Differences in help-seeking behaviour between men and women with multiple pelvic floor symptoms: a qualitative study.

To characterize the association between thoracic (T) and lumbar (L) spinal curvature and pelvic floor (PF) symptoms (pelvic organ prolapse, urinary incontinence [UI], fecal incontinence [FI]). Of women undergoing a bone mineral density scan from January 2007 to October 2010, patients who completed PF symptom questionnaires and had T and/or L spine radiographs or computed tomography examinations within 3 years of questionnaire completion were included in this study. The spine angles were measured using the Cobb angle method. The T and L curvatures were categorized as hypokyphosis (<20°), normal T kyphosis (20-40°), hyperkyphosis (>40°), hypolordosis (<40°), normal L lordosis (40-70°), and hyperlordosis (>70°). The presence and type of UI were identified with the 3 Incontinence Questionnaire and FI with the Modified Manchester Questionnaire. Pelvic organ prolapse was defined as a positive response to the presence of a bulge question from the PF Distress Inventory-20. Of 1665 eligible women, 824 and 302 (mean age 64 ± 10 for both) had T and L spine images, respectively. No differences in PF symptoms were observed in the T or L spine groups categorized by hypo-, normal, and hyperkyphosis/lordosis except for urgency UI being more prevalent in the hypolordosis group (P = 0.01). However, upon further characterization using logistic regression, no association was noted between PF symptoms and T or L spine angles; no differences in the mean angles were found between women with versus without PF symptoms (P ≥ 0.05). The current study shows that the T and L spinal curvatures are not associated with the presence of PF symptoms.

Association of coccygodynia with pelvic floor symptoms in women with pelvic pain.

In the United States, around 9 million women are affected by pelvic pain due to conditions such as interstitial cystitis/bladder syndrome, fibromyalgia, pelvic floor myalgias, chronic opioid use, or irritable bowel syndrome. Treatment options for concurrent pelvic floor disorders and pelvic pain can prove challenging due to the overall desire to avoid exacerbating overall pain while optimizing pelvic floor symptoms. The primary aim of this study was to compare both perioperative pelvic muscle training and vaginal reconstructive surgery among women who experienced or lacked preoperative pain and to inform better approaches to management of women with preoperative pain. The study was a secondary analysis of the Operations and Pelvic Muscle Training in the Management of Apical Support Loss (OPTIMAL) randomized clinical trial, as performed via the Pelvic Floor Disorders network. The main study's design was a 2 × 2 randomized factorial design with a surgical intervention and a perioperative behavioral intervention. The Eunice Kennedy Shriver National Institute of Child Health and Development data and specimen hub provided the data for this study. Included were 374 women undergoing surgery for both stress urinary incontinence and stage 2–4 pelvic organ prolapse from 2008 to 2013. All participants underwent vaginal prolapse repair and midurethral sling, and were randomized to either perioperative pelvic muscle therapy or usual care. The Pain scale, the Pelvic Floor Impact Questionnaire, the Pelvic Floor Distress Inventory, and the Patient Global Impression of Improvement were all completed by patients at baseline and repeated through month 24. The OPTIMAL trial had a primary outcome of surgical success as defined by anatomical success, but the primary outcome of this secondary analysis was a change in pain scale scores over 24 months after surgery. Three hundred seventy-four women participated in the original trial, with 368 in this secondary analysis. One hundred nine of the 368 women reported preoperative pain. Women with pelvic pain were more likely to be Hispanic, but there were no differences in surgical procedures performed, hospital stay, complications (ie, bladder injury, suture exposure, etc), or estimated blood loss in women with and without pelvic pain. Women with preoperative pain experienced greater pain at all time points, but also exhibited greater pain improvement at 24 months after surgery. Women with preoperative pain had worse baseline pelvic floor symptoms than those without pain. Although women with pain and women without pain had improvements in distress symptoms measured with the Pelvic Floor Distress Inventory, women with pain saw a greater improvement after surgery. All distress subscales improved significantly more in women with pain than women without pain. One additional interesting finding was that women randomized to sacrospinous suspension and pelvic muscle therapy had greater improvements in postoperative pain than those randomized to usual care. Notably, rates of surgical anatomic success and extent of Patient Global Impression of Improvement were not different between women with and without pain. Strengths of the study include its design as a secondary analysis of a large prospective multicenter randomized controlled trial. A substantial proportion of participants reported at least moderate pain at baseline but were not selected based on preoperative pain. Women in the trial were randomized to types of vaginal reconstructive surgery and pelvic muscle training, which allowed the authors to draw conclusions in categories of physical therapy treatments and surgeries for women with and without preoperative pain. Limitations of the study include a lack of preoperative pain data, pain diagnoses, and participant medications in the OPTIMAL trial. Furthermore, the study used no validated pain scale and was limited by OPTIMAL trial data collection intervals. Thankfully, data collected at numerous points over 24 months in some regard accounted for pain symptoms over time. The study found that, for patients with preoperative pain, significant improvement in pelvic floor symptoms and pain takes place after vaginal reconstructive surgery. Similar postoperative improvement rates were found. In addition, perioperative pelvic floor muscle training may be beneficial for patients with planned sacrospinous ligament fixation.

Management of patients with chronic pelvic pain (CPP) is an actual interdisciplinary problem of modern clinical medicine. CPP is chronic or persistent pain lasting more than 6 months, which is located in the structures related to the male or female pelvis and is associated with negative cognitive, behavioral, and emotional consequences, as well as with lower urinary tract, bowel, and pelvic floor symptoms, and reproductive and sexual dysfunction. In accordance with the biopsychosocial model, CPP is the result of a dynamic interaction of biological, psychological and sociocultural factors. When diagnosing CPP, it is most acceptable to phenotype patients according to the UPOINTS classification.To implement the treatment strategy, it is necessary to adhere to a multidisciplinary personalized approach to pain management with active patient participation. Cognitive behavioral therapy (CBT) occupies an important place in the treatment of CPP. There is clinical and neurophysiological evidence of the efficiency of CBT in patients with CPP, a protocol has been developed for the combined use of CBT and physical therapy. CBT is recommended to be included in a comprehensive treatment and rehabilitation program for patients with CPP.

Cycling has become a popular athletic activity worldwide and can lead to genital and pelvic floor dysfunction. This review summarizes the current body of evidence about the epidemiology of genital and pelvic floor symptoms in female cyclists, the therapy, and preventive interventions. Two electronic meta-databases, OvidSP™ and Deutsches Institut für Medizinische Dokumentation und Information (DIMDI), comprising 40 individual databases, were searched for studies that described genital and pelvic floor symptoms in association with cycling and studies that tested possible therapies and prophylactic measures. For the literature search we explored the search terms "female", "bicycling", "pelvic floor", "lower urinary tract symptoms", and "vulvar diseases". The search retrieved 1,219 articles, leaving 763 articles after removal of duplicates, and finally 12 articles eligible for review. We assessed 10 observational and 2 experimental studies. Genital and pelvic floor symptoms related to bicycling were pain, tenderness, neuropathy, urological dysfunction and skin lesions. Broader and conventionally shaped saddles were associated with fewer symptoms compared with cut-out saddle designs. The quality of existing studies is generally low, but there is evidence that female cyclists suffer from similar problems to male cyclists, ranging from minor skin lesions to severe sequelae such as pain and neurological deficiencies.

Many patients with pelvic floor complaints, including urinary and fecal incontinence, micturition and defecation problems, pelvic organ prolapses, pelvic pain, and painful intercourse, receive pelvic physical therapy treatment. Based on available evidence, pelvic floor complaint profiles, including these complaints, have not been described using real-world pelvic physical therapy records and multi-complaint clustering methods. Pelvic floor complaint profiles may help to enhance therapists' clinical reasoning and patients' understanding and self-disclosure. This retrospective file review study explores preliminary complaint profiles and associations between pelvic floor complaints. Pelvic physical therapists entered recorded pelvic floor complaints from self-selected pregnant, parous, and nulliparous patients' files in an online survey. Complaints were extracted from clinical records and coded as binary (recorded/not recorded). Descriptive statistics and correlations were calculated, and latent class analysis was performed to gain insight into pelvic floor complaint profiles and their associations with pregnancy and parity. Model selection was based on BIC/log-likelihood statistics and expert clinical review. A model with five profiles was selected based on statistical and theoretical selection criteria. One profile showed the highest probabilities for recorded pelvic pain, one for recorded defecation and micturition problems, one for recorded fecal incontinence and defecation problems, another for recorded pelvic organ prolapses and urinary incontinence, and one for recorded painful intercourse and micturition problems. The first and second profiles appeared most characteristic for pregnant patients, the third and fourth for parous patients, and the fifth for nulliparous patients. The identified profiles may facilitate the inclusion and consideration of potential contributing factors for combined pelvic floor complaints in clinical practice and scientific research. Addressing pelvic floor complaints in profiles may help pelvic healthcare providers during their history-taking, enhance multidisciplinary treatment approaches, and help patients understand experienced combinations of pelvic floor complaints. This may ultimately benefit women's pelvic health.

Background and Objectives: Chronic pelvic pain (CPP) represents a major public health problem for women with a significant impact on their quality of life. In many cases of CPP, due to gynecological causes-such as endometriosis and vulvodynia-improper pelvic floor muscle relaxation can be identified. Treatment of CPP with pelvic floor hypertonicity (PFH) usually involves a multimodal approach. Traditional magnetic stimulation has been proposed as medical technology to manage muscle hypertonicity and pelvic pain conditions through nerve stimulation, neuromodulation, and muscle relaxation. New Flat Magnetic Stimulation (FMS)-which involves homogeneous rather than curved electromagnetic fields-has the potential to induce sacral S2-S4 roots neuromodulation, muscle decontraction, and blood circulation improvement. However, the benefits of this new technology on chronic pelvic pain symptoms and biometrical muscular parameters are poorly known. In this study, we want to evaluate the modification of the sonographic aspect of the levator ani muscle before and after treatment with Flat Magnetic Stimulation in women with chronic pelvic pain and levator ani hypertonicity, along with symptoms evolution. Materials and Methods: A prospective observational study was carried out in a tertiary-level Urogynaecology department and included women with CPP and PFH. Approval from the local Ethics Committee was obtained before the start of the study (protocol code: MAGCHAIR). At the baseline, the intensity of pelvic pain was measured using a 10 cm visual analog scale (VAS), and patients were asked to evaluate their pelvic floor symptoms severity by answering the question, "How much do your pelvic floor symptoms bother you?" on a 5-answer Likert scale. Transperineal ultrasound (TPU) was performed to assess anorectal angle (ARA) and levator ani muscle minimal plane distance (LAMD). Treatment involved Flat Magnetic Stimulation alone or with concomitant local or systemic pharmacological therapy, depending on the patient's preferences. FMS was delivered with the DR ARNOLD system (DEKA M.E.L.A. Calenzano, Italy). After the treatment, patients were asked again to score the intensity of pelvic pain using the 10 cm visual analog scale (VAS) and to evaluate the severity of their pelvic floor symptoms on the 5-answer Likert scale. Patients underwent TPU to assess anorectal angle (ARA) and levator ani muscle minimal plane distance (LAMD). Results: In total, 11 patients completed baseline evaluation, treatment, and postoperative evaluation in the period of interest. All patients underwent eight sessions of Flat Magnetic Stimulation according to the protocol. Adjuvant pharmacological treatment was used in five (45.5%) patients. Specifically, we observed a significant increase in both ARA and LAMD comparing baseline and post-treatment measurements (p < 0.001). Quality of life scale scores at baseline and after treatment demonstrated a significant improvement in both tools (p < 0.0001). Conclusions: Flat Magnetic Stimulation, with or without adjuvant pharmacological treatment, demonstrated safety and efficacy in reducing pelvic floor hypertonicity, resulting in improvement in symptoms' severity and sonographic parameters of muscular spasm.

Purpose: The purpose of this cross-sectional study was to assess the association of extrapelvic muscular stiffness measures with pelvic floor symptoms and clinical impairments in women with chronic pelvic pain (CPP). In addition to bivariate correlations, exploratory factor analysis (EFA) was used to identify multivariate clinical presentation patterns of CPP. Methods: Muscle stiffness measurements of 11 extrapelvic muscles were taken in 149 women with CPP. Associations between muscle stiffness and clinical measures such as pelvic floor function, pain, psychosocial status, and urogynecology history were calculated. In addition, variables were assessed using EFA to identify patterns of CPP. Results: There were small but significant correlations between muscle stiffness measurements and clinical measures. Three categorizations of CPP symptoms and impairments emerged from the 25 continuous variables chosen for EFA. These could be classified as follows: (1) pelvic floor dysfunction and psychosocial involvement; (2) muscle stiffness of the hips and thighs; and (3) muscle stiffness of the low back and abdomen, collectively making up 49.1% of the variance. Discussion: Stiffness of commonly treated extrapelvic muscles was not strongly correlated to pain level or health history of women with CPP. The first EFA component is consistent with patients routinely seen by pelvic health physical therapists, and the latter components are consistent with those who may benefit initially from orthopedic physical therapy. Further research looking at the relationship of muscle stiffness, pelvic floor function, and movement impairments is needed. EFA may be a starting point to better understand who may be appropriate for orthopedic physical therapy treatment versus specialized pelvic health physical therapy care.

Natural history of lower urinary tract symptoms in treatment-seeking women with pelvic organ prolapse; the Symptoms of Lower Urinary Tract Dysfunction Research Network (LURN)

Several studies have shown that men with lower urinary tract symptoms are more likely to experience erectile dysfunction. All except 1 of these studies were cross-sectional, limiting inferences about whether lower urinary tract symptoms precipitate erectile dysfunction. The association between lower urinary tract symptoms and incident erectile dysfunction was examined prospectively in the Health Professionals Follow-Up Study. Lower urinary tract symptoms were assessed biennially by the American Urological Association symptom index, which captures symptoms of frequency, urgency and force of urinary stream. Severe lower urinary tract symptoms was defined as a symptom score of 20 points or greater and no lower urinary tract symptoms was defined as a score of 7 points or less in men not treated for lower urinary tract symptoms. In 2000 the men were asked to rate erectile function for several periods. Erectile dysfunction was defined as poor or very poor function, or erectile dysfunction medication use, while no erectile dysfunction was defined as very good or good function and no erectile dysfunction medication use. We estimated the RR using Poisson regression, adjusting for age and other potentially confounding factors. We observed 3,953 incident erectile dysfunction cases among 17,086 men. Men with severe lower urinary tract symptoms in 1994 or earlier had a statistically significant 40% higher risk of erectile dysfunction subsequently than men without lower urinary tract symptoms. The risk of erectile dysfunction increased with increasing lower urinary tract symptom severity (p trend <0.0001). The positive association between lower urinary tract symptoms and erectile dysfunction was stronger in younger than in older men (p interaction = 0.03). This study provides evidence that men with lower urinary tract symptoms are more likely to have erectile dysfunction subsequently.

Urinary bladder and rectum share a common embryological origin. Their autonomic and somatic innervations have close similarities. Moreover, the close proximity of these two organ systems could suggest that dysfunction in one may influence, also mechanically, the function of the other. Therefore, it is not surprising that defecation problems and lower urinary tract symptoms (LUTS) occur together, as reported in the literature. To study the relationship between constipation and LUTS focusing on what is evidence-based. We searched the Medical Literature Analysis and Retrieval System Online (MEDLINE) database in February 2010 to retrieve English language studies (from 1997 to 2009) and the 2005, 2006 and 2007 abstract volumes of the European Association of Urology (EAU), American Urological Association (AUA) and International Continence Society (ICS). We present the findings according to the studied population in four groups: (a) children, (b) middle-aged women, (c) elderly and (d) neuropathic patients. Most published studies that correlated rectal and bladder dysfunction were carried out in children or in young women. On the other hand, there are few studies regarding the association between constipation and LUTS in the elderly and in neuropathic patients. Several studies in children documented that constipation is linked to urinary tract problems, including infections, enuresis, vesicoureteral reflux and upper renal tract dilatation. The underlying pathophysiology of these findings has not yet been clearly defined. Studies in middle-aged women also support a high prevalence of constipation among patients suffering from urinary tract dysfunction. Furthermore, an association between constipation and urinary incontinence, as well as between constipation and pelvic organ prolapse, has been suggested. The only prospective study in constipated elderly with concomitant LUTS demonstrates that the medical relief of constipation also significantly improves LUTS. Finally, the available data on neuropathic patients suggest that stool impaction in the rectum may mechanically impede bladder emptying. However, most of the studies only include a small number of patients, are not prospective and are uncontrolled. Therefore, there is a need for large-scale, controlled studies to further improve evidence and to provide a valid recommendation for all groups, especially for the elderly and neuropathic patients.

To provide a clinical opinion based on current literature reporting on the effects of peri-operative pelvic floor muscle training (PFMT) on postoperative pelvic floor symptoms, recurrent treatment after pelvic organ prolapse (POP) surgery and current clinical practice in the Netherlands. The PubMed database was searched, with dates from 1966 to May 2012, for all types of studies reporting on the effects of peri-operative PFMT on recurrent treatment and/or pelvic floor symptoms after POP surgery. Also, current clinical practice in the Netherlands was evaluated. Two small randomised controlled trials (RCTs), with differences in the population included, were identified. The first RCT concluded that peri-operative PFMT reduced the risk of pelvic floor symptoms 12 weeks after surgery and improved the quality of life. The second trial concluded that there is no significant beneficial effect 12 months after surgery. However, when looking at the reported outcomes in this trial micturition symptoms and quality of life improved more in the treatment group too. Studies evaluating whether peri-operative PFMT reduced the rate of recurrent treatment for POP-related symptoms, were not identified. This lack of evidence reflects the current clinical practice, as most gynaecologists do not offer peri-operative PFMT to their patients. Peri-operative PFMT may reduce the risk of pelvic floor symptoms and improve the quality of life after POP surgery, although evidence is insufficient to implement this in current clinical practice. Since the results of the two RCTs on this topic are promising, there is an urgent need for robust, well-designed trials to evaluate the efficacy and (cost-)effectiveness of peri-operative PFMT.

Introduction As novel therapies continue to enhance the survival rates of patients with gynecologic cancers, it is increasingly important to prioritize quality of life concerns. Pelvic floor disorders (PFD) are common among women, and research indicates that those with gynecological cancer experience more pelvic floor symptoms. Many patients in gynecologic oncology (GO) do not receive urogynecology evaluations before, during, or after treatment. As well, disruptions to anatomy during surgery and radiation can make it more difficult and less safe to intervene after treatment. Objective This quality improvement study aims to assess the effectiveness and thoroughness of PFD management in GO patients. Should we identify a need, this study will advocate for the establishment of a streamlined urogynecology referral pathway for patients undergoing treatment for gynecologic cancers. Methods A retrospective study was conducted at an academic institution over a two-year period. Women aged 18 and older were included if they presented as new patients in the division of GO between April 1, 2022, and April 1, 2023, and scheduled an appointment with the division of urogynecology and reconstructive pelvic surgery (URPS) between April 1, 2022, and April 1, 2024. The primary outcome of interest was the number of women who met this criterion. Secondary outcomes included the rates, types, and treatment of pelvic floor disorders (PFDs). Results There were 28 included patients. The mean (SD) age was 62 (17). Types of neoplasms included 5 (17.9%) ovarian, 11 (39.3%) uterine, 0 cervical, 1 (3.6%) vaginal, and 11 (39.3%) other. For cancer treatment, 1 (3.6%) underwent radiation, 2 (7.1%) chemotherapy, 15 (53.6%) surgery, and 13 (46.4%) no treatment. There were 22 (78.6%) patients who had some screening for PFD at their initial GO visit, although the degree of screening varied. Of those screened, 14 (63.6%) patients had no PFD symptoms, 0 reported pelvic organ prolapse (POP), 6 (27.3%) urge urinary incontinence (UUI), 6 (27.3%) stress urinary incontinence (SUI), 0 fecal incontinence, and 1 (4.5%) sexual dysfunction. There were 22 patients examined for PFD at their initial GO visit. Of those, 18 (81.8%) had no documented PFD finding, whereas 4 (18.2%) exhibited POP, 0 incontinence, and 0 vaginismus. The average time from initial GO visit to initial URPS visit was 214.4 days. Notably, 11(39.3%) had a canceled URPS visit. Of those who had an URPS visit, diagnoses included: 0 vaginismus, 0 dyspareunia, 5 (29.4%) recurrent urinary tract infection (UTI), 1 (5.9%) cystocele, 1 (5.9%) rectocele, 1 (5.9%) apical prolapse, 0 procidentia, 8 (47.1%) SUI, 9 (52.9%) UUI, 0 overflow incontinence, 6 (21.4%) mixed urinary incontinence, 0 intrinsic sphincter deficiency, and 5 (29.4%) something not specified. There were 8 (28.6%) patients reporting PFD symptoms began before oncology treatment, 3 (10.7%) reporting symptoms began afterwards, and 17 (60.7%) reporting unknown symptom initiation. Conclusions This study indicates a need for more thorough PFD screening and examination in GO patients and a more reliable referral pathway with expedited treatment. Next steps involve developing a system to more effectively identify GO patients with PFD and subsequently have them referred for expedited evaluation and treatment. Disclosure No.

Is Pelvic Osteotomy Associated with Lower Risk of Pelvic Organ Prolapse in Postpubertal Females with Classic Bladder Exstrophy?

Levator ani muscle avulsion is a risk factor for inferior outcomes after native tissue pelvic organ prolapse repair. In a previously published study, we found no such association 1 year after the Manchester procedure (anterior repair combined with cardinal and uterosacral ligament suspension and perineal repair). The aim of the present study was to compare women with and without levator ani muscle avulsions in terms of patient-reported and anatomical outcomes, and failure rates in the same cohort after 5 years. Five-year prospective cohort study of 143 women operated on for anterior and/or mid-compartment pelvic organ prolapse with the Manchester procedure between October 2014 and January 2017, Clinical Trial study number NCT02246387. Levator ani muscle avulsions (uni- or bilateral) were diagnosed at inclusion by transperineal ultrasound. Primary outcome at 5-year follow-up was subjective bulge symptoms (question 3, Pelvic Floor Distress Inventory-20). Secondary outcomes were total score from the same questionnaire, sexual distress (Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12), subjective cure, Pelvic Organ Prolapse Quantification scale measurements, defining optimal outcomes as anterior compartment stage <0-1 and mid-compartment point C ≤-5, and new surgical or conservative prolapse treatment. Among 143 women followed up after 5 years, the avulsion rate was 52.4%. Both groups showed similar reductions in bulge symptoms, pelvic floor symptoms, and anatomical anterior- and mid-compartment measurements. Sexual distress improvement was significantly greater for women with avulsion (Mean change difference: -3.4 (-6.4 to -0.5)). Multivariate regression revealed no significant effect of avulsion on symptom scores, cure rates, or need for new prolapse treatment. Women with avulsion had half the odds of obtaining an optimal anterior compartment outcome compared to those without avulsion (adjusted odds ratio: 0.5 (0.2-0.9)). Although women with levator ani muscle avulsion had lower odds of achieving an optimal anterior compartment outcome, the overall anatomical changes from preoperative to 5 years were similar in both groups. Importantly, avulsion did not impact symptom improvement, patient-reported outcomes, or the need for further treatment. These findings support the Manchester procedure as an effective and durable surgical option for women with POP, regardless of avulsion status.