Pelvic Floor

Introduction and hypothesisThis manuscript from Chapter 3 of the International Urogynecology Consultation (IUC) on Pelvic Organ Prolapse (POP) describes the current evidence and suggests future directions for research on the effect of pelvic floor muscle training (PFMT) in prevention and treatment of POP.MethodsAn international group of four physical therapists, four urogynecologists and one midwife/basic science researcher performed a search of the literature using pre-specified search terms on randomized controlled trials (RCTs) in Ovid Medline, EMBASE, CINAHL, Cochrane, PEDro and Scopus databases for publications between 1996 and 2021. Full publications or expanded abstracts in English or in other languages with abstracts in English were included. The PEDro rating scale (0-10) was used to evaluate study quality. Included RCTs were reviewed to summarize the evidence in six key sections: (1) evidence for PFMT in prevention of POP in the general female population; (2) evidence for early intervention of PFMT in the peripartum period for prevention and treatment of POP; (3) evidence for PFMT in treatment of POP in the general female population; (4) evidence for perioperative PFMT; (5) evidence for PFMT on associated conditions in women with POP; (6) evidence for the long-term effect of PFMT on POP. Full publications in English or in other languages with abstracts in English and expanded abstracts presented at international condition specific societies were included. Internal validity was examined by the PEDro rating scale (0-10).ResultsAfter exclusion of duplicates and irrelevant trials, we classified and included 2 preventive trials, 4 trials in the post-partum period, 11 treatment trials of PFMT for POP in the general female population in comparison with no treatment or lifestyle interventions, 10 on PFMT as an adjunct treatment to POP surgery and 9 long-term treatment trials. Only three treatment studies compared PFMT with the use of a pessary. The RCTs scored between 4 and 8 on the PEDro scale. No primary prevention studies were found, and there is sparse and inconsistent evidence for early intervention in the postpartum period. There is good evidence/recommendations from 11 RCTs that PFMT is effective in reducing POP symptoms and/or improving POP stage (by one stage) in women with POP-Q stage I, II and III in the general female population, but no evidence from 9/10 RCTs that adding PFMT pre- and post -surgery for POP is effective. There are few long-term follow-up studies, and results are inconsistent. There are no serious adverse effects or complications reported related to PFMT.ConclusionsThere are few studies on prevention and in the postpartum period, and the effect is inconclusive. There is high-level evidence from 11 RCTs to recommend PFMT as first-line treatment for POP in the general female population. PFMT pre- and post-POP surgery does not seem to have any additional effect on POP. PFMT is effective and safe but needs thorough instruction and supervision to be effective.

The purpose of this review is to present our researches on the pelvic outlet muscles, including the pelvic floor and perineal muscles, which are responsible for urinary function, defecation, sexual function, and core stability, and to discuss the insights into the mechanism of pelvic floor stabilization based on the findings. Our studies are conducted using a combination of macroscopic examination, immunohistological analysis, 3D reconstruction, and imaging. Unlike most previous reports, this article describes not only on skeletal muscle but also on smooth muscle structures in the pelvic floor and perineum to encourage new understanding. The skeletal muscles of the pelvic outlet are continuous, which means that they share muscle bundles. They form three muscle slings that pass anterior and posterior to the anal canal, thus serving as the foundation of pelvic floor support. The smooth muscle of the pelvic outlet, in addition to forming the walls of the viscera, also extends in three dimensions. This continuous smooth muscle occupies the central region of the pelvic floor and perineum, thus revising the conventional understanding of the perineal body. At the interface between the levator ani and pelvic viscera, smooth muscle forms characteristic structures that transfer the lifting power of the levator ani to the pelvic viscera. The findings suggest new concepts of pelvic floor stabilization mechanisms, such as dynamic coordination between skeletal and smooth muscles. These two types of muscles possibly coordinate the direction and force of muscle contraction with each other.

BackgroundThere is a risk of pelvic floor dysfunction (PFD) from baby delivery. Many clinical guidelines recommend pelvic floor muscle training (PFMT) as the conservative treatment for PFD because pelvic floor muscles (PFMs) play a crucial role in development of PFD. However, there is disagreement about the method and intensity of PFM training and the relevant measurements. To pilot the study in PFM training, we designed a Pelvic Floor Workout (PEFLOW) for women to train their pelvic through entire body exercises, and we planned a trial to evaluate its effectiveness through comparing the outcomes from a group of postpartum women who perform PELFLOW at home under professional guidance online with the control group.Methods/designThe randomized controlled trial was projected to be conducted from November 2021 to March 2023. A total of 260 postpartum women would be recruited from the obstetrics departments of the study hospital and women would be eligible for participation randomized into experimental or control groups (EG/CG) if their PFM strength are scaled by less than Modified Oxford grading Scale (MOS) to be less than grade 3. Women in EG would perform a 12-week PEFLOW online under the supervision and guidance of a physiotherapist, while women in CG would have no interventions. Assessments would be conducted at enrollment, post intervention (for EG) or 18th to 24th week postpartum (for CG), and 1 year postpartum. Assessment would be performed in terms of pelvic floor symptoms, including MOS, cough stress test, urinary leakage symptoms, pelvic organ prolapse quantitation (POP-Q), and vaginal relaxation, clinic examinations including Pelvic floor electrophysiological test, Pelvic floor ultrasound and Spine X-ray, overall body test including trunk endurance test, handgrip test, body composition test, and questionnaires including International Physical Activity Questionnaire Score-Short Form(IPAQ-SF), Pelvic Floor Distress Inventory Questionnaire-20 (PFDI-20), Pelvic Floor Impact Questionnaire-7 (PFIQ-7), the 6-item Female Sexual Function Index (FSFI-6), and the Pittsburgh Sleep Quality Index (PSQI). Primary analysis will be performed to test our main hypothesis that PEFLOW is effective with respect to strengthen PFM strength.DiscussionThis trial will demonstrate that pelvic floor-care is accessible to most women and clinical practice on PFD may change relevantly should this study find that Online PEFLOW approach is effective to improve PFMs.Trial registrationClinicalTrials.gov, NCT05218239.

ImportanceRehabilitation training methods for stress urinary incontinence (SUI) need to be based on a global postural exercise, involving overall core muscle strength, core stability, and balance of the pelvis and spine. The pelvic floor workout (PEFLOW) program was developed to promote in-pregnancy pelvic floor muscle training to prevent postpartum SUI.ObjectiveTo assess the effectiveness of PEFLOW in preventing postpartum SUI.Design, setting, and participantsThis multicenter randomized clinical trial was conducted across 9 hospitals in China. Eligibility criteria were primiparous women aged 20 to 40 years, with singleton pregnancy of less than 16 weeks' gestation, and who visited the outpatient obstetric department of 1 of the 9 hospitals from August 1, 2020, to June 6, 2022. Participants, who were followed up through January 17, 2024, were randomly assigned to the exercise group or the control group and were followed up at 37 weeks' gestation and 6 weeks, 3 months, 6 months, and 12 months post partum. Primiparous women with severe complications; SUI or pelvic organ prolapse; and/or a history of cervical insufficiency, recurrent miscarriage, or induced labor were excluded. Intention-to-treat (ITT) analysis was conducted between May 1 and July 1, 2024.InterventionParticipants in the exercise group were trained to practice PEFLOW from 28 weeks' gestation to delivery, with checkups and guidance provided every 2 weeks. Participants in the control group were provided usual medical care.Main outcome and measureThe primary outcome was the incidence of SUI at 6 weeks post partum among participants in the exercise and control groups. SUI was diagnosed based on urinary leakage when abdominal pressure increased or detected from a stress test. Symptomatic SUI and the Modified Oxford Scale (MOS) score were recorded.ResultsA total of 764 women (median [IQR] age, 29 [27-32] years) were randomized into the exercise group (n = 382) and the control group (n = 382). ITT analysis showed that the incidence of SUI at 6 weeks post partum was significantly lower in the exercise group than the control group (8.7% [32 of 367] vs 13.9% [50 of 360]), with a risk difference of 5.17 (95% CI, 0.36-10.03) percentage points (P = .03). The proportion of women with an MOS score of 4 or higher at 6 weeks post partum was significantly higher in the exercise group than the control group (17.8% [68 of 382] vs 7.9% [30 of 382]), with a risk difference of 9.95 (95% CI, 5.05-14.87) percentage points (P Conclusions and relevanceIn this multicenter randomized clinical trial, PEFLOW effectively reduced SUI incidence at 6 weeks post partum. This finding suggests that PEFLOW is effective in preventing SUI in pregnancy.Trial registrationChinese Clinical Trial Registry Identifier: ChiCTR2000029618.