Pelvic Floor Movement Research Articles

A Prospective Feasibility Study to Differentiate Sacral Neuromodulation Lead Electrode Configurations Using Motor and Sensory Thresholds and Locations of Sensation.

Background Accurate positioning and effective programming of sacral neuromodulation (SNM) relies upon the use of several acute stimulation measurements. While the clinical utility of these acute measurements including pelvic floor motor thresholds (PFMT), toe/leg motor thresholds (TMT), and sensory thresholds (ST), are widely accepted, their usefulness in quantitative research remains unclear. The purpose of this prospective study was to test these measurements and gauge their utility in future research. Methods Eight participants received Axonics SNM, 6 Medtronic Interstim II, and 2 Medtronic Micro SNM. PFMT was measured after implantation. ST and the location of sensation (LOS) were measured immediately postoperatively (PO), at pre-release from the surgery center (PR), and during a follow-up clinic visit (FU). Thresholds were compared across contact and time using linear mixed-effects models. Results Significant differences in PFMT were found across electrode configurations, with stimulation through proximal contacts exhibiting lower PFMT than distal configurations. ST displayed no significant differences across electrodes and showed minimal changes over time. LOS exhibited substantial variability across patients and periods. Conclusions Results suggest that PFMT were able to differentiate differences across electrode configurations that may be useful for future quantitative research. The lack of differences in ST and LOS across electrode configurations was interesting given the focus on these measurements clinically. Future testing is to confirm these limitations.

Transperineal pelvic floor ultrasound in male.

The pelvic floor (PF) is a highly complex structure which may be affected by various stimulating factors like decreased PF support. As ultrasound can dynamically observe the position and mobility of anatomical structures, However, there are very few studies on PF ultrasound in males. Twenty-one male patients with normal conditions underwent transperineal pelvic floor ultrasound (TPFU) examination. Ultrasound was performed in a supine lithotomy position. The probe was pressed on the sagittal plane of the perineum and adjusted till the anorectal angle, as well as bladder, were located and the median prostate and pubic symphysis were visible on the sagittal plane. TPFU was carried out to observe the patterns of pelvic floor movement during different phases, measure ultrasound parameters of the PF in men, and assess the potential applications and prospects of the male PF. Two-dimensional male PF ultrasound can detect the bladder, prostate, male urethra, anus, rectum. Resting, Valsalva, and contraction phases of the PF are clearly shown, the pelvic organs in the Valsalva phase shift to the dorsal foot side, and shift to the cephalic ventral side when the levator ani muscle (LAM) contracts. Three-dimensional male PF ultrasound can visually show the shape and structure of the levator ani muscle hiatus. It is a feasible examination tool for detecting PF disorders. However, there are still many fields to explore in the future.

Preliminary data on the neurophysiological evaluation of male sexual dysfunction in patients with pelvic ring fractures: a multicenter retrospective study.

Traumatic pelvic ring fractures include several comorbidities due to the close anatomical relationship between the skeletal system, pelvic organs, and neurovascular structures. In this retrospective multicenter study, we evaluated patients complaining of sexual dysfunction following pelvic ring fractures, assessed through different neuro-physiological examinations. Patients were enrolled one year after the injury according to their reported ASEX scores and evaluated on the basis of the Tile's type of pelvic fracture. Lower limb and sacral somatosensory evoked potentials, pelvic floor electromyography, bulbocavernosus reflex and pelvic floor motor evoked potentials were recorded, according to the neurophysiological indications. A total of 14 male patients (mean age 50.4; 8 subjects Tile-type B and 6 Tile-type C) were enrolled. The ages between the Tile B group and the Tile C group of patients were not significantly different (p=0.187), while the ASEX scores were significantly different (p=0.014). In 57% of patients (n=8), no alterations in nerve conduction and/or pelvic floor neuromuscular responses were found. In 6 patients, electromyographic signs of denervation were revealed (2 patients), and alterations of the sacral efferent nerve component were detected in 4 patients. Sexual dysfunctions after a traumatic pelvic ring fracture are more common in Tile-type B. Our preliminary data did not reveal a significant association with neurogenic aetiology. Other causes could explain the complaining impairments.

Considering non-bladder aetiologies of overactive bladder: a functional neuroimaging study.

To better understand the neuropathophysiology of overactive bladder (OAB) in women by characterising supraspinal activity in response to bladder distention and cold stimulation. We recruited 24 female participants, 12 with OAB (median [interquartile range, IQR] age 40[32-42]years) and 12 healthy controls (HCs) without lower urinary tract (LUT) symptoms (median [IQR] age 34[28-44]years), and assessed LUT and cognitive function through neuro-urological examination, 3-day bladder diary, urodynamic investigation, and questionnaires. Functional magnetic resonance (MR) imaging using a 3-T scanner was performed in all participants during automated, repetitive bladder filling and draining (block design) with 100mL body temperature (37°C) saline using a MR-compatible and MR-synchronised infusion-drainage device until strong desire to void (HIGH-FILLING/DRAINING) and bladder filling with cold saline (4°C, i.e. COLD). Whole-brain and region-of-interest analyses were conducted using Statistical Parametric Mapping, version 12. Significant between-group differences were found for 3-day bladder diary variables (i.e. voiding frequency/24h, P<0.001; voided volume/void, P=0.04; and urinary incontinence [UI] episodes/24h, P=0.007), questionnaire scores (International Consultation on Incontinence Questionnaire-Female LUT symptoms [overall, filling, and UI scores, all P<0.001]; the Overactive Bladder Questionnaire short form [symptoms and quality-of-life scores, both P<0.001]; the Hospital Anxiety and Depression Scale [anxiety P=0.004 and depression P=0.003 scores]), as well as urodynamic variables (strong desire to void, P=0.02; maximum cystometric capacity, P=0.007; and presence of detrusor overactivity, P=0.002). Age, weight and cognitive function (i.e. Mini-Mental State Examination, P=1.0) were similar between groups (P>0.05). In patients with OAB, the HIGH task elicited activity in the superior temporal gyrus, ventrolateral prefrontal cortex (VLPFC), and mid-cingulate cortex; and the COLD task elicited activity in the VLPFC, cerebellum, and basal ganglia. Compared to HCs, patients with OAB showed significantly stronger cerebellar activity during HIGH-FILLING and significantly less activity in the insula and VLPFC during HIGH-DRAINING. The present findings suggest a sensory processing and modulation deficiency in our OAB group, probably as part of their underlying pathophysiology, as they lacked activity in essential sensory processing areas, such as the insula. Instead, accessory areas, such as the cerebellum, showed significantly stronger activation compared to HCs, presumably supporting pelvic-floor motor activity to prevent UI. The novel findings of the present study provide physiological evidence of the necessity to consider non-bladder aetiologies of bladder symptoms.

A systematic review and activation likelihood estimation meta-analysis of the central innervation of the lower urinary tract: Pelvic floor motor control and micturition.

PurposeFunctional neuroimaging is a powerful and versatile tool to investigate central lower urinary tract (LUT) control. Despite the increasing body of literature there is a lack of comprehensive overviews on LUT control. Thus, we aimed to execute a coordinate based meta-analysis of all PET and fMRI evidence on descending central LUT control, i.e. pelvic floor muscle contraction (PFMC) and micturition.Materials and methodsA systematic literature search of all relevant libraries was performed in August 2020. Coordinates of activity were extracted from eligible studies to perform an activation likelihood estimation (ALE) using a threshold of uncorrected p <0.001.Results20 of 6858 identified studies, published between 1997 and 2020, were included. Twelve studies investigated PFMC (1xPET, 11xfMRI) and eight micturition (3xPET, 5xfMRI). The PFMC ALE analysis (n = 181, 133 foci) showed clusters in the primary motor cortex, supplementary motor cortex, cingulate gyrus, frontal gyrus, thalamus, supramarginal gyrus, and cerebellum. The micturition ALE analysis (n = 107, 98 foci) showed active clusters in the dorsal pons, including the pontine micturition center, the periaqueductal gray, cingulate gyrus, frontal gyrus, insula and ventral pons. Overlap of PFMC and micturition was found in the cingulate gyrus and thalamus.ConclusionsFor the first time the involved core brain areas of LUT motor control were determined using ALE. Furthermore, the involved brain areas for PFMC and micturition are partially distinct. Further neuroimaging studies are required to extend this ALE analysis and determine the differences between a healthy and a dysfunctional LUT. This requires standardization of protocols and task-execution.

Comparing Motor Control of the Lumbosacral Region and Pelvic Floor Muscle Strength and Performance in Women with C-Section and Vaginal Birth

Background: Delivery is a physiological process that may cause neurophysiological changes in the lumbosacral region. Objectives: The current study aimed to compare motor control of the lumbosacral region and pelvic floor muscle strength and performance in women with C-section and vaginal birth. Methods: In this cross-sectional study, 120 prim parous women referring to healthcare centers in Karaj (Iran) during 2019 are studied. The participants were selected using convenience sampling. The motor control of the lumbosacral region was examined by four clinical tests (standing bent, active straight leg raising, bent knee fall out, and knee lift abdominal test) using a pressure biofeedback unit. Muscle strength and performance were measured using the Oxford scoring system and the PFPI-20 questionnaire, respectively. Data were analyzed using independent t-test, Mann-Whitney, and Chi-square tests. Statistical significance was considered when P value &lt; 0.05. Results: Based on the standing bent test, a significant difference was found between those in vaginal delivery and C-section groups (P = 0.011). Also, the mean scores of muscular strengths (P = 0.009) and pelvic floor muscular function (P = 0.01) in the vaginal delivery group were significantly higher than the C-section group. Conclusions: the mean scores of pelvic floor motor control, pelvic floor muscular strength, and function in the C-section group were higher than those in the vaginal delivery group. This study demonstrated the necessity of postpartum pelvic floor muscle rehabilitation, especially in vaginal delivery.

133 - A systematic review and activation likelihood estimation meta-analysis of the central innervation of the lower urinary tract: Pelvic floor motor control and micturition

133 - A systematic review and activation likelihood estimation meta-analysis of the central innervation of the lower urinary tract: Pelvic floor motor control and micturition

Development of a wireless accelerometer-based Intravaginal device to detect pelvic floor motion for evaluation of pelvic floor dysfunction

Urinary incontinence (UI) is experienced by an estimated 51% of women in the U.S. and often results from impaired function or weakening of the pelvic floor muscles. Pelvic floor muscle training (PFMT) is a frontline nonsurgical treatment, yet a number of symptomatic individuals cannot accurately perform a pelvic floor muscle contraction with simple verbal or written instruction. Long-term adherence to PFMT regimens is often a barrier to resolution of symptoms. Various biofeedback tools have been utilized to aid correct pelvic floor muscle performance and adherence. One novel device, the leva® Pelvic Digital Health System, utilizes an intravaginal probe embedded with MEMS accelerometer sensors that allow real-time visualization of the shape and motion of the vagina during PFMT. Early positive results with this device prompted design of a wearable version. The purpose of this study was to design a wearable, wireless clinical research device to optimize MEMS accelerometer sensor placement to detect maximal movement during a pelvic floor muscle exercise (PFME) and to test the form factor for retention and user acceptability. The device comprised a ring designed to sit at the fornix with an extension following the length of the vagina. This paper presents design components and results from clinical testing of 10 subjects. It was determined that a ring form factor alone, similar to other vaginal rings (pessaries, estrogen rings) provided less accurate visual information about PFME performance. By contrast, we determined that a ring with an extension allowed for device retention and improved real-time detection of vaginal shape and motion during PFMT.

Transcranial magnetic stimulation and bladder function: A systematic review

ObjectiveWe aimed at assessing the usefulness of motor evoked potentials (MEPs) for exploring the integrity of striated sphincters and pelvic floor motor innervation in normal subjects and of repetitive transcranial magnetic stimulation TMS (rTMS) in patients with neurogenic bladder dysfunction. MethodsA systematic literature search was conducted using PubMed and Embase. ResultsWe identified, reviewed and discussed 11 articles matching the inclusion criteria. ConclusionsThe assessment of MEPs could represent a useful tool in the investigation of patients with urologic disorders. High frequency rTMS can improve detrusor contraction and/or urethral sphincter relaxation in patients with multiple sclerosis and bladder dysfunction. Low frequency (LF) rTMS seems to be an effective treatment of neurogenic lower urinary tract dysfunctions in subjects with Parkinson’s disease and possibly other neurodegenerative disorders. Furthermore, rTMS might have the potential to restore bladder and bowel sphincter function after incomplete spinal cord injury. LF rTMS could also relieve some symptoms of bladder pain syndrome and chronic pelvic pain. SignificanceThe clinical applicability of MEPs appears to be questionable, since a poor reproducibility was detected for all pelvic floor muscles. The use of rTMS in this field is emerging and the results of a few preliminary studies should be replicated in controlled, randomized studies with larger sample sizes.

6 - High field single subject brain mapping of pelvic floor motor control. A 7-Tesla fMRI study

6 - High field single subject brain mapping of pelvic floor motor control. A 7-Tesla fMRI study

Normal values for assessment of anal sphincter morphology, anorectal motion, and pelvic organ prolapse with MRI in healthy women.

Endoanal MRI and MR defecography are used to identify anal sphincter injury and disordered defecation. However, few studies have evaluated findings in asymptomatic healthy people. The effects of BMI and parity on rectoanal motion and evacuation are unknown. In 113 asymptomatic females (age 50±17years, Mean±SD) without risk factors for anorectal trauma, anal sphincter appearance, anorectal motion, and pelvic organ prolapse were evaluated with MRI. The relationship between age, BMI, and parity and structural findings were evaluated with parametric and non-parametric tests. The anal sphincters and puborectalis appeared normal in over 90% of women. During dynamic MRI, the anorectal angle was 100±1º (Mean±SEM) at rest, 70±2° at squeeze, and 120±2° during defecation. The change in anorectal angle during squeeze (r=-.25, P<.005), but not during evacuation (r=.13, P=.25) was associated with age. In the multivariable models, BMI (P<.01) and parity (P<.01) were, respectively, independently associated with the intersubject variation in the anorectal angle at rest and the angle change during squeeze. Ten percent or fewer women had had descent of the bladder base or uterus 4cm or more below the pubococcygeal line or a rectocele measuring 4cm or larger. Only 5% had a patulous anal canal. In addition to age, BMI and parity also affect anorectal motion in asymptomatic women. These findings provide age-adjusted normal values for rectoanal anatomy and pelvic floor motion.

The physiological motor patterns produced by neurons in the nucleus retroambiguus in the rat and their modulation by vagal, peripheral chemosensory, and nociceptive stimulation.

The nucleus retroambiguus (NRA) is a neuronal cell group in the medullary ventrolateral tegmentum, rostrocaudally between the obex and the first cervical spinal segment. NRA neurons are premotor interneurons with direct projections to the motoneurons of soft palate, pharynx, and larynx in the nucleus ambiguus in the lateral medulla as well as to the motoneurons in the spinal cord innervating diaphragm, abdominal, and pelvic floor muscles and the lumbosacral motoneurons generating sexual posture. These NRA premotor interneurons receive very strong projections from the periaqueductal gray (PAG) in the context of basic survival mechanisms as fight, flight, freezing, sound production, and sexual behavior. In the present study in rat we investigated the physiological motor patterns generated by NRA neurons, as the result of vagal, peripheral chemosensory, and nociceptive stimulation. The results show that the NRA contains phasic respiratory modulated neurons, as well as nonphasic tonically modulated neurons. Stimulation in the various rostrocaudal levels of the NRA generates site-specific laryngeal, respiratory, abdominal, and pelvic floor motor activities. Vagal and peripheral chemosensory stimulation induces both excitatory and inhibitory modulation of phasic NRA-neurons, while peripheral chemosensory and nociceptive stimulation causes excitation and inhibition of nonphasic NRA-neurons. These results are in agreement with the concept that the NRA represents a multifunctional group of neurons involved in the output of the emotional motor system, such as vomiting, vocalization, mating, and changes in respiration.

MP72-09 A STANDARDIZED UROLOGICAL EXAMINATION FOR WOMEN AND MEN WITH UROLOGIC CHRONIC PELVIC PAIN SYNDROMES: A MAPP NETWORK SITE-SPECIFIC STUDY

You have accessJournal of UrologyInfections/Inflammation/Cystic Disease of the Genitourinary Tract: Interstitial Cystitis1 Apr 2016MP72-09 A STANDARDIZED UROLOGICAL EXAMINATION FOR WOMEN AND MEN WITH UROLOGIC CHRONIC PELVIC PAIN SYNDROMES: A MAPP NETWORK SITE-SPECIFIC STUDY Claire Yang, Jane Miller, Adam Omidpanah, and John Krieger Claire YangClaire Yang More articles by this author , Jane MillerJane Miller More articles by this author , Adam OmidpanahAdam Omidpanah More articles by this author , and John KriegerJohn Krieger More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1622AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES There have not been any physical examination findings reported to be specific to patients with urologic chronic pelvic pain syndromes (UCPPS). Our objective was to perform a standardized examination for both women and men with UCPPS. METHODS Participants were enrolled in the MAPP Epidemiology Phenotyping Study. Our study included an expanded physical examination using the same technique in women and men, looking at 4 categories: a) extrapelvic, regional tenderness (including abdomen, flank, and back) b) pelvic floor and pelvic organ tenderness, c) pudendal nerve sensory function, and d) pelvic floor motor function. Comparisons of women and men were performed separately. Patients with UCPPS, positive controls with chronic fatigue syndrome and healthy, and pain free controls were enrolled. RESULTS The examination was performed in 65 UCPPS cases (31 F, 34 M), 30 positive controls (15 F, 15 M), and 41 healthy controls (23 F, 18 M). There were no differences in pudendal nerve sensory function and pelvic floor motor function, when comparing cases with healthy controls, and cases with positive controls. Female and male cases were more likely to have tenderness than healthy controls in the following regions: right and left levator muscles, right and left obturator muscles, and right and left urogenital diaphragm. Female cases were more likely than healthy controls to have suprapubic, symphysis pubis, posterior superior iliac spine and bimanual examination tenderness. Positive controls also demonstrated tenderness in pelvic and extrapelvic regions, but less frequently than in cases, and more so in women than in men. CONCLUSIONS This extended examination revealed that pelvic and extrapelvic tenderness was found most frequently in UCPPS cases than in healthy and positive controls. Female positive controls also demonstrated tenderness. This examination can be used with female and male patients with UCPPS, and may prove helpful for phenotyping them. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e955 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Claire Yang More articles by this author Jane Miller More articles by this author Adam Omidpanah More articles by this author John Krieger More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

3: Pelvic floor muscle motor unit recruitment: Kegels vs specialized movement

Pelvic floor exercise is clearly established as appropriate first line treatment for stress urinary incontinence and overactive bladder. The effectiveness of exercise relates to the degree of motor unit recruitment achieved during exercise. To date the Kegel exercise has been the most common recommendation for pelvic floor conditioning and rehabilitation. The purpose of this study is to compare the traditional Kegel exercise to specialized movements that incorporate voluntary pelvic floor contraction at a point in the movement where the pelvic floor is naturally engaged. Between January 2014 and May 2015 one hundred consecutive patients referred for pelvic floor rehabilitation were instructed as to how to perform 10 different movements know to naturally engage the pelvic floor. Subjects wore small wireless surface EMG sensors recording muscular activity from the pelvic floor, gluteals, lower abdominal muscles, and the lower extremity adductors. Video clips synchronized to 4-channel EMG were recorded for each movement. Each clip began with an isolated pelvic floor contraction before the subject performed one of the ten specialized pelvic floor movements. Mean peak pelvic floor activity during the isolated PF contraction were compared to the peak pelvic floor activity achieved during the movement. Percent Greater Than Isolated Kegel1.Lunge: 42% (0-80) p<0.0012.Squat: 30% (-40-75) p<0.0013.Side Lying Bent Knee Lift: 25% (14-72) p<0.0014.Side Lying Straight Leg Circle: 25% (-33-63) p<0.0015.Butterfly: 36% (-25-90) p<0.0016.Bridge: 56% (15-82) p<0.0017.Corkscrew: 21% (-50-57) p<0.0018.Hovering: 49% (-12-80) p<0.0019.All 4s Bent Knee Lift: 30% (-22-71) p<0.00110.Cat Into Cow: 41% (-5-73) p<0.001 Each of the ten movements produced a mean statistically significant increase in PF activity than traditional (stationary) Kegel exercises. Specialized movements, when performed in conjunction with voluntary pelvic floor contractions may provide greater motor unit recruitment than traditional Kegel exercises. Individuals vary as to the degree of enhanced engagement with any given movement.

MR Defecography, a Diagnostic Test to Evaluate the Pelvic Floor Motion in Patients with Dyssynergic Defecation after Biofeedback Therapy

Background: Dyssynergicdefecation is a major cause of chronic functional constipation as a common digestive complaint. We clinically evaluated the effects of biofeedback therapy on the pe lvic floor motion indices through magnetic resonance (MR) defecography, quality of life and depression in patients with dyssynergic defecation. Methods: In this clinical trial study, among patients referring to the Colorectal Clinic of Hazrat Rasoul Hospital, 22 subjects were randomly assigned into two equal groups (n= 11) to receive either standard only or biofeedback and standard therapy. Dynamic changes of the pelvic floor were mea sured by MR defecography. During the simulated defecation, two MR defecography dynamic indices including abnormal anorectal angle change an d perineal descent were measured before and after

English

BACKGROUND: Pelvic floor dysfunction is one of the common conditions encountered in female patient's especially uterine descent; cystocele and rectocele are faced by elderly parous women. At present there is no fixed ultrasound criteria to evaluate the pelvic floor. About 11-15% of the general populations who attend outpatient department suffer from various degrees of these problems. Ultrasound imaging of pelvic floor will help the patient from unnecessary complications and reduce the morbidity by delineating pelvic floor anatomy with dynamic studies. OBJECTIVES: To define pelvic floor ultrasound anatomy and to define fixed criteria for diagnosis of problems by 2D ultrasound and to apply the same to qualify and quantify problems. METHODS: Prospective ultrasonographic analysis of sequentially selected 50 cases presenting with pelvic floor dysfunction, and diagnosed clinically by gynecologists were included. INTERPRETATION AND CONCLUSION: Ultrasound is an invaluable, minimally invasive, highly accurate and cost effective procedure for assessment of pelvic floor movement of uterus, bladder and rectum with strain is best assessed on real time ultrasound.

Dynamic pelvic floor ultrasound for lower urinary tract symptoms in children – Initial report on normative values

PurposeLower urinary tract symptoms (LUTS) are common in children. The aim of this study was to determine normal values for pelvic floor movement in asymptomatic controls to allow comparison with symptomatic children with dysfunctional voiding (DV) in the next phase of the study. Material and methodsOne hundred children between the ages of 5–17 years were recruited prospectively as controls. All were asked to perform a voluntary pelvic floor contraction manoeuvre with a full bladder. All scans were performed on a Vivid I GE ultrasound machine with a 4–9 MHz curvilinear probe. M Mode was used to determine the direction of pelvic floor (levator plate-LP) movement, the distance in cms and the endurance in seconds. Each measurement was taken 3 times. ResultsSix children were unable to understand and perform the manoeuvre and were excluded. The median age was 10 years (range 4–17). The median LP movement was 0.3 cm (range 0.1–1.6) and cranial in 86/94 (91%). The median endurance time was 5.8 s (range 2.3–15.5). For the (n = 59) younger children aged 4–11, the 95% normal reference range for LP movement was 0.1 cm–1.4 cm and for endurance was 2.5–13.5 s. For the (n = 33) older children aged 12–17, the 95% normal reference range for LP movement was 0.2 cm–1.2 cm and for endurance was 2.3–15.5 s. There was a significant correlation (Pearson r = 0.39, P = 0.001) between average LP movement and endurance. ConclusionsThis study gives the normal reference ranges for the variables measured. A further study is currently underway examining the same variables in children with dysfunctional voiding (DV) and comparing these with the reference range.

Semi‐automated vectorial analysis of anorectal motion by magnetic resonance defecography in healthy subjects and fecal incontinence

Inter-observer variability limits the reproducibility of pelvic floor motion measured by magnetic resonance imaging (MRI). Our aim was to develop a semi-automated program measuring pelvic floor motion in a reproducible and refined manner. Pelvic floor anatomy and motion during voluntary contraction (squeeze) and rectal evacuation were assessed by MRI in 64 women with fecal incontinence (FI) and 64 age-matched controls. A radiologist measured anorectal angles and anorectal junction motion. A semi-automated program did the same and also dissected anorectal motion into perpendicular vectors representing the puborectalis and other pelvic floor muscles, assessed the pubococcygeal angle, and evaluated pelvic rotation. Manual and semi-automated measurements of anorectal junction motion (r = 0.70; P < 0.0001) during squeeze and evacuation were correlated, as were anorectal angles at rest, squeeze, and evacuation; angle change during squeeze or evacuation was less so. Semi-automated measurements of anorectal and pelvic bony motion were also reproducible within subjects. During squeeze, puborectalis injury was associated (P ≤ 0.01) with smaller puborectalis but not pelvic floor motion vectors, reflecting impaired puborectalis function. The pubococcygeal angle, reflecting posterior pelvic floor motion, was smaller during squeeze and larger during evacuation. However, pubococcygeal angles and pelvic rotation during squeeze and evacuation did not differ significantly between FI and controls. This semi-automated program provides a reproducible, efficient, and refined analysis of pelvic floor motion by MRI. Puborectalis injury is independently associated with impaired motion of puborectalis, not other pelvic floor muscles in controls and women with FI.

Assessment and Comparison of Regional Pelvic Floor Motion in Health and Fecal Incontinence: A Population-Based Case-Control Study

Background: Current understanding is that the external anal sphincter (EAS) is a circular or “donut shaped” muscle which contracts in a circumferential manner to increase the anal canal pressure. Anterior end of the EAS muscle fibers are inserted into the midline structure of perineal body and posteriorly the EAS is attached to the coccyx by a fibro-aponeurotic structure, i.e. “anococcygeal raphe”. A separate set of superficial muscles of the perineum, i.e. transverse perinea (TP), originate from the right and left pubic rami (laterally) and are inserted into the perineal body in the midline. Aim: We assessed the EAS and TP muscles morphology using 3D transperineal ultrasound (US), magnetic resonance (MR) imaging & MR diffusion tensor imaging (DTI). DTI probes the anisotropic nature of cellular water diffusion in the tissue structure that allows one to infer the direction of muscle fibers & micro-structural organization In Vivo. Studies were conducted in 15 nullipara women. Results: Analysis of MR and US images (Fig. 1), 1 mm apart and perpendicular to the axis of anal canal, revealed that the cranio-caudal extent of transverse perinei and EAS are identical. As one follows the EAS muscle from the right and lateral directions they merge into the TP muscles. Transverse DTI images (Fig.2, top) revealed that, for the perineal body and the lateral, medial and posterior aspects of EAS: (1) angle of fibers (a) S/I axis of subject was 79.5o, 65.7o, 78o and 85o respectively, i.e. they were all closely aligned towards the transverse plane. (b) A/P axis of the subjects, were 77.3o, 10.9o, 21.4o and 75.0o respectively, suggesting a novel configuration shown in the schematic in Fig.2 (bottom). (2) Fractional anisotropy (FA), a robust intra-voxel measure equal to 0 for perfectly isotropic and 1 for perfectly anisotropic diffusion (e.g. in a long thin tube), was significantly lower (0.22+0.01) for perineal body compared to lateral (0.4+0.04), medial (0.38+0.03), and posterior (0.38+0.03) aspects of EAS muscles. Based on studies of the fiber tracts in the brain, the lower value of FA in the perineal body strongly suggests crossing over of the EAS muscle fibers from the right side of EAS into the left TP and vice versa, compared to unidirectional fibers in the other 3 regions. Conclusions: US, MRI and DTI studies validate our novel hypothesis of a “purse string” EAS in which anteriorly, the EAS muscle fibers continue as the transverse perinea while posteriorly, as anococcygeal raphe to be inserted into the coccyx.

Gynecological Surgery and Low Back Pain in Older Women

To determine sacroiliac joint compliance characteristics and pelvic floor movements in older women relative to gynecological surgery history and back pain complaints. Single-visit laboratory measurement. University clinical research center. Twenty-five women aged 65 years or older. Sacroiliac joint compliance measured by Doppler imaging of vibrations and ultrasound measures of pelvic floor motion during the active straight leg raise test. Doppler imaging of vibrations demonstrated test reliability ranging from 0.701 to 0.898 for detecting vibration on the ilium and sacrum sides of the sacroiliac joint. The presence of low-back pain or prior gynecological surgery was not significantly associated with a difference in the compliance or laxity symmetry of the sacroiliac joints. No significant difference in pelvic floor movement was found during the active straight leg raise test between subject groups. All P values were ≥.4159. Prior gynecological surgery and low-back pain were not significantly associated with side-to-side differences in the compliance of the sacroiliac joints or in significant changes in pelvic floor movement during a loading maneuver in a group of older women.