Neurol Urodyn. massage as therapeutic intervention for female 15:302-393. patients with interstitial cystitis and high-tone pelvic floor dysfunction. Ural. 2004;64(5):862-865. 23. Brubaker L, Benson JT, Bent A, et al. (1997)Trans- vaginal electrical stimulation for female urinary 33. Lilius HG, Oravisto KI,Valtonen EI. Origin of pain in interstitial cystitis. Scand I Urol Nephrol. 1973; 7:150-152. 34. Whitmore K, Kellog-Spradt S, and Fletcher E. Comprehensive assessment of pelvic floor dys- function. Issues in Incontinence. 1998:1-10.

2.2 Examination of Patients with Pelvic Organ Prolapse Ursula M. Peschers Examination of POP should aim at reproduc- assessment are necessary in order to come to a ing a patient's own observation. Assessment definitive prolapse diagnosis allowing for specific should separate between quality (which organ treatment. Qualitative assessment is based on is prolapsedi) and quantity (what is the extenti) carefully clinical examination, followed by of POP. The ICS prolapse staging system is a imaging techniques (see Ultrasound, MRI) and validated and necessary tool for any studies in some cases final diagnosis reveals only during on the treatment of POP. POP stage I and II surgery. are very common in women after vaginal childbirth and very rarely are the origin of A variety of classifications of POP are in use . symptoms. To precisely describe the degree of POP the Inter- national Continence Society published a system Pelvic organ prolapse (POP) might cause a variety of quantitative description of POP.2 This systems of urogynecological problems. While some allows to measure the degree of prolapse exactly women simply have the feeling of a bulge pro- and to give an exact descriptions of its amount. truding out of the vagina and causing discomfort The interobserver and intraobserver reliability of while sitting others cannot empty the bladder the classification system has been shown.Y or the bowel completely or have symptoms of urinary or anal incontinence. It has to be kept in Systematic classification is important as it mind, however, that stages less than grade II in allows to measure and to compare the success of the ICS prolapse staging system normally do not different treatment options including physio- cause specific symptoms.' therapy for POP. Patients with prolapse have defective pelvic Conditions of Examination support allowing the vagina and the uterus to descent below their normal position. The organs The examiner should see and describe the lying directly adjacent to the virgina (the bladder maximum protrusion noted by the individual and the rectum) follow the vagina downwards. during her daily activities. If in doubt the patient Traditionally the organ that is lying next to the herself may be the best witness to decide on the part of the vagina that has prolapsed names the maximal descent by the help of a handhold prolapse, e.g. in case of anterior vaginal wall pro- mirror. Usually the prolapse descends more in lapse this is called a cystocele. Qualitative (which the standing position. The bladder should be is the prolapsed organ behind the vaginal walli) empty because otherwise the patient might and quantitative (how much prolapse is itl) hesitate to strain for fear of leaking urine. A pair of separated vaginal specula should be used to investigate one compartment of the vagina while the others are reduced by the speculum. lOS

106 U.M. Peschers sponds to the insertation of the uterosacral ligaments. If the cervix is elongated a large difference between e and D will be found. Point D is not applicable for patients after hysterectomy. • Posterior compartment: (Point Ap and Bp): posterior vaginal wall. Point Ap corresponds to the position of Aa but there is no anatomical landmark on the posterior vaginal wall. By definition Ap is located at -3 ern in a patient without prolapse of the posterior vaginal wall and its maximum protusion is +3 cm. Point Bp is the most distal part of the posterior vaginal wall between Ap and the cervix or the vaginal pb cuff. FIGURE 2.2.1. Quantative description of pelvic organ position. Additionally the total vaginal length (tvl), and gh= genital hiatus;VA = vagina; RE= rectum; pb= perineal body. the size of the genital hiatus (gh) and of the The description forthemeasurement points Aa, Ba, C, D, Bp, and perineal body (pb) are measured. The measure- Ap isfound in Chapter 1.6. ment of the lengths do not have minus or plus attached. Quantitative Description of Pelvic Organ Position (Fig. 2.2.1) The Ies recommends recording the position of the points and the lengths in a simple 3 by 3 box. The vagina contains three compartments. Each However, introducing each measured point into compartment has one or two points whose posi- a special grid has rendered both: Simple and easy tion has to be measured. The maximum protru- communicative. (see Figs. 2.2.2-2.2.5). sion of each compartment has to be evaluated while the other compartments are held back with Stages are assigned according to the most speculum: severe portion of the prolapse when the full extend to the protrusion has been demonstrated. • Anterior compartment (Point Aa and Ba): anterior vaginal wall with the adjecent organs Stage 0: No prolapse. urethra, bladder neck and the bladder. Aa cor- Stage I: The most distal part of prolapse is >1 ern responds to the bladder neck and is usually easily identified by the urethrovesical crease on above the level of the hymen. From a clinical the anterior vaginal wall, 3 cm from the outer point of view stage I prolapse is not a patho- meatus. By definition Aa is always located in a logic condtion. range from -3 em to +3 em from the hymen . Ba represents the most distal part of the anterior Measurement -3Aa -3 8a -8e vaginal wall between Aa (corresponding to the bladder neck) and the cervix or the vaginal 4 oh 3 Db 1° tvl cuff. In a patient without prolapse Ba is located -3Ao -3 80 -10D at -3 em, Graphical diagram • Middle compartment: (Point e and D): cervix 10 8 6 4 2 0 -2 -4 -6 -8 -10 or vaginal cuff (after hysterectomy), posterior fornix. In patients with a uterus Point D corre- G·... ... ,/ 10 8 6 4 2 0 -2 -4 -6 -8 -10 FIGURE 2.2.2. From Viereck etal.,Geburtsh. u.Frauenheilk. 1997; 57:177-182, Abb. 2a, p. 179.

2.2. Examination of Patients with Pelvic Organ Prolapse 107 Stage II: The most distal part of prolapse is located Measurement e+3Aa +5Sa -2 between -1 em and +1 ern. Clinically stage II leads to symptoms very rarely. 5 ah 2 ob 7.5tv1 Stage III: The most distal part of prolapse is -3Ac -2 So - D located at more than +1 cm beyond the hymen but protrudes no further than the total vaginal Graphical diagram length minus 2 ern. 10 8 6 4 2 o -2 -4 -6 -8 -10 Stage IV: Prolapse further than stage III. 1/ ~ The following letter qualifiers name the leading part of the prolapse: r...... a = anterior vaginal wall 10 8 6 4 2 0 -2 -4 -6 -8 -10 p = posterior vaginal wall C = vaginal cuff FIGURE 2.2.4. From Viereck etal., Geburtsh. u.Frauenheilk. 1997; Cx = Cervix 57:177-182, Abb. 3a, p.180. Even though the ICS classification for POP seems anterior and posterior vaginal wall (Points Ba to be complicated it has been shown that it is easy and Bp) and the vaginal cuff (Point C) are to use after a while. Studies regarding the treat- found 8 em beyond the hymen (+8). The total ment of POP should always include the ICS vaginal length (tvl) is 9 cm. Tvl (9) minus classification. maximum prolapsed point (8) results into 1. Staging: Grade IV. The following four examples demonstrate how Patient # 3: A patient presents with prolapse of to apply the staging system: the anterior vaginal wall after hysterectomy. The vaginal cuff does not prolapse beyond the Patient # 1: Normal anatomy, no prolapse. The hymen. Aa is located at +3 ern. Ba is protruding points Aa, Ba, Ap, and Bp are all located at further to +5 ern and is the leading part of the -3 ern because there is no prolapse of the ante- prolapse. C is found inside the vagina at -2 ern. rior and the posterior vaginal wall. The cervix The total vaginal length is 7.5 ern, is located 8 ern above the hymen (C = -8) and Point D (insertion of the sacrouterine liga- tvl (7.5) minus Ba (5) = 2.5. Staging: Grade ments 10cm above the hymen (D = -10). The IlIa. vaginal length is 10 em, the genital hiatus 4 ern Patient # 4: Prolapse of the posterior vaginal wall and the perineal body 3 ern. Staging: Grade O. after hysterectomy. The anterior vaginal wall (Aa and Ba at -3) and the vaginal cuff (C at -6) Patient # 2: A patient presents with total protru- do not descend. The leading point of the pro- sion of the vaginal cuff after hysterectomy. lapse is Bp 4 ern beyond the hymen. The total Point Aa and Ap are located at their maximum vaginal length is 4 em. position at +3 ern. The most distal parts of the tvt (7) minus Bp (4) = 3. Staging: Grade I1Ip. Measurement +3Aa +8ga +Bc Measurement e-3Aa -3Sa -6 5 ah 2 ob 9 tvl 5 ah 2 ob 7tv1 +3Ac +8go - D +2Ac +4so - D Graphical diagram Graphical diagram 10 8 6 4 2 0 -2 -4 -6 -8 ·10 10 8 6 4 2 0 -2 -4 -6 -8 -10 I ..... t 10 8 6 4 2 0 -2 -4 -6 -8 -10 10 8 6 4 2 0 -2 -4 -6 -8 -10 FIGURE 2.2.3. From Viereck etal.,Geburtsh.u. Frauenheilk. 1997; FIGURE 2.2.5. From Viereck etal, Geburtsh. u. Frauenheilk. 1997; 57:177-182, Abb. 2b, p.179. 57:177-182, Abb. 3b, p.180.

108 U.M. Peschers References 3. Hall AF, Theofrastous JP, Cundiff GW, Harris RL, Hamilton LF, Swift SE, Bump RC. Interobserver 1. Swift S, Woodman P, O'Bogle A, Kahn M, Valley M, and intraobserver reliability of the proposed Bland J, Wang W, Schaffer J. Pelvic organ support International Continence Society, Society of study (POSST): The distribution clinical definition Gynecologic Surgeons, and American Urogyneco - and epidemiologic concition of pelvic organ support logic Society pelvic organ prolapse classification defects. Am J Obstet Gynecol 2005;1992:795-802. system. Am J Obstet Gynecol 1996;175:1467-1470; discussion 1470-1471. 2. Bump RC, Mattiasson A, Bo K, Brubaker LP, DeLancey JO, Klarskov P, et al. The standardization 4. Viereck V, Peschers U, Singer M, Schuessler B. of terminology of female pelvic organ prolapse and Metrische Quantifizierung des weiblichen Genital- pelvic floor dysfunction. Am J Obstet Gynecol prolapses: Eine sinnvolle Neuerung in der Prolaps- 1996;175:10-17. diagnostik? Geburtsh Frauenheilk 1997;57:177-182.

2.3 Urodynamics Ursula M. Peschers Key Message • if voiding problems are present • if at least 2 months conservative treatment did Not every woman with urinary incontinence needs urodynamic testing before physiotherapy. not improve symptoms Nevertheless, a physiotherapist should be famil- • before any planned continence surgery iar with the purpose and technique of urodynam- • after failed incontinence surgery. ics for several reasons: Urodynamic Techniques: Definitions 1. To understand normal function and patho- and Technical Performance physiology of the lower urinary tract based on urodynamic investigation. The International Continence Society has pub- lished several papers to standardize definitions 2. To understand when urodynamic studies are and measurement techniques.':\" necessary. Urodynamics can be used to evaluate lower 3. To understand that urodynamic results may urinary tract symptoms and signs of lower help to improve physiotherapy in certain urinary tract dysfunction. patients. Lower urinary tract symptoms include the This chapter summarizes the indications for uro- following : dynamic evaluation, introduces the basics of this technique, and shows typical patient profiles and • storage symptoms (increased daytime fre- their corresponding urodynamic traces. quency, nocturia, urgency, stress urinary in- continence, urge urinary incontinence, mixed Indications urinary incontinence, noctural enuresis, and other types of incontinence and bladder Many patients present to the urogynecology sensation) clinic with unclear symptoms. Ideally, urody- namics should reproduce the patient's symptoms • voiding symptoms (slow stream, splitting and under controlled conditions. However, reality spraying, intermittent stream, hesitancy, strain- shows that this is not always possible. Therefore, ing, terminal dribble) and post micturition urodynamic investigations cannot substitute for symptoms (incomplete emptying, post mictu- a thorough patient history and a good physical rition dribble) examination. Conventional urodynamic studies are performed Patients should undergo urodynamics in the urodynamic laboratory. They involve artifi- cial filling of the bladder via a catheter with a • if history and physical examination do not lead specified liquid at a specified filling rate and to a diagnosis temperature (Fig. 2.3.1, A and B). In contrast, 109

110 U.M. Peschers Urodynamic studies provide information about the storage function of the bladder (fill- ing cystometry or cystometrogram [CMG]), the voiding function (uroflowmetry, pressure-flow studies), and the function of the urethra (urethral pressure measurement/profilometry, leak point pressure measurements). Bladder filling with contrast medium allows for simultaneous fluoro- scopic imaging of bladder filling and voiding. Electromyographic (EMG) studies of the pelvic floor muscles (with surface electrodes) or of the urethral sphincter muscle (with needle or wire electrodes) can be added. Uroflowmetry A Voiding is the result of opening of the outlet (relaxation of the urethra and the pelvic floor B =-~ muscles) and an increase of pressure from above (the detrusor). An obstructed outlet or a FIGURE 2.3.1. (A)Urodynamic lab withapatient insupine position weak detrusor pressure or contraction of under investigation. (8) The pressure lines are in bladder/urethra the pelvic floor leads to pathological voiding and arectal catheter forabdominal pressure measurement as well patterns. as asurface electrode forpelvic floor muscle recording. Uroflowmetry is a simple, noninvasive test that ambulatoryurodynamics studies the lowerurinary measures and plots the amount of voided urine tract during natural filling, while the patient is (y axis) per time unit (x axis) in milliliters per engaged in every day activities. Todate, this test is second while the patient sits on a micturition not adequately validated and rarely used and, thus, chair. The voided volume, the voiding time, the will not be described in this chapter. average flow rate, and the maximum flow Qmax should be recorded (Fig. 2.3.2). For women, a peak flow rate (Qmax) of 15-20 mlls is regarded as normal. As Qmax is dependent on the voided volume, a minimal bladder volume of 150ml is recommended. Even in normals, flow curves differ individu- ally, as well as in the same person, depending on several factors (e.g., bladder filling, degree of abdominal pressure, contractile status of the pelvic floor muscle). A normal detrusor contraction combined with a normal bladder outlet results in a smooth, arc- shaped flow rate curve with high amplitude. A flattened asymmetric curve with a slow- declining end part might be caused by obstruc- tion (e.g., after continence surgery or in women with a neuropathic pelvic floor) or from a weak detrusor. If women void by straining only, a typical interrupted flow pattern is resulting (see patient example # 4 and Fig. 2.3.7).

2.3. Urodynamics 111 FIGURE 2.3.2. Urine flow curve and its Maximum flow rate description terminology. (Source: Cardozo and Staskin, 2001.) o Average o flow rate o o o o o o o o ·-t,----- --- o ,,o ·o ,o o iL T :L_Maxim_um flow rate I Flow time Filling Cystometry and Pressure • First desire to void, which is the feeling that Flow Studies the patient would pass urine if conveniently possible, but that voiding could still be Filling cystometry and pressure-flow studies are postponed. invasive procedures that involve artificial filling of the bladder. During filling, the detrusor pres- • Strong desire to void, which is defined as a per - sure (y axis) is constantly monitored and plotted sistent desire to void without fear of leakage. against the filled volume (x axis). • Maximum cystometric capacity, which is As the pressure generated by the detrusor reached when the patient has a very strong urge muscle cannot be measured directly, the in- to void and can no longer delay micturition. travesical pressure (Pves) is measured with an intravesical probe, intraabdominal pressure is • Bladder compliance, which describes the rela- measured with an intrarectal probe, and the tionship between change in bladder volume detrusor pressure (Pdet) is calculated by subtract- and change in detrusor pressure (rnl/cm H20). ing pabd from Pves (Fig. 2.3.1 B). During voiding, Compliance is reduced if the bladder is unable the flow curve is plotted parallel to the detrusor to stretch during filling (e.g., after radiation or pressure. radical pelvic surgery). This leads to a steady increase in intravesical pressure. Pressure can be measured either by fluid filled lines connected to external pressure transducers • Normal detrusor function, which is present or by pressure transducers mounted on a catheter when there is no or little increase in bladder (microtip transducers). The equipment should pressure during bladder filling. No involuntary include at least three measurement channels (two phasic contractions should occur despite prov- for pressure, one for flow), a display (monitor or ocation tests (e.g., coughing). printer), and secure storage of three pressures (Pabd' P vess Pdet) and flow (Q) as tracings against Spontaneous or provoked involuntary detrusor time. contraction during the filling phase is defined as detrusor hyperactivity. If the patient leaks urine Several landmarks are necessary for the inter- during a sudden increase of abdominal pressure pretation of results, as follows: in the absence of the detrusor contraction (e.g., a cough) this is defined as urodynamic stress • First sensation, which occurs when the patient incontinence. first becomes aware of the filling. Pressure-flow studies allow examiners to determine detrusor function during voiding

112 U.M. Peschers Abdominal Abdominal Abdominal Maximum pressure opening pressure at abdominal (em H20) pressure maximum flow pressure Intravesical ~ pressure Pabd cont (em H20) Intravesical maximum flow Detrusal pressure opening Intravesical pressure (em H20) pre~u:::;r;;;;e~~~a,tm.... aximum flow Flow rate t (mU s) Maximum Intravesical intravesical contraction pressure pressure at IDetrusor mlaximum flow opening Detrusor pressure pressure at maximum flow FIGURE 2.3.3. Example ofa pressurelflow recording during filling AP, McGuire EJ, Abrams P: Pelvic floor disorders. Philadelphia: and micturition. (Nomenclature as recommended by the Inter- Elsevier Saunders; 2004: 205. With permission from Elsevier.) national Continence Society.) (Source: adaptation from Bourcier by measuring flow and voiding pressure at the 3. Detrusor-urethral or pelvic floor dyssynergia, same time. which is uncoordinated detrusor contraction and pelvic floor/urethral muscle relaxation. The same equipment is used as for uroflow and filling cystometry. After filling the bladder to Urethral Pressure Measurement maximum capacity, the patient attempts to void with the intravesical and the intrarectal catheter Understanding urethral function is important to still in place. Two pressures (Pabd' Pves) and the the investigation of stress incontinence. Urethral flow (Q) are recorded. The detrusor pressure Pdft pressure is the pressure needed to open a closed is calculated simultaneously (Figs. 2.3.2 and (collapsed) urethra. The measurements are prone 2.3.3; see Chapter 1.5). to artifacts caused by the catheters (stiffness, direction of the tip) and by the patient (move- Pressure-flow studies are not required in ment, etc.). women with stress urinary incontinence unless pathological micturition (e.g., residual urine or The urethral closure pressure profile is a graph reduced uroflow) is present; this is to distinguish indicating the pressure along the length of the between three main causes: urethra (urethral pressure profile) (Fig. 2.3.4, A and B). It is calculated by subtracting the inter- 1. Intravesical obstruction 2. Weak detrusor function (hypocontractile or acontractile detrusor)

2.3. Urodynamics 113 FIGURE 2.3.4. (AI Schematic drawing ur hral pr tran du r (pure) ofthe technique for urethral pressure measurement. Apuller device is retract- tran uc r (p ) ing the catheter with the pressure transducer at constant speed through A the urethra, registrating the pressures alongside theurethra while atthesame time intravesical pressure is measured. Subtracting Pm from Pura is theurethral closure pressure Pelo, (AI. (Source: reprinted from Cardozo and Staskin, 2001.) (8) Urethral pressure profile trace at rest and its description termi- nology according to ICS definition. 8 vesical pressure (PVt,) from the intraurethral and relaxation of the levator ani to a decrease, in pressure (Pur.)' Both pressures are measured by a urethral pressure. ' A constant pelvic muscle con- transducer, one constantly lying in the bladder traction results in an abnormally high urethral (Pves), while the other is withdrawn with constant pressure. If the urethral connection to the pelvic speed (1mm/s) alongside the urethra (pur.), either floor muscles is damaged (e.g., by childbirth), at rest or during physical stress (stress profile). contraction of these muscles are unable to The maximum urethral closure pressure (MUCP) increase the intraurethral pressure. is age dependent and its normal range is between 50 and 80em H20 . AMUCPof <20 H20 is regarded During coughing, the pressure transmission as a low-pressure urethra.' The functional ure- ratio can be determined; it is the increment in thral length is the length of the urethra, along urethral pressure on stress as a percentage of the which urethral pressure exceeds intravesical simultaneously recorded increment in intra- pressure. vesical pressure. Stress urinary incontinence is ideally represented when the closure pressure In women with normal pelvic floor anatomy, equals 0 em H20 during every cough alongside the the urethra is connected to the levator ani muscle urethra (see Patient # 2; Fig. 2.3.6 B). It has to be by connective tissue (see chapter 1.1). Contrac- understood that the stress profile is very often tion of the levator ani muscle leads to an increase, subjected to artifacts.

114 U.M. Peschers Leak Point Pressure comitant contraction of the striated urethral sphincter,\" The abdominal leak point pressure is the minimum intravesical pressure at which leakage Her cough stress profile (Fig. 2.3.5 C) shows a occurs because of increased intrave sical pressure positive pressure transmission onto the urethra in the absence of a detrusor contraction. It is during coughing, indicating that there might be commonly performed by letting the patient cough also reflex activity present within the striated or strain with a full bladder (300ml) until leakage sphincter muscle and/or the pelvic floor muscle. occurs. Although the examination technique is widely used, there is still no standardization on During filling cystometry (Fig. 2.3.5 D) the how to measure this pressure. detrusor pressure remains stable despite provo- cational coughs. AValsalva maneuver at a bladder As it is known that the cough leak point pres- filling of 300ml with a pressure increase of 80 cm sure is significantly higher than the Valsalva leak H20 does not lead to urinary leakage, also indi - point pressure, it should be stated which maneu- cating the intactness of the sphincter mechanism. ver is used to provoke leakage.\" Additionally the Maximum bladder capacity normally exceeds size of the intravesical catheter/ its position 400ml. Compliance is unmeasurably low because (intravesical or intravaginal), and the bladder of the failure of an increase in detrusor pressure volume't\" have a significant influence on the during filling up to 400ml. results. Also, it is likely that the leak point pres- sure is higher if the patient contracts the pelvic Patient # 2: Stress-Incontinent Woman floor muscles. A 34-year-old woman who has undergone three Typical Case Examples vaginal deliveries. No previous pelvic surgery. During examination no significant prolapse can Patient # 1:The Continent Woman with be found. She is hardly able to contract her pelvic Normal Voiding floor muscles. She describes symptoms of stress urinary incontinence and denies any urgency. A 20-year-old nulliparous woman with no incon- With the bladder almost empty she leaks while tinence symptoms and is able to contract her coughing and straining in the supine position. pelvic floor muscles voluntarily. There is no pelvic organ descent, nor prior pelvic surgery. During urodynamics she has a normal voiding pattern and a normal filling cystometry (see The patient is able to void normally (Fig. 2.3.5 patient #1). A). The flowchart is bell-shaped with final spikes (arrows), indicating additional abdominal strain. Figure 2.3.6 a shows the urethral pressure mea- surement at rest. Her maximum flow rate (Qrnax)is 25.7ml/s, and her voided volume is 353ml. She is able to volun- Her MUCP is 14mm H20 , her functional ure- tarily interrupt her urine flow (arrow) during thral length is 23em. Active contraction of the micturition with the help of a pelvic floor muscle PFR does not increase urethral closure pressure, contraction (Fig. 2.3.5 A). indicating either an inability to contract the pelvic floor muscle or damage to its connection Her urethral pressure profile at rest shows with the urethra. The very low urethral closure a MUCP of 72ern H20 (Fig. 2.3.5 B). The high pressure «20cm H20 ), together with a cough pressure measured indicates the intactness of leak point pressure of 43ern H20 , indicates intrin- the intrinsic urethral closure mechanism. sic urethral insufficiency, a condition in which However, it could also indicate that her pelvic denervation or defects within the sphincter unit, floor is not completely relaxed because of the rather than hypermobility of the urethra, is the urodynamic examination. Active contraction primary cause of stress urinary incontinence.. of the PFM increases the pressure (Fig. 2.3.5 B). This condition is generally difficult to treat with This shows that the pelvic floor is able to influ- physiotherapy. ence the sphincter unit with or without a con- The stress profile shows a negative closure pressure along side the length of the urethra (Fig. 2.3.6 B) representing the absence of any closure

2.3. Urodynamics 11S Uroflow w ith abdominal and pelvic floor EMG (SlectroMyo§ramm) abdominal straining Volume (ml) II •• Flow (mVs) •I voluntary stop of micturition EMG of pelvic floor muscles 20 30 Time (s) EMG of abdominal muscles ~ Muscles relaxed A o 10 ~ Muscles in action Urethral closure pressure profile at rest l.CFRJO I..O'Rnax _ A- _ I LCPR70 J) nm 0 I N -~ / t /i is \"tI 0. 0 5 10 1'5 20 25 with pe lvic floor mu scles max imally contracted LCPR70 A- II o 1 .:Ng 1 .\"g 0. 5(} o 5 10 15 mm B FIGURE 2.3.5. (A) Uroflowmetry. Urine flow pattern in a normal traction to interrupt midstream. (8) Urethral closure pressure female. Arrows pointing down indicate straining episodes in order profile (at rest): Pelvic floor muscle completely relaxed (upper tospeed up urine flow attheend ofmicturiton. Voluntary inter- curve). Maximal pelvic floor muscle contraction during measure- ruption of the urine stream by contraction of the pelvic floor ments leads toa typical sharp increase in closure pressure atthe muscle indicated by an arrow pointing up. EMG tracing indicates inner third of the urethra (arrow) clearly exceeding a relaxed pelvic floor muscle relaxation to allow normal uroflow and con- closure pressure profile.

116 U.M. Peschers Stressprofile ,.\\ I rJ\\ ~I ~ 0 5 10 15 rrm 250 200 0 ~ 150 Ii 1 l 0 5 10 15 rrm eo 80 0 0 \"-.-----'r~ ~ ~1 10 15 V ~1 20 rrrn 0 11 Q. ( Filling Cystometry ---- FIGURE 2.3.5. (C) Cough stress profile ofa continent female. Pura is the pres- 1 rro:1 sure measured alongside the urethra; 0 Pvo< measures the pressure in the bladder at the same time; Pelo, is the .N pressure calculated by subtracting PVt, from Pura.lt stands for theclosure pres- ~1 sure of the urethra during coughing. Positive pressure transmission during I the coughs indicates reflex contrac- tions of the pelvic floor muscles. (0) 0 Normal filling cystometry of a contl- nent female without symptoms ofOAB. 1 Pves is the pressure measured in the 0 bladder during constant filling; Pabdis the pressure in the rectum which N stands for the intraabdominal pres- sure; Pdt' isthedetrusor pressurewhich ~1 is calculated by subtracting Pabd from t•:& Pvo<' Q. nin 0 100 1:;0 200 250 JOO JW ~1 t 5 0 rro:1 ;; '0 Q. D

2.3. Urodynamics 117 Hypotonic Urethra o 1 20 rrrn A N 15 .J: 15 20 rrm Ii o \"ll Q. o 5 10 Cough stress profile 1 0 N J: Ii 1 e \"Q. o 21 J: Ii 1 l 05 15 20 25 rrm 20 40 00 70 1 11 0 N ..J: 5 0 \"ll Q. 0 10 15 20 25 rrm B FIGURE 2.3.6. (A) Urethral closure pressure profile (atrest) ofastress incontinent female withahypotonic urethra (intrinsic sphincter deficiency). Max. urethral closure pressure: 18cm H20. (8) Cough stress profile of the same patient.

118 U.M. Peschers barrier of the urethra when the patient starts Patient # 4:Overactive Bladder Syndrome coughing. A 63-year-old woman presents with symptoms of Patient # 3: Voiding Dysfunction urgency and urge incontinence. She complains about the need to void every hour during the A 54-year-old woman presenting with voiding daytime and three to four times during the night. difficulties after abdominal colposuspension for stress urinary incontinence two years ago. She When feeling the urge to void, she leaks while does not have incontinence. During pelvic exam- trying to get to the toilet. A prolapse of the ante- ination there is no prolapse. The anterior vaginal rior vaginal wall is found, but no urinary tract wall and the bladder neck are immobile during infections are evident. straining. There is 80ml of residual urine, and there is no urinary infection. Despite a hyperac- Filling cystometry reveals uninhibited detru- tive contraction of the detrusor muscle, the urine sor hyperactivity, starting early after the bladder flow is low and intermittent. Additional flow is filled above 100ml and immediately leading to spikes are the result of concomitant abdom inal a complete loss of stored urine (Fig. 2.3.8). The straining (Fig. 2.3.7). very high uninhibited detrusor contractions are indicative of a neurological disease as the origin, rather than an idiopathic cause. Pressure flow study 1 .0... :I: 5 ;; ~ 10 20 J:) o 10 20 J:) 040 III 00 100 110 120 FIGURE 2.3.7. Pressure flow study ofa female with voiding diffi- (8mils) thus indicating intravesical obstruction. Arrows indicate culties after incontinence surgery. Although detrusor pressure additional straining efforts to further press out intravesical with 30cm H20 is quite high, resulting urine flow rate is low urine.

2.3. Urodynamics 119 Pressure flow study .. l ·10 10 20 XI FIGURE 2.3.8. Filling cystometry in afemale withDAB I wet(high pressure motor urge incontinence). (Source: reprinted withpermis- sion from Wall LL, 1993.) References in stress incontinent women. Neurourol Urodyn. 2000;19(6):677-681. 1. Abrams P, Cardozo L, Fall M, et al. The standardi- 7. Bump RC, Elser DM, Theofrastous JP, et al. Val- sation of terminology of lower urinary tract func- salva leak point pressures in women with genuine tion. Neurourol Urodyn. 2002;21:167-178. stress incontinence: reproducibility, effect of cath - eter caliber, and correlations with other measures 2. Lose G, Griffiths DJ,Hosker GL,et al. Standardisa- of urethral resistance. Continence Program for tion of urethral pressure measurement: report Women Research Group. Am J Obstet Gynecol. from the Standardisation Sub-Committee of the 1995;173(2):551-557. International Continence Society. Neurourol 8. Miklos JR, Sze EH, Karram MM. A critical Urodyn. 2002;21:258-260. appraisal of the methods of measuring leak-point pressures in women with stress incontinence. 3. Schaefer W, Abrams P, Liao L, et al. Good urody- Obstet Gynecol. 1995;86(3):349-352. namic practices: uroflowmetry, filling cystometry, 9. Theofrastous JP,Cundiff GW,Harris RL, et al. The and pressure-flow studies. Neurourol Urodyn. effect of vesical volume on Valsalva leak-point 2002;21 :261-274. pressures in women with genuine stress urinary incontinence. Obstet Gynecol. 1996;87:711-714 . 4. Wall LL, Norton PA, DeLancey JO. Practical uro - 10. Miller JM, Umek WH, DeLancey JO, et al. Can dynamics. In: Wall LL, Norton PA, DeLancey JO, women without visible pubococcygeal muscle in editors. Practical urogynecology. Baltimore: MR images still increase urethral closure pres- Williams & Wilkins; 1993. sures? Am J Obstet Gynecol. 2004;191:171-175 . 5. Baessler K, Miska K, Draths R, et al. Effects of voluntary pelvic floor contraction and relaxation on the urethral closure pressure. lnt Urogynecol J Pelvic Floor Dysfunct. 2004;16:187-190. 6. Peschers UM, Jundt K, Dimpfl T. Differences between cough and Valsalva leak-point pressure

2.4 Applying Urodynamic Findings to Clinical Practice Christopher K. Payne Key Message mittee of the 3rd International Consultation on Incontinence found mostly low level grades 4 This chapter depicts how urodynamic studies are and 5 evidence (case series and expert opinion) helpful in deciding whether or not surgery and to support the use and interpretation of urody- physiotherapy are appropriate treatment/strate- namic tests in the majority of clinical situations.I gies for stress, urge, and mixed incontinence, as The Committee on Research Methodology well as voiding dysfunction. Carefully selected pointed out the need for large-scale prospective practically based opinions are, given as there is a studies to determine the predictive value of uro- lack of evidenced-based data thus far. dynamic tests in determining optional treatment for patients with incontinence.' Thus, although Introduction the urodynamic diagnosis may suggest a prefer- able course of action, the ultimate decision must As described in previous chapters, urodynamic incorporate the goals and values of the patient as studies are used to evaluate women with inconti- well as the locally available resources. nence and lower urinary tract symptoms in two common clinical settings: It is rare that only one form of treatment is acceptable, and common that available data 1. Preference for surgical therapy in women with do not clearly define the \"best\" or \"optimal\" clinically predominant stress incontinence therapy. symptoms Despite the limitations, urodynamic studies 2. Unsatisfactory response after empirical appli- remain the primary method of evaluating lower cation of conservative measures. urinary tract complaints. Interpreting urody- namic studies and counseling the patient about Urodynamic studies are also employed InI- therapy calls for a combination of clinical exper- tially, when the complexity of the clinical situa- tise and empathetic understanding of the patient's tion prevents making a provisional diagnosis. condition and objectives. The most common uro- Some clinicians prefer to test all patients before dynamic scenarios are discussed below and are, any therapy is administered. In any case, once in most cases, reflective of expert opinion. the examination has been completed, the clini- cian will need to interpret the findings and Pure Stress Incontinence counsel the patient about the relevant treatment options. Unfortunately, there is considerable dis- When conservative measures are preferred, uro- agreement on the meaning and significance of dynamic studies are not typically performed, yet many urodynamic tests and little evidence on the option of conservative therapy should not which to base opinions. The Urodynamics Com- be ignored when counseling patients after uro- 120

2.4. Applying Urodynamic Findings to Clinical Practice 121 dynamic testing. First, there is no evidence that patch electrodes and/or direct urethral pressure specific urodynamic findings (e.g., severe incon- measurement can be used to establish baseline tinence as manifested by low leak pressure or function-a simple survey could include evalua- presence of urethral sphincter dysfunction as tion of voluntary contraction strength and dura- shown by a low urethral closure pressure), or tion, \"quick flicks,\" and response to cough and clinical criteria (e.g., age, obesity, prior inconti- bulbocavernosus stimulation. When preopera- nence surgery) define patient groups less likely to tive urodynamic studies indicate an increased respond to pelvic floor rehabilitation.\"Therefore, chance of postoperative retention (hypocontrac- no patient should be primarily excluded from tile bladder) a concerted effort to manage the pelvic floor muscle training (PFMT) if they are problem with conservative measures should be willing to train. Expert opinion suggests that considered before surgical intervention. patients with a positive stress test and a good voluntary pelvic floor muscle contraction, which The following three urodynamic criteria define is not coordinated during a cough, represent a the ideal candidate for surgical treatment of particularly attractive group for PFMT. The stress incontinence: chance for successful conservative treatment is very high, given that leakage is controlled after 1) There is significant and objective stress instructions to perform both cough and contrac- leakage tion simultaneously. This could be performed on a \"see and treat\" basis in connection with the 2) There is no or minimal associated detrusor urodynamic assessment. ' The authors believe overactivity that conservative therapy with pelvic muscle exercises and/or biofeedback should be strongly 3) Voiding dynamics are normal. recommended when pelvic floor strength is poor and the objective severity of stress urinary incon- Such patients are highly likely to have favorable tinence (SUI) is low, as there is substantial room outcomes with surgical treatment and should be for improvement. encouraged to undergo surgery if so inclined. There are many groups that experts feel are The presence of detrusor overactivity does not less likely to respond to conservative measures. in any way preclude surgical treatment of stress For example, patients who show no urethral incontinence (seesection on mixed incontinence), mobility on clinical examination or perineal but it does call for different counseling. When ultrasound despite a sustained voluntary con- the filling phase is stable, the patient is simply traction. Some experts also identify patients who informed about the risk of de novo overactivity/ are able to perform a sustained contraction in urge incontinence as appropriate to the chosen which either the urethra is not adequately lifted procedure, approximately 0-27% for fascial upwards or is not kept in this position (e.g.during slings, 1-16% for colposuspension, and probably a cough) as poor candidates for training. In this less for tension-free midurethral slings. ' In con- case, there is presumably a poor connection of trast, patients with documented detrusor overac- the urethra to the puborectalis muscles. This tivity are counseled about the likelihood of the entity is easily encountered during digital exami- resolution of urge symptoms. For all patients nation or perineal ultrasound. Others have with preoperative urgency, symptoms persists in suggested that patients with chronic bronchitis 30-50% of patients, but this rate may be higher or athletes in endurance sports are not good in those patients with documented detrusor over- candidates. activity, particularly those with high pressure unstable contractions.' In some of these cases, Urodynamic studies may help identify the urgency can even increase despite resolution of patients most appropriate for conservative stress incontinence, particularly if the operation therapy by highlighting poor voluntary function creates any voiding dysfunction. of the pelvic floor. To define that weakness, the urodynamic examination must isolate and assess Finally, it is important to demonstrate normal voluntary and reflex pelvic floor activity. Perineal voiding. Urinary retention is one of the most serious complications of stress incontinence surgery and is not always reversible. If there is no clinical reason to suspect voiding problems, a normal uroflow and low postvoid residual will

122 (.K. Payne suffice. Patients with abnormally low flow rates, forming a treatment plan. The clinician's goal patterns suggesting Valsalva voiding, elevated is to: residual urine, or medical problems correlated with bladder dysfunction (e.g.,diabetes or lumbar • Select patients who are most likely to benefit spine disease) are probably investigated by a from surgical therapy pressure-flow voiding study. In the absence of high quality prospective data, it is most appropri- • Identify patients who are most likely to suffer ate to assume that a patient who depends on from persistent urge symptoms after surgery. abdominal straining to void will be at higher risk for urinary retention after any type of The urodynamic study gives an assessment of stress incontinence procedure, including injec- pelvic floor muscle strength to correlate with the tion therapy, and to counsel accordingly.\" On the physical exam, an objective measure of the sever- other hand, low pressure bladder contractions ity of the stress incontinence component, and an are not necessarily worrisome . Women with objective measure of the degree of bladder dys- stress incontinence often have very low urethral function. Those patients with more severe SUI resistance and, thus, may void without a de- and better pelvic floor function are better candi- tectable contraction. If the flow curve is normal, dates for surgery than are patients with less SUI, the peak flow rate is normal, and the residual is weaker pelvic floor muscles, and more severe low, there should be no increased risk of detrusor overactivity. In the latter case, surgery retention. should be employed only if concerted efforts at conservative therapy fail. Pure Detrusor Overactivity It is generally felt that patients with mixed The patient with clinically pure urge incontinence incontinence have poorer outcomes with surgery is typically managed with pharmacotherapy, for stress incontinence because of the possib- behavioral techniques, and pelvic floor exercises. ility of persistent urge symptoms, although The primary role for urodynamics is when these data are conflicting and incomplete . Therefore, simple measures fail and more invasive treatment these patients should usually be offered PMFT is being considered. Here, the role of urodynamic as a first-line treatment, with or without con- studies is to identify other treatable problems, comitant drug treatment (e.g, anticholinergics, such as associated stress incontinence or bladder Duloxetine). outlet obstruction, for which curative therapy exists. Also, patients with low pressure overactiv- Dysfunctional Voiding ity and leakage should be referred for biofeedback training and/or electrical/magnetic stimulation As with the case of acontractile bladder, dysfunc- before considering sacral neuromodulation or tional voiding is seen much more frequently in reconstructive surgery. pressure-flow urodynamic studies than it is as an actual important clinical issue. The pressure- Patients with high pressure overactive contrac- flow study must be correlated with the clinical tions must have good pelvic floor function; if they symptoms and a free-flow/residual urine deter- were unable to oppose the overactive contraction mination. Very often, the low flow rate and high appropriately then there would be leakage before EMG activity are only artifacts of the testing situ- high pressures could be generated . ation for the reasons mentioned above. When the clinical complaints, free-flow, and pressure-flow True Mixed Incontinence study do all suggest a diagnosis of dysfunctional voiding , consideration should be given to the The patient with true mixed incontinence, both possibility of neurogenic bladder with detrusor- SUI and detrusor overactivity incontinence on sphincter dyssynergia. (see Chapter 1.5,Fig. 1.5.2 urodynamic testing, presents a challenge in B). This diagnosis mandates a search for a supra- sacral spinal cord lesion. In the absence of a neu- rogenic cause, the diagnosis is dysfunctional voiding and the treatment options include pelvic

2.4. Applying Urodynamic Findings to Clinical Practice 123 floor physical therapy with maximal emphasis on editors. Plymouth, UK: Health Publicat ions, Ltd.; treatment of a hypertonic pelvic floor, which is 2005 . often found in these patients, biofeedback, and 4. Schrepferman CG, Griebling TL, Nygard IE, et al. sacral neuromodulation. Resolution of urge symptoms following sling cysto- urethropexy. J Urol. 164:2000 :1628-1631. References 5. Nguyen JK. Diagnosis and treatment of voidi ng dysfun ction caused by urethral obstruction after 1. Griffiths D, Kondo A, Bauer S, et al. Dynamic anti-incontinence surgery. Obstet Gynecol. 2002: testing. In: Incontinence. Abrams P, Cardozo L, 468-475. Khoury S, et al., editors. Plymouth, UK: Health 6. Wilson P, Berghmans B, Hagen S, et al. Adult con- Publications, Ltd.; 2005. servative management. In: Incontinece. Abrams P, Cardozo L, Khoury S, et al., editors. Plymouth, UK: 2. Payne CK, van Kerrebroeck P, Blaivas J, et al. Health Publications, Ltd.; 2005. Research methodology. In: Incontinence. Abrams 7. Miller JM, Ashton JA, DeLancey JOL. A pelvic P, Cardozo L, Khoury S, et al., editors. Plymouth, muscle precontraction can reduce cough -related UK: Health Publications, Ltd.; 2005. urine loss in selected women with mild SUI. J Am Geriatr Soc. 1998;46:870-874. 3. Smith ARB, Daneshgari F, Dmokowski R, et al. 8. Anger JT, Rodriguez LV. Mixed incontinence: Surgery for stress incontinence in women. In: stres sing about urge. Curr Urol. Rep 6;2004:427. Incont inece. Abrams P, Cardozo L, Khoury S, et al.,

2.5 Anorectal Physiology David Z. Lubowski and Michael 1. Kennedy Key Message function completely normally without the other. Continence and defecation both involve colonic The most import clinical manifestation of abnor- and anorectal function, and the term \"anorectal mal anorectal physiology is anal incontinence, physiology\" is misleading because any discus- and this, together with its causes, is comprehen- sion about anorectal function must now include sively reviewed in this chapter. The physiology the colon in order to have clinical relevance. includes studies on anorectal and colonic func- tions, using manometric and electrophysiologi- A variety of tests are available to study anorec- cal studies. The latter includes motor and sensory tal and colonic function. Some are useful in nerve conduction and electromyography. Mea- everyday clinical practice, whereas other tests surements of colonic transit rely on radioisotope have an important research role. This chapter studies, such as defecation scintigraphy, and examines the available physiological tests, dynamic studies , such as defecography. and places each in a clinical context. It is impor- tant to carefully select those tests which will Endoanal ultrasound using static and rotating provide useful clinical information for each probes is widely available and used for anal individual patient, as each patient has a sphincter morphology. tolerance level for anorectal tests above which he or she will become less compliant, and Anal incontinence is defined as the involun- exceeding this level with unhelpful tests will be tary loss of stool or flatus and is a distressing counterproductive. condition frequently seen by clinicians. It has previously been estimated that the prevalence of Anorectal Manometry anal incontinence may be as high as 15%1 in the general community and up to 20% of patients in The anal canal's high pressure zone is the most elderly care institutions. important component of the continence mecha- nism . Anal pressure may be measured at differ- Introduction ent levels in the anal canal, usually at approxi- mately l-cm intervals. Several recording devices When a patient presents with anal incontinence, are available, such as perfusion catheters, micro- a thorough investigation is required to find evi- balloons, sleeve catheters, or strain gauge trans- dence of neuropathy, muscle weakness, colonic ducers. Perfusion catheter systems are the most abnormality, or combinations of these. Normal commonly used. The maximum diameter of the anorectal function requires an intact anatomy recording device should be no greater than 5mm and is a complex, multifactorial physiological because large-diameter catheters may artificially process . The mechanisms of continence and raise anal pressure.' defecation are interdependent, and neither can 124

2.5. Anorectal Physiology 125 Perfusion Systems TABLE 2.5.1. Normal mean anal pressures A perfusion catheter is perfused with water at a Sun and Loening-Baucke Williams etal.s' constant rate, from 0.4 to 0.6 mLlmin. A minimum Read\" and Anuras\" mmHg of four pressure channels are generally required. Each channel terminates at a side-hole, the first Resting pressure cmH,O mmHg 62 (5) being 2 ern proximal to the tip for recording rectal Mean 64 (5) pressure. Three centimetres proximal to this is Mean male 91 (5) 60 (13) the first of three side-holes placed 1ern apart for Mean female 61 (6) 63(12) 189 (10) recording anal pressure. One channel opens at Squeeze 50(13) 142 (7) th e tip to allow inflation of a rectal balloon. The pressure 257 (20) catheter is positioned with the distal recording Mean 107 (13) 204 (54) Perfusion side-hole in the lowest part of the anal canal, Mean male 238 (38) where the basal resting pressure is allowed to sta- Mean female Perfusion 159 (45) bilize for 1-3 min. The subject is then requested Method to maximally contract the sphincter for 3-5 s Strain gauge three times at lO-s intervals. The subject is also asked to cough forcefully three times at lO-s Values in parentheses are standard deviations. intervals. In th is way both internal and external sphincter strength are assessed. state of continuous intrinsic contraction,' which Normal Recordings has phasic variation known as slow waves. These Resting Anal Pressure are more apparent when resting pressure is ele- Resting anal pressure is largely caused by the vated, and they occur at a rate of 6-20 per minute intern al sphincter (Fig. 2.5.1). The muscle is in a with an amplitude 10-25 ern H z0 4 Additionally, • ultra-slow waves are high-pressure waves with a frequency of 1-3 per minute; they are found in 5% of normal sub jects,' but in approximately 50% when maximum resting pressure is greater than 100cm HzO.6 They are frequently present in conditions caused by internal sphincter spasm, 400 such as hemorrhoids' and anal fissure.\" There is ~ 300 4 Rest Squeeze Cough RAR no consensus as to which part of the ultra-slow I~ 200 wave should be regarded as the maximal resting 100 o~====:::::==~~=:::!...-----j pressure, and it is best to document peak and 400 trough pressures, as well as mean pressure. It is ~ 300 3 important to note that there is wide variation in I5 200 41000gl========~~~===l resting and squeeze pressure, depending on the methodology, and there are also variations in 5~300 2 repeatability studies.\" Resting pressure is lower -- I 21000 0 r - -..... ------.....NU\\)L.NUv-~ in women than in men'? and decreases with age.\" 01- --1 Generally, a pressure of between 50 and 100ern 400 H20 is considered normal (Table 2.5.1). Spontaneous relaxation of the internal sphinc- ~ 300 200 ter has been shown to occur at a mean of 7 times I~ 100 per hour, \" thus, a \"sampling reflex\" allows the O..----r----r-------,r------I mucoas of the upper anal canal to discriminate o 50 Seconds100 150 gas from stool. Spontaneous relaxations occur FIGURE 2.5.1. Anorectal manometry using a perfusion system. more frequently than normal in patients with Channell isrecording justwithinthe anal verge, andchannels 2 and3 progressively more proximally inthe anal canal. Channel 4 fecal incontinence.\" This is caused by a rise in isrectal pressure. Pressures at rest, during muscle contraction and thenduring coughing areshown. Rectal pressure increasesduring rectal pressure due to rectal distension or con - coughing but notwithvoluntary contraction. traction\" mediated via an intramural neural pathway\" and known as the rectoanal inhibitory reflex (Fig. 2.5.2).

126 D.Z. Lubowski andM.L. Kennedy o 30 4 Rest Squeeze Cough Electrophysiology :~£120 IIl Manometry gives some indication of sphincter function and can help determine whether 5 10x sphincter weakness is likely to be the cause of 0 symptoms. However, other tests, such as electro- myography and/or ultrasound, may be needed to o 30 3 determine the underlying pathology. :~£120 L L1 Motor Nerve Conduction Studies 5 10Ig Pudendal Nerve Terminal Motor Latency o 30 2 A A. 1 For further background see Chapter 2.8. Stretch- :~£120 A ~ A- induced damage to the pudendal nerve may be 5 10'0 50 Seconds 100 measured using motor conduction studies. Elec- 150 trical stimulation of the pudendal nerve distal to 0 the ischial spine is carried out as described by Kiff and Swash.\" A disposable electrode (Dantec :ro 30 13L40, Skovlunde, Denmark) with an adhesive backing is placed on the gloved index finger with :~20 a node immediately proximal to the finger-tip 5 10 (Fig. 2.5.3). The finger is inserted into the rectum with the tip of the finger positioned at one ischial 0 spine. Square -wave stimuli lasting for 0.1ms are delivered at l-s intervals, and the amplitude is o progressively increased to 20rna. The fingertip is repositioned until it lies over the pudendal nerve, FIGURE 2.5.2. Rectoanal reflex. With distension of the rectal at which time a reproducible tracing with short- balloon there is a rise in rectal pressure (channel 4). Pressure est possible pudendal latency is obtained. The falls inthe upper- and mid-anal canal (channels 3 and 2) due to ischial spine cannot be accurately palpated in internal sphincter relaxation, and then returns toward the basal many subjects and the correct position of the level. Pressure in the lowest part oftheanal canal rises (channel finger is determined by a reproducible tracing 1) due to reflex contraction of the subcutaneous external with minimum latency. The latency is defined as sphincter. the time from stimulus to the point of takeoff when the impulse reaches the recording electrode This reflex is tested by rapid balloon distension at the external sphincter. of the rectum while simultaneously recording anal pressure. A fully deflated latex balloon, The validity of this test remains in doubt, and attached to the tip of a perfusion catheter, is some institutes regard it as unreliable. In our inserted into the rectum. Resting anal pressure is practice, it has become clear that the test requires allowed to stabilize, and the rectal balloon is then an experienced technician to produce repetitive inflated with 20-mL increments of air. A fall in reliable measurements. resting anal pressure of 20%, followed by return to the resting level, constitutes a positive reflex. Normal Recordings Voluntary Contradion Pressure Initially, the average of the left and right pudendal latencies was calculated.\" However, The external sphincter is in a state of tonic partial nerve damage is often asymmetrical and contraction, contributes about 15%of the resting pressure,' and is controlled by the spinal Onuf's nucleus. The external sphincter produces the vol- untary contraction pressure\" and is measured as the increase above the resting pressure (see Fig. 2.5.1). Like the resting pressure, it is lower in women and reduces with age.\" The external sphincter undergoes reflex and concomitant con- traction in response to a rise in abdominal pres- sure , and this is tested as the \"cough pressure.\" In some cases, a more accurate measure of exter- nal sphincter strength is obtained with the cough pressure (Fig. 2.5.1)/ 8which should be routinely tested during anal manometry.

2.5. Anorectal Physiology 127 TABLE 2.5.2. Normal mean pudendal latencies Reference Pudendal motor latency (ms) Kiff and 2.1 (0.2) Swash\" Snooks et al.\" 1.9(0.2) Rogers et al.\" 1.95 (1.7-2.25) Beevors et al.29 Right 1.9(0.2); left 2.0 (0.2) Values inparentheses arestandard deviation orrange. Electromyography For further background to this subject refer to Chapter 2.8. Single-Fiber Electromyography FIGURE 2.5.3. Disposable pudendal electrode and connector When a stretch-induced nerve injury occurs, (Dantec, Denmark). The electrode is mounted onthe right index action potentials pass down the fastest conduct- finger with theanode at thefinger-tip, with the recording elec- ing nerve fibers that remain intact. Therefore, trodes at the base ofthefinger. significant nerve damage may occur before motor latencies become prolonged. Examination of the the latencies should be reported separately.\" innervated muscle provides evidence of nerve (Table 2.5.2) Pudendal nerve terminal motor damage at an earlier stage . Single-fiber EMG is latency increases with age.\" The amount of peri- the most accurate method of testing for denerva- neal descent correlates with pudendal latency.\" tion and reinnervation of skeletal muscle, by An acute, severe stretch injury during vaginal recording action potentials from individual delivery,22.23.24 or a repetitive injury due to chronic muscle fibers (Fig. 2.5.4).31 Denervation of skele- straining at stool,\":\" may result in nerve damage. tal muscle is accompanied by reinnervation from This is supported by evidence of acute prolonga- neighboring axons. Histological studies show the tion of pudendal latency during straining in normal random distribution of type 1 and type 2 patients with abnormal perineal descent.26 Pro- fibers replaced by type 1 and type 2 grouping.\" longed pudendal latencies are found in several These changes can be measured accurately with disorders associated with difficult vaginal deliv- single-fiber EMG, which consists of a 25-llm- ery or chronic straining at stool, including fecal diam platinum wire insulated in a stainless steel incontinence,\" severe constipation,\" hernor- cannula,and terminating end-on at the side of the rhoids,\" and uterine prolapse.\" Prolonged cannula, 5 mm proximal to the tip (recording pudendal latencies can differentiate minor soiling surface = 2511m). from major incontinence.\" The changes of denervation and reinnervation can be quantified by calculating the fiber density, which is a measure of the number of muscle fibers in a motor unit within the area of uptake of the single-fiber electrode\" (e.g., the average number of fibers recorded at 20 sites in the muscle) . With reinnervation, the number of muscle fibers within this area increases, and the number of recorded spikes in the action potentials increases corre- spondingly. Normal fiber density in the external anal sph incter is 1.5 (SD 0.16);34 fiber density

128 D.Z. Lubowski andM.L. Kennedy Normal Anal and Rectal Sensation 2 The anal mucosa is richly innervated with nerve endings and is sensitive to touch , pain, tempera- Reinnervation ture, and movement . Pain sensation extends 0.5-1.5 em above the level of the dentate line. 3 Sensory fibers travel via the pudendal nerves to the S2-S4 nerve roots. FIGURE 2.5.4. Single-fiber electrode shown superimposed on normal muscle to demonstrate the recording surface of thewire Mucosal electrosensitivity is one measure of electrode on the side of cannula. The field of electrical uptake rectal sensation. Current is applied to the anal involves only a small number of muscle fibers. (b) Recording of mucosa and the sensory threshold is quantita- muscle fibers in a normal muscle (above) and a denervated tively measured A ring electrode (Dantec, Skov- muscle (below). The denervated and reinnervated muscle has lunde , Denmark) is placed on a Foley catheter fibergrouping, resultinginalarger number ofmuscle fibers inthe with the balloon deflated. The stimulator delivers motor unit, and hence the polyphasic action potentials shown a current lasting O.l -ms at a rate of five cycles per diagramatically. (c) Single-fiber EMG recording from a reinner- second, and the amplitude is increased from zero vated muscle showing anormal action potential(left) and apoly- in OJ-rnA increments until a tingling or tapping phasic action potential (right) , (Source: Stalberg and Trontelj, sensation is felt by the patient. The test is repro- 1979.) ducible\" and provides an accurate measure of anal sensation. Normal median values and range\" are: Lower anal canal (rnA) 4.8 (3.0-7.0) Midanal canal (rnA) 4.2 (2.0-6.0) Upper anal canal (rnA) 5.7 (3.3-7.3) Anal sensation is an important part of the conti- nence mechanism and is reduced in patients with neurogenic Incontinence.\" Rectal sensation plays an important role in the continence mechanism, and a sensation of rectal filling is also an integral part of normal defeca- tion . The rectum is sensitive to distension but lacks pain receptors. Rectal sensation is tested by balloon distension of the rectum (Table 2.5.3) or with mucosal electro sensitivity. greater than 2.0 indicates denervation with Balloon Distension reinnervation. A balloon attached to a catheter is inserted into Single-fiber EMGis a reproducible test.\" Fiber the rectum, with the lower edge of the inflated density increases with age.\" It is increased in balloon lying on the pelvic floor. Three endpoints conditions associated with stretch-induced are taken: (1) the volume first felt, which is the pudendal neuropathy, including fecal inconti- rectal sensitivity threshold; (2) the volume pro - nence, rectal prolapse,\" urinary stress inconti- ducing the urge to defecate; and (3) the volume nence,\" and uterine prolapse .\" Single-fiber EMG causing intolerable pain, which is called the is more invasive than other tests of pudendal maximum tolerable volume. Air and water can be function . Although it is more accurate, it is often used to inflate the balloon. used solely for patients in whom there is clinical evidence of neurogenic muscle weakness, but The ability to evacuate the rectum may be pudendal latency and mucosal electrosensitivity tested by rectal balloon expulsion. A balloon is are normal. inserted into the rectum and inflated with 50mL warm water. The subject is instructed to expel

2.5. Anorectal Physiology 129 TABLE 2.5.3. Rectal sensation showing balloon distension volumes in normal subjects Balloon distension volume Mean (ml) Urge to (years) Reference 29 RST defecate MTV Method loening- 17 (8) 173 (64) Bolus air 72 110 (10) Baucke and 22 17 (9) 151 (61) 178 (20) Bolus air Anuras\" 12 (1) 75 (10) 176 (20) Bolus air Sun etal.s8 20 (5) 128 (10) 230 (21) Continuous air 216 (20) 20 (6) 130 (12) 20ml/min Continuous water 43 (10) 167 (7) 20ml/min 40(10) 175 (10) Continuous air 100ml/min Continuous water 100ml/min Values inparentheses are standard deviations.RST, rectal sensitivity threshold; MTV, maximum toler- able volume. the balloon, and if this cannot be done then it is hours after ingestion. The colon is divided in inflated to a point that is closer to the volume right, left, and sigmoid/rectal segments for anal- producing the urge to defecate. However, balloon ysis. Segmental transit is expressed in one of two expulsion is an unphysiological test and should ways; either the percentage of isotope retained in be interpreted with caution. It does form the basis each segment and total percentage retained, or as of one form of biofeedback training. the midpoint of the isotope column (mean activ- ity position).\" Total percentage retention is Measurement ofColonic Function significantly increased in patients with severe idiopathic constipation (Fig. 2.5.5).41 The total Constipation is a common clinical problem and the objective measurement of colonic function is essential. Symptoms that are seemingly referable to the anorectal region may have their origin higher in the colon in some patients, and anorec- tal function cannot always be considered in isolation. Colonic Transit Studies Current techniques to measure colonic transit FIGURE 2.5.5. Radioisotope colon transit study. Subject with time use radioopaque markers or radioisotopes. severe constipation. There isprolonged retention of isotope in the For marker studies, all laxatives are ceased for at colon to 96 hours. least 48 hours, and 20 markers are swallowed. A single radiograph is taken on day 5 and in normal subjects at least 14 (80%) have been passed. The test is a measure of whole gut transit time, but since colonic transit time forms a large compo- nent of this, it is a useful, simple method of assessing colonic transit time. For radioisotope studies, the isotope is given orally and the abdomen is scanned with a wide- field-of-view gamma camera 6, 24, 48, 72, and 96

130 D.Z. Lubowski and M.L. Kennedy percentage retained is a simple measure for mal colon in patients with obstructed defecation clinical use and can be compared with normal including those with anismus, suggesting a more data . diffuse colonic abnormality rather than an ano- rectal abnormality alone. Defecation Scintigraphy Dynamic Imaging ofthe Rectum Recently, colon transit scintigraphy has been Several methods are available. Scintigraphic adapted as a research tool to assess the rectum methods provide a quantitative measure of rectal and colon during defecation. The impetus for evacuation, but do not demonstrate the anatomy this arose from the hypothesis that in some of the anorectum;therefore, defecography using patients with obstructed defecation there may barium has been more widely used. be an underlying diffuse colonic abnormality. Oral indium-l11-DTPA (4MBq) is given as for Defecography (Defecating Proctogram) standard colon scintigraphy, and then on the fol- lowing day, when the subject develops a normal Dynamic imaging of the rectum has been used call to stool, the colon and rectum are for over 30 years.\" Avariety of anatomical abnor- screened immediately before, during, and after malities and disorders of function have been defecation .\" identified in patients with obstructed defecation. Defecography does not assess defecation under Colonic Manometry physiological conditions because it ignores the normal sensory responses, as well as the colonic Colonic manometry is still largely a research tool, motor events, during defecation. but is now becoming clinically relevant. There is evidence from ambulatory anorectal manometry The barium mixture used varies widely. A that vigorous colonic propulsion may cause fecal mixture which approximates the volume and incontinence, so that an apparently \"anorectal\" consistency of stool is optimal, but these param- condition may actually arise from the colon. Sim- eters are variable in normal subjects. A solid arti- ilarly, defecation is not only a process of rectal ficial stool may alter the process of evacuation\" evacuation but also involves propulsive activity and a standard mixture has not been established. in the colon. Typically, barium is diluted 1.5:4 in water and mixed with potato starch to form a thick paste. Colonic manometry has been studied by The mixture is instilled while the patient lies in placing a catheter colonoscopically into the the lateral position. The line of the anal canal is prepared colon.\" The catheter is fed manually defined radiologically. Lateral radiographs are through the nose and checked fluoroscopically to obtained with the subject sitting on a water-filled prevent curling in the stomach. Recording is balloon ring or plastic commode to eliminate an begun when the catheter tip reaches the rectum. air interface. X-rays are obtained at rest, while coughing, during a Valsalva maneuver, and The motor events surrounding normal defeca- during evacuation of the barium. The examina- tion are recorded under physiological condi- tion room should be darkened and the number of tions.\" In the hour preceding \"defecation,\" a observers limited. series of up to three propagating waves arise in the proximal colon: the origin of each wavearises Normal Evacuation progressively more distally. In the 15 minutes before defecation, up to three propagating waves As straining begins, abdominal pressure pro- were again seen, but the reverse pattern was seen duces a slight concavity of the anterior rectal (each successive propagating wave having arose wall (Fig. 2.5.6). The pelvic floor descends, the more proximally). These propagating waves were anorectal angle widens, the anal canal begins to associated with the urge to defecate at the end of the wave. There was a marked reduction of prop- agating sequences both in the distal and proxi-

2.5. Anorectal Physiology 131 FIGURE 2.5.6. Proctogram showing descent of the perineum FIGURE 2.5.7. Proctogram showing anterior rectocele which fails from theresting tothestraining position. Descent is measured in toempty after evacuation. relation to the line ofthe ischial tuberosities which are usually clearly visualized. open, shortens, and becomes funnel shaped . Intussusception is the prolapse of the rectal Rectal evacuation begins and emptying is com- wall that occurs within the rectum (rectorectal), pleted. A slight degree of rectal wall intussus- within the anal canal (rectoanal), or there may be ception may occur normally. There are very external rectal prolapse. Minor infoldings of the few studies in normal controls, particularly rectal wall are seen in up to 45% of asymptomatic in young women, because of the radiation subjects\" and are considered normal. There is exposure . There is wide variation in normal debate about the clinical importance of intus- values.\" susception, particularly in relation to symptoms of obstructed defecation.\" The anorectal angle is measured at rest, during contraction of the pelvic floor muscles, and Neurogenic incontinence is associated with during defecation. The angle measures about 90 perineal descent and a widened anorectal angle degrees at rest, is more acute (60-80 degrees) at rest.50 There may be leakage of barium during during contraction, and more obtuse (mean 130 coughing or a Valsalva maneuvre, which is a degrees, range 120-145 degrees) during evacua- useful, simple test to help determine whether tion.\" In an individual subject, the exact mea- sphincter weakness is the cause of the surement is not as important as the change that incontinence. occurs from the rest to straining positions . Findings at Defecating Proctography Endoanal Ultrasound Small rectoceles are a normal finding in asymp- The anal sphincters may be seen clearly using an tomatic women.\" The size is measured anteriorly endoanal probe. Two systems are available: a from a line drawn upwards from the anterior wall rotating 7MHz or 10MHz probe housed within of the anal canal. Precisely what size rectocele a water-filled plastic cone (Bruel and Kjaer, will cause symptoms is not defined, but a bulge Gentofte, Denmark) or a static linear 7MHzprobe. greater than 2-3 em is considered abnormal. The rotating probe provides a 360 degree horizon- Failure of the rectocele to empty is an important tal cross-sectional image at each level, and is finding (Fig. 2.5.7). inserted into the rectum and then withdrawn from

132 Anal sphincters D.Z. Lubowski and M.L Kennedy Anal sphincters FIGURE 2.S.8. Normal ultrasound, rotating probe. (A) Mid-anal canal. Intract internal sphincter (I), external sphincter (E). (B) Anterior internal and external sphincter defect. (Source: Dr. Peter Stewart, Sydney, Australia.) AB the top of the anal canal to the anal verge. The 2. Gibbons CP,Bannister JJ, Trowbridge GA,et al. An linear probe produces a longitudinal image of the entire sphincter length and recordings are taken analysis of anal sphincter pressure and anal com- at several points in each quadrant. pliance in normal subjects . Int I Colorectal Dis. 1986;1:231-237. The internal sphincter is a well-defined 3. Lestar B, Penninckx F, Kerremans R. The compo- hypoechoic layer. Beyond this is the thick echo- sition of anal basal pressure: An in vivo and in genic external sphincter ring (Fig. 2.5.8). The vitro study in man . Int I Colorectal Dis. 1989; internal sphincter ring is absent in the lowest 4:118-122. part of the anal canal. In the upper anal canal the 4. Hancock BD, Smith K. The internal sphincter and puborectalis is seen above the upper limit of the external sphincter. Lord's procedure for haemorrhoids. Br I Surg. Abnormal Findings 1975;62 833-866. 5. Hancock BD.Internal sphincter and the nature of The normal internal sphincter thickness increases with age from 1mm at under 20 years to 2-3 mm haemorrhoids. Gut. 1977;18:651-655. in the elderly.51Therefore a 3-mm intern al sphinc- 6. Haynes WG, Read NW. Anorectal act ivity in man ter in a young patient is abnormal. It is thin in patients with neurogenic incontinence, in keep- during rectal infusion of saline: a dynamic assess- ing with the known muscle atrophy in that condition.52 ment of the anal continence mechanism. I Physiol. Defects in the internal and external sphincter 1982;330:45-56. can be found following fistulotomy, lateral sphincterotomy, and, in some cases, after vaginal 7. Sun WM, Read NW, Shorthouse AI. The hyperten- delivery.P'\" sive anal cushion as a cause of the high anal pres- Endoanal ultrasound detects external sphinc- sures in patients with haemorrhoids. Br I Surg. ter defects as accurately as EMG,55and has become 1990;77:458-462. the procedure of choice for sphincter mapping because it causes much less discomfort than EMG 8. McNamara MI, Percy IP, Fielding IR. A manomet- using a needle. ric study of anal fissure treated by subcutaneous References lateral internal sphincterotomy. Ann Surg. 1990; 211:235-238. 1. Lam TCF, Kennedy ML, Chen FC, et al. Prevalence 9. Ryhammer AM, Laurberg S, Hermann AP. Test- offaecal incontinence: obstetric and constipation- related risk factors; a popul ation-based study. retest repeatability of anorectal physiology tests in Colorectal Dis. 1999;1:197-203. healthy volunteers. Dis Colon Rectum . 1997; 40:287-292. 10. Sun WM, Read NW. Anorectal function in normal subjects: the effect of gender. Int I Colorectal Dis. 1989;4:188-196. 11. Ryhammer AM, Laurberg S, Sorensen FH. Effects of age on anal function in normal women. Int I Colorectal Dis.1997;2:225-229. 12. Orkin BA, Hanson RB, Kelly KA, et al. Human anal motility while fasting, after feeding and during sleep. Gastroenterol. 1991;100:1016- 1023.

2.5. Anorectal Physiology 133 13. Sun WM, Read NW, Miner PB, et al. The role of 29. Beevors MA, Lubowski DZ, King DW, et al. Puden - transient internal sphincter relaxation in faecal dal nerve damage in women with symptomatic incontinence. Int J Colorectal Dis. 1990;5:31-36. utero-vaginal prolapse. Int J Colorectal Dis. 1991; 6:24-28 . 14. Naudy B, Planche D, Monges B, Salducci J. Relax- ations of the internal anal sph incter elicited by 30. Kafka NJ, Coller JA, Barrett RC, et al. Pudendal rectal and extra-rectal distensions in man . In: neuropathy is the only parameter differentiating Roman C, editor. Gastrointestinal Motilit y. leakag e from solid stool incontinence. Dis Colon London: MTP Press; 1984:451-458. Rectum. 1997;40:1220-1227. 15. Lubowski DZ, Nicholls RJ, Swash M, et al. Neural 31. Lubowski DZ, Swash M, Henry MM. Neural mech- control of internal anal sphincter function. Br J an isms in disorders of defaecation. In Grundy D, Surg. 1987;74:668-670. Read NW, editors. Clinical Gastroenterology. Gas- trointestinal Neurophysiology. London: Bailliere 16. Keighley MRB, Henry MM, Bartolo DCC, et al. Tindall/WB Saunders; 1988:201-203. Anorectal physiology measurement: report of a working party. Br J Surg. 1989;76:356-357. 32. Parks AG, Swash M, Urich H. Sphincter denerva- tion in ano -rectal incontinence and rectal pro- 17. Loening-Baucke V,Anuras S. Effects of age and sex lapse. Gut. 1977;18:656-665. on anorectal manometry. Am J Gastroenterol. 1985;80:50-53. 33. Trontel j JV, Staiberg E. Single fiber electromyog- raphy in studies of neuromuscular function. Adv 18. Meagher AP, Lubowski DZ, King DW. The cough Exp Med BioI. 1995;384:109-119. response of the anal sphincter. Int J Colorectal Dis. 1993;8:217. 34. Neill ME, Swash M. Increased motor unit fibre dens ity in the external sphincter muscle in 19. KiffES, Swash M. Slowed condu ct ion in the puden- anorectal incontinence: a single fibre EMG dal nerves in idiopathic (neurogenic) faecal incon - study. J Neurol Neurosurg Psychiatry. 1980;43: tinence. Br J Surg. 1984a;71:614-616. 343-347. 20. Lubowski DZ, Jones PN, Swash M, et al. Asym- 35. Rogers J, Laurberg S, Misiewicz JJ, et al. Anorectal metrical pudendal nerve damage in pelvic floor disorders. Int J Colorectal Dis. 1988;3:1 58-160. physiology validated: a repeatability study of the motor and sensor y tests of anorectal function. Br 21. Ho YH, Goh HS. The neurophysiological signifi- J Surg. 1989;76:607-609. cance of perineal descent. Int J Colorectal Dis. 36. Laurberg S, Swash M. Effects of ageing on the ano- 1995;10:107-111. rectal sphi ncters and their innervation. Dis Colon Rectum. 1989;32:734-742. 22. Snooks SJ, Setchell M, Swash M, et al. Injury to the 37. Neill ME, Parks AG, Swash M. Physiological studies innervation of the pelvic floor musculature in of the pelvic floor in idiopathic faecal inconti- childbirth. Lancet. 1984;2:546- 550. nence and rectal prolapse. Br J Surg. 1981;68: 531 -536 . 23. Snooks SJ, Swash M, Math ers SE, et al. Effect of 38. Smith ARB, Hosker GL, Warrell DW. The role vaginal delivery on the pelvic floor: a 5 year follow- of partial denervation of the pelvic floor in the up. Br J Surg. 1990;77:1358-1360. aetiology of genitourinary prolapse and stress incontinence of urine. A neurophysiological study. 24. Sultan AH, Kamm MA, Hudson CN. Pudendal Br J Obstet Gynaecol. 1989;96:24-28. nerve damage during labour: prospective study 39. Roe AM, Bartolo DCC, Mortensen NJMcC. before and after childbirth. Br J Obstet Gynaecol. New method for assessment of anal sensation in 1994;101:22-28. various anorectal disorders. BrJSurg. 1986;73:310 - 312. 25. Snooks SJ,Barnes PRH, Swash M, et al. Damage to the innervation of the pelvic floor musculature in 40. Rogers J, Henr y MM, Misiewicz JJ. Combined chronic constipation. Gastroenterol. 1985;89:977- 981. sensory and motor deficit in primary neuropathic faecal incontinence. Gut. 1988;29:5-9. 26. Lubowski DZ, Swash M, Nicholls RJ, et al. Increase 41. Smart RC, McLean RG, Gaston-Parry D, et al. in pudendal nerve terminal motor latency with Comparison of oral iodine-131-cellulose and defaecation straining. Br J Surg. 1988;75:1095- Indium -Il l DTPA as tracers for colon transit scin- 1097. tigraphy: anal ysis by colon activity profiles. J Nucl Med. 1981;32:1668-1674. 27. Kiff ES, Swash M. Normal prox imal and delayed 42. Lubowski DZ, Meagher AP, Smart RC, et al. Scin- distal conduction in the pudendal nerve s of tigraphic assessment of colonic function during patients with idiopathic (neurogenic) faecal incon- defaecation. Int J Colorectal Dis.1995;10:91-93. tinence. J Neurol Neurosurg Psychiatry 1984;47: 820-823. 28. Bruck CE, Lubowski DZ, King DW. Do patients with haemorrhoids have pelvic floor denervation? Int J Colorectal Dis. 1988;3:210-214.

134 D.Z. Lubowski and M.L. Kennedy 43. Furukawa Y, Cook IJ, Panagopoulos V, et al. Rela- 52. Swash M, Gray A, Lubowski DZ, et al. Ultrastruc- tionship between sleep patterns and human tural changes in internal sphincter in neurogenic colonic motor patterns. Gastroenterol. 1994;107: faecal incontinence. Gut 1988;29:1692-1698. 1372-1381. 53. Sultan AH, Kamm MA, Hudson CN, et al. Anal- 44. Dinning PG, Kennedy ML, Lubowski DZ, et al. sphincter disruption during vaginal delivery. N Manometric findings in the unprepared proximal Engl J Med 1993;329:1905-1911. colon in patients with severe obstructed defaeca- tion . Gastroenterol. 1996;110:657. 54. Sultan AH, Kamm MA, Bartram CI, et al. Anal sphincter trauma during instrumental delivery. 45. Burhenne HJ. Intestinal evacuation study: A new lnt J Gynaecol Obstet. 1993;43:263-270. roentgenologic technique. Radiol Clin. 1964;33: 79-84. 55. Sultan AH, Kamm MA, Talbot IC, et al. Anal sphincter endosonography for identifying exter- 46. Bannister J}, Davison P, Timms JM, et al. Effect nal sphincter defects confirmed histologically. Br of stool size and consistency on defecation. Gut. J Surg. 1994;81:463-465. 1987;28:1246-1250. 56. Williams N, Barlow J, Hobson A, et al. Manomet- 47. Shorvon PJ, McHugh S, Diament NE, et al. Defe- ric asymmetry in the anal canal in controls cography in normal volunteers: normal results and patients with fecal incontinence. Dis Colon and implications. Gut 1989;30:1737-1749. Rectum. 1995;38:1275-1280. 48. Finlay IG (moderator). Symposium: Proctography. 57. Snooks SJ,Swash M, Henry MM, et al. Risk factors lnt J Colorectal Dis.l988;3:67-89. in childbirth causing damage to the pelvic floor innervation: a precursor of stress incontinence. 49. van Tets WF, Kuijpers JHC. Internal rectal intus- lnt J Colorectal Dis. 1986;1:20-24. susception - fact or fancy? Dis Colon Rectum. 1995;38:1080-1083. 58. Sun WM, Read NW, Prior A, et al. Sensory and motor responses to rectal distension vary accord- 50. Pinho M, Yoshioka K, Keighley MRB. Are pelvic ing to rate and pattern of balloon inflation. Gas- floor movements abnormal in disordered defaeca- troenterol. 1990;99:1008-1015. tion? Dis Colon Rectum . 1991;34:1117-1119. 59. Stalberg E, Trontelj J. Single Fibre Electromyo- 51. Burnett SJ, Bartram CI. Endosonographic varia - graphy. Surrey: Mirvalle Press; 1979. tions in the normal internal anal sphincter. lnt J Colorectal Dis. 1991;6:2-4.

2.6 Ultrasound Imaging Kaven Baessler and Heinz Kolbl Key Messages and easily learned, performed, and taught; it is accepted and easily understood by women; and it • Perineal ultrasound has an important role in is commonly available, is carried out by gyne- the clinical evaluation of pelvic floor dynamics cologists, and does not require the involvement in women with stress and urge incontinence, of a radiologist. Because of the lack of radiation, and pelvic organ prolapse, as follows: ultrasound permits prolonged imaging of pelvic - dynamic assessment of pelvic floor muscle floor function, especially when used as a feed- activity during functional task s such as back method for pelvic floor rehabilitation. Fluid- coughing and straining filled structures can be visualized without the - assessment of efficacy of pelvic floor use of contrast medium. Perineal ultrasound re-education (translabial or introital ultrasound) has almost - pre and postoperative assessment completely replaced lateral cystourethrography - search for pathologies, especially in women because of its advantages and similar results. ':' It with overact ive bladder is the instrument of choice to image the dynam- ics of the pelvic floor during coughing and strain- • Use as a Biofeedback tool in pelvic floor ing. Although MRI can give very precise pictures, re-education it is not universally accessible and is expensive . With the recent advance of real-time three- • Scientific evaluation of pelvic floor dynamics to dimensional ultrasound, pelvic floor images compare women with and without pelvic floor similar to those produced by an MRI can be disorders as well as pre and post partum. obtained. The Scope ofUltrasound Imaging of Perineal ultrasound is also a noninvasive and the Pelvic Floor painless alternative to the Q-tip or cotton-swab test, where a Q-tip is inserted into the urethra Ultrasound scanning has gained popularity and and angles are measured during straining, cough- importance for nearly all body parts and func- ing, and pelvic floor contraction.' Simultaneous tions. In urogynecology, bladder neck imaging imaging during urodynamics studies is also has become routine practice and has provided possible.' another piece in the jigsaw puzzle of pelvic floor assessment. Although abdominal ultrasound can give rea- sonably static and dynamic images of the filled The advantages of ultrasound in the assess- bladder, and also, indirectly, of a pelvic floor con- ment of pelvic floor disorders are numerous: traction, by visualizing bladder base elevation,' there is no radiation; it is painless and may be perineal ultrasound is usually preferred because noninvasive, easily applied supine and standing, of its superior quality and more direct imaging. Obesity, suprapubic incisions, and advanced 135

136 K.Baessler and H.Kiilbl pelvic organ prolapse can make accurate and be relevant when used in research. Different meaningful abdominal scanning impossible. It bladder volumes do not seem to affect bladder is, however, the approach of choice for the non- neck mobility in a clinically significant way,?-9 invasive observation of the concomitant or but bladder neck funneling is usually better primary action of the transversus abdominis observed at higher volumes of approximately muscle.\" 300mlY Three-dimensional ultrasound of the urethra, Depending on the purpose of the ultrasound bladder, anal sphincter, and pelvic floor is pri- the probe can be applied in the supine , sitting, or marily a research tool, but is becoming more standing position. The bladder, bladder wall, used for perineal scanning. Intraurethral ultra- urethra, bladder neck, pubic symphysis, vagina, sound two- and three-dimensional ultrasound uterus, rectum, anorectal junction, puborectalis scanning also remains mainly a research tool. sling, anal sphincter, and ureteric jets can be However, endoanal ultrasound is the gold stan- visualized. With perineal ultrasound, the urethra dard in the assessment of the anal sphincter in appears as hypoechoic because of the smooth women with fecal incontinence. muscle orientation of the urethra. The striated urethral muscle is not easily differentiated with This chapter will describe the use of ultra- perineal ultrasound, probably because of the sound in the clinical assessment of the pelvic amount of connective tissue and fiber orientation floor and as a research tool in the evaluation of giving off a similar echogenicity as the sur- the physiology and pathophysiology of pelvic rounding structures. Because of the substan- floor function. In the first part of the chapter, the tial improvement of ultrasound equipment with different ultrasound techniques are depicted better resolution, the insertion of a urethral cath- while the second part informs about the func- eter to demarcate the urethra and the bladder tional findings. neck with the filled catheter balloon is no longer necessary. The vagina is hyperechoic , but is not Applications, Equipment, and Pelvic persistently identifiable. The insertion of ultra- Floor Structures sound gel into the vagina can be helpful if required. The position and the descent of the Perineal and Introital Ultrasound uterus, bladder, rectum, and an enterocele can be determined.l\":\" although quantification of pelvic The use of a curved linear array scanner with organ prolapse is limited, especially when the frequencies between 3.5 and 5 (7.5) MHz for prolapse extends beyond the introitus. Stool and perineal (synonym translabial) ultrasound or an gas can seriously disturb the images, particularly endovaginal probe with (5) 7-lOMHz placed on after repeated straining. the introitus is recommended. For a perineal ultrasound, the probe is placed on the perineum The German Urogynecology Association has in the midsagittal plane with plenty of ultrasound advocated a standardization of perineal ultra- gel to allow for good contact. The labia may have sound to assist with clinical assessment and facil- to be parted to obtain a satisfactory image. In itate research. \" Figure 2.6.1 explains the different contrast to endovaginal ultrasound, perineal measurements that can be obtained. The pubic ultrasound does not affect the topography of the symphysis is used as the reference structure. Its bladder as long as there is no prolapse beyond the central axis represents the x axis and the perpen- introitus and not too much pressure on the peri- dicular line at the inferior edge of the symphysis neal probe, as this can displace the bladder neck represents the y axis, thus, allowing the calcula- cranially.' Introital ultrasound with an endovagi- tion of the coordinates of the bladder neck posi- nal probe may interfere with the exact assess- tion and its mobility vectors. ment of bladder neck mobility, pelvic organ prolapse, and pelvic floor contraction. This may According to the primary focus, the probes can not be important in the clinical setting, but can be tilted more towards the urethra and bladder or towards the anal sphincter and rectum (Fig. 2.6.2). To visualize the anal sphincter muscle, the curved probe has to be orientated on the perineum

2.6. Ultrasound Imaging 137 FIGURE 2.6.1 . The pubic symphysisserves asthereference struc- FIGURE 2.6.2. Sagittal scan/plan. Orientation ofthe ultrasound ture with the X-axis running along its longitudinal axis and the probe according tothefocus oftheexamination. Y-axis crossing perpendicularly at theinferior border ofthesym- physis.The rotational orangle alpha ismeasured between the Y- shape (Fig. 2.6.3), which has been described as axis and a line determined by the bladder neck position and \"tenting\" in three-dimensional ultrasound.\" the inferior border ofthe pubic symphysis. Angle alpha is the posterior urethrovesical angle. Bladder wall thickness can be measured using perineal, introital, or vaginal ultrasound. An perpendicular to the axis of the anal canal (Fig. increased bladder wall thickness of more than 2.6.3). Although currently inferior to endoanal 5 mm has been reported to be associated with ultrasound, perineal ultrasound can be used to detrusor overactivity (Fig. 2.6.5).18 Urethral assess anal sphincter integrity and allows visual- diverticula, suburethral cysts , fibroids, tumors, ization of the mucosa, internal, and external anal or foreign bod ies may also be detected .\" Imaging sphincter without distortion of the anatomy (Fig. the urethral and bladder neck mobility after a 2.6.3).14.15 bladder neck suspension or suburethral tape procedure can help in the assessment of post- Paravaginal (lateral) support of the anterior operative voiding dysfunction (see DVD).19 vaginal wall can be imaged by placing the ultra- sound probe transversely onto the perineum and Abdominal Ultrasound vaginal introitus and by orientating it ventrally (Fig. 2.6.4).16In a transverse image, a vagina with To visualize the bladder base and endopelvic normal paravaginal support has a \"butt erfly\" fascia, suprapubic placement of the scanner with FIGURE 2.6.3. Coronal scan. Placement ofthe ultrasound probe transverse totheaxis oftheanal canal tovisualise the mucosa and theinternal and external sphincter muscles without distortion.

138 K. Baessler and H.Kiilbl FIGURE 2.6.4 Coronal scan. With placement of the ultrasound probe transverse on the perineum and introitus, the vagina with its lateral support (paravaginal attachment) can be visualised. The vagina has a \"butterfly\" shape when imaged coronally. lower frequencies (3.5-5 MHz)is required. Higher Intraurethral, Endoanal, and Three- frequencies (5-10MHz) are recommended to Dimensional Ultrasound image the transversus abdominis muscle in the horizontal (transverse) plane on the lateral The equipment for an intraurethral ultrasound abdominal wall,\" Abdominal ultrasound is very ranges from 7.5- to 1O-MHz mechanically rotated limited in the investigation and visualization endoprobes with catheter sizes between 6.2-9 of the pelvic floor, particularly of the urethra French. Intraurethral ultrasound is feasible and and bladder neck. There is no standardization has been shown to correlate well with histological of the assessment although measurements of examinations of the urethra.i' The striated ure- the bladder displacement during a pelvic floor thral sphincter assumes an omega-shape caused contraction have been reported to be by the loss of signal at the 6 o'clock position.\":\" reproducible.v\" For endoanal ultrasound, there are sector scan- ners that cover nearly 360 degrees, and there are Imaging of paravaginal support has been mechanically rotated, 360-degree endoprobes . attempted with transabdominal ultrasound. The Frequencies between 7.5 and 10MHz are cur- methods cannot easily be standardized because rently used, with the higher frequency producing of the lack of reference points and difficult delin- superior images. (see Chapter 1.7.) eation of the endopelvic fascia and vagina.\":\" Results are conflicting and vaginal examination There are several different scanners with 3D remains the gold standard. facilities available, mainly curved probes, but also endoprobes for intraurethral and endoanal ultrasound. The use of a 3D endoanal probe to explore the urethra at rest and during pelvic floor contraction has been shown to be feasible.\" The perineal 3Dapplication can demonstrate the rela- tionship between urethra, suburethral tape, and vagina .\" It holds great promise for the assess- ment of the pelvic floor muscle before and after delivery as puborectalis avulsions from the pubic bone can be identified.I? Sonographic Evaluation of Pelvic Floor Function FIGURE 2.6.5. Perineal ultrasound oftheminimally filled bladder, Valsalva, Straining, and Coughing sagittal plane. Bladder wall thickness measured atthree different sites. Mean measurements above 5mm are indicative ofdetrusor Imaging of the position of the bladder neck at rest overactivity. and during coughing, straining, and pelvic floor

2.6. Ultrasound Imaging 139 contraction and assessment of bladder neck test that might result in concomitant pelvic floor contraction instead of relaxation in some mobility are currently the cornerstones of peri- women.\" Table 2.6.1presents bladder neck mobil- ity measurements during Valsalva and coughing neal ultrasound scanning. Position and mobility obtained in different studies. of the bladder neck can reliably be measured In a normal subject, the bladder neck is usually stabilized during coughing as part of the abdomi- using a coordinate system with the pubic sym- nal/pelvic floor muscle coactivation.\" Therefore, bladder neck mobility is not as extensive during physis as a reference point.\" coughing as during straining.l\":\" Furthermore, bladder neck mobility is significantly reduced The bladder neck position at rest is signifi- when a pelvic floor contraction is performed before coughing (\"the Knack\").\" In continent cantly lower in the upright position compared nulliparous women, without the Knack, the bladder neck was displaced by a median of 4.6mm with the supine position.f\":\" Bladder neck (up to 19.5mm); with the Knack, the median dis- placement was zero (up to 17mm). This effect was descent during straining or a Valsalva maneuver not as manifest in stress incontinent women who might have susta ined damage to the pelvic in young, nulliparous, continent women has been floor, its innervation, or the fascial support structures.\" reported between 0 and 40mm. 27 30 To distin- - guish between normal bladder neck mobility and bladder neck hypermobility, a cutoff value of 5 mm 29,31 or 14mm 32,33 has been used . However, bladder neck hypermobility is not clearly defined . Confounding factors include the difficult stan- dardization of a Valsalva maneuver (forced expi- ratory effort against a closed glottis to increase intrapleural pressure, resulting in bradycardia and hypotonia) and that it is a nonphysiological TABLE 2.6.1. Measurements of bladderneck mobility and posterior urethrovesical anglein different populations Bladder neck mobility on Author Continent controls Incontinent subjects P Valsalva 0.7 0.42 60cmH,O Peschers\" young NP, n= 39 young NP, SUI, n= 10 <0.001 40cmH,O Dietz\" 14±9mm(2-31) 18±10mm Reed'9 young NP, = 106 0.001 maximal straining Howard\" 17±9mm 9-12 months pp, Vo, PP, <0.001 Bladder neck mobility on premenopausal NP, n= 48 SUI, n= 23 Chen's 6.3 ± 0.42 mm (0-18.7) <0.001 Coughing young continent NP, n= 17 14.8±6.4mm <0.001 Peschers\" 12.4± 4.7mm Posterior urethrovesical Howard\" young continent PP, n= 18 various complaints, no angle 14.5±7.0mm POP, n= 78 Miller' n =39 Supine: 18.1 ±4.6mm Alper\" 9± 6mm (4-32) Standing: 16.1 ± 3.4mm young continent NP, n= 17 8.2±4 .1 mm 9-12 months pp, vo, PP, young continent PP, n= 18 9.9±4.0mm SUI, n= 23 young continent NP, n= 11 13.8 ± 5.4mm median 5.4 mm, range 20 SUI, n= 50 with \"Knack\" Rest: 95± 11 (70-117) median 2.9mm, range 18.3 Valsalva: 103 ± 16 (84 - 142) continent age-matched, n= 50 Rest:93 ± 5° (85-110) Valsalva:96± 8 (85-130) NP = nulliparous, PP = primiparous, SUI = stress urinary incontinence, pp= post partum, Vo = vaginal delivery.

140 K. Baessler and H. Kiilbl After vaginal delivery, there was a significant stood by the women. The displacement of the loss of bladder neck support at rest and increased pubocervical fascia during a pelvic floor contrac- bladder neck mobility during straining. The tion can also be measured transabdominally' position of the bladder neck at rest and during and has been reported between 8.2 mm and straining was lower postpartum compared with 17mm, respectively, depending on primary nulliparous controls and with women who had an transversus abdominis or pelvic floor elective cesarean section.\":\":\" contraction.\" Bladder neck funneling during coughing and Using perineal ultrasound, bladder neck eleva- straining is often visible in stress incontinent and tion during a voluntary levator ani muscle con- parous women, but has not been demonstrated in traction has been shown to significantly decrease continent nulliparous women.f -\" Intravesical after vaginal delivery and to return to antepar- contrast medium can help delineate the bladder tum values after 6-10 weeks in most women.\" neck and potential funneling during straining or coughing.P'\" Color Doppler has successfully The thickness of the pelvic floor muscle can be been used to demonstrate urethral leakage, measured perineally, with the ultrasound probe although the stress test probably remains the placed paramedially in the sagittal direction.\" gold standard.\" Nulliparous continent women had a significantly thicker pelvic floor muscle at rest (median The posterior urethrovesical angle (Fig. 2.6.1) 0.77ern) and during contraction (median 0.99ern) significantly increases during straining in both than incontinent nulliparous women (median continent and stress incontinent women (Table 0.60em and 0.83em, respectively). 2.6.1).42 Stress incontinent women displayed a significantly greater angle at rest and while Micturition and Defecation straining than continent women.\" The posterior urethrovesical angle was significantly increased Perineal ultrasound imaging during micturition six weeks after childbirth (67 vs. 57 degrees pre- in the physiological sitt ing position demonstrated partum).\" Nulliparous controls had a smaller that the bladder neck opens in continent volun- angle compared with postpartum women (44 vs. teers and incontinent patients. In most women, 67 degrees). there was also bladder neck descent.\" Similarly, perineal imaging during defecation (evacuation The bladder neck-symphysial angle (Fig. 2.6.1) of ultasonographic gel) in the unphysiological has been suggested to identify women with stress left-lateral position documented a widening of urinary incontinence better than bladder neck the anorectal angle and descent of the anorectal mobility. The angle was significantly greater at junction.\" These investigators also used the sym- rest and Valsalva in stress incontinent women physis-based coordinate system for their mea- compared with continent women of similar age surements, which correlated well with results and other demographics.\" The angle correlated obtained with conventional defecography. reasonably with digital pelvic floor contraction assessment and vaginal perineometry using an Ultrasound asa Biofeedback Tool air-filled pressure transducer.\" Pelvic Floor Contraction Biofeedback via ultrasound can be given to enhance understanding and improve pelvic floor Provided that the subject can perform a sufficient function during (before = Knack) coughing and pelvic floor contraction and the attachment of straining.f:\" The \"Knack,\" a pelvic floor contrac- the anterior endopelvic fascia to the puborec- tion that is generated before coughing or sneez- talis muscle is intact, the cranial and ventral ele- ing to prevent urinary leakage, can be taught vation of the bladder neck elevation during a using perineal ultrasound.P'\" The knack has pelvic floor contraction is clearly visible on been confirmed to improve the stability of the perineal ultrasound (see DVD). This pattern can bladder neck during coughing. Straining and be used for pelvic floor education, as the images Valsalva are not exactly physiological activities with the pelvic floor structures are easily under- but can be used as a substitute for activities that

2.6. Ultrasound Imaging 141 involve increased intraabdominal pressures like tion procedures. Ultrasound Obstet Gynecol. nose-blowing, defecation, bending, or playing a 1996;7:347-352. wind instrument. In conjunction with perineal 8. Pregazzi R, Sartore A, Bortoli P, et al. Perineal ultrasound, abdominal ultrasound is a valuable ultrasound evaluation of urethral angle and instrument in assessing the synergy of the pelvic bladder neck mobility in women with stress floor and deep abdominal muscles. It can be used urinary incontinence. BJOG. 2002;109:821-827. for pelvic floor re-education especially for retrain- 9. Dietz HP, Wilson PD. The influence of bladder ing of functional tasks that result in urinary volume on the position and mob ility of the ure- leakage in the individual subject. 50 throvesical junction. Int Urogynecol J Pelvic Floor Dysfunct. 1999;10:3-6. Visual feedback via endoanal ultrasound has 10. Beer-Gabel M, Teshler M, Schechtman E, et al. been studied in patients with fecal incontinence. Biofeedback with endoanal ultrasound and anal Dynamic transperineal ultrasound vs. defecogra- manometry did not prove to be of additional benefit compared to digital feedback.\" phy in patients with evacuatory difficulty: a pilot study. Int J Colorectal Dis. 2004;19:60-67. Conclusion II. Tunn R, Petri E. Introital and transvaginal ultra- sound as the main tool in the assessment of uro- Ultrasound is an excellent tool to assess pelvic genital and pelvic floor dysfunction: an imaging floor function and dysfunction and is suitable as panel and practical approach. Ultrasound Obstet an instrument for biofeedback-directed pelvic Gynecol. 2003;22:205-213 . floor (re)-education. 12. Dietz HP, Haylen BT, Broome J. Ultrasound in the quantification of female pelvic organ prolapse. References Ultrasound Obstet Gynecol. 2001;18:511-514. 13. Tunn R, Schaer G, Peschers U, et al. Updated rec- I. Kolbl H, Bernaschek G, Wolf G. A comparative ommendations on ultrasonography in urogyne- study of perineal ultrasound scanning and ure- cology. Int Urogynecol J Pelvic Floor Dysfunct. throcystography in patients with genuine stress 2005;16:236-241. incontinence. Arch Gynecol Obstet. 1988;244:39- 14. Peschers UM, DeLancey JO, Schaer GN, et al ultra- 45. sound of the anal sph incter: normal anatomy and sphincterdefects. BrJObstetGynaecoI.1997;104:999- 2. Troeger C, Gugger M, Holzgreve W, et al. Correla- 1003. tion of perineal ultrasound and lateral chain ure- 15. Cornelia L, Stephan B, Michel B, et al. Trans- throcystography in the anatomical evaluation of perineal versus endo-anal ultrasound in the detec- the bladder neck. Int Urogynecol J Pelvic Floor tion of anal sphincter tears. Eur J Obstet Gynecol Dysfunct. 2003;14:380-384 . Reprod BioI. 2002;103:79-82 . 16. Martan A, Masata J, Halaska M, et al. Ultrasound 3. Caputo RM, Benson JT. The Q-tip test and ure- imaging of paravaginal defects in women with throvesical junction mobility. Obstet Gynecol. st ress incontinence before and after paravaginal 1993;82:892-896. defect repair. Ultrasound Obstet Gynecol. 2002; 19:496-500. 4. Schaer GN, Koechli OR, Schussler B, et al. Can 17. Dietz HP, Steensma AB, Hastings R. Three- simultaneous perineal sonography and urethro- dimensional ultrasound imaging of the pelvic cystometry help explain urethral pressure varia- floor: the effect of parturition on paravaginal tions? Neurourol Urodyn. 1997;16:31-38. support structures. Ultrasound Obstet Gynecol. 2003;21:589-595. 5. Thompson JA, O'Sullivan PB. Levator plate move- 18. Khullar V, Cardozo LD, Salvatore S, et al. Ultra- ment during voluntary pelvic floor muscle con- sound: a noninvasive screening test for detrusor traction in subjects with incontinence and prolapse: a cross-sectional study and review. Int instability. Br J Obstet Gynaecol. 1996;103:904- Urogynecol J Pelvic Floor Dysfunct. 2003;14:84- 88. 908. 19. Vierhout ME, Hoi M. Vaginal ultrasound studies 6. Sapsford RR, Hodges PW. Contraction of the pelvic floor muscles during abdominal maneu- before and after successful colposuspension and vers . Arch Phys Med Rehabil. 2001;82:1081-1088. in continent controls. Acta Obstet Gynecol Scand. 1998;77:101-104. 7. Schaer GN, Koechli OR, Schussler B, et al. Perineal 20. Bo K, Sherburn M, Allen T. Transabdominal ultra- ultrasound: determination of reliable examina- sound measurement of pelvic floor muscle activity when activated directly or via a transversus