Traditional Gymnastic Exercises for the Pelvic Floor Often Lead to Bladder Neck Descent – a Study Using Perineal Ultrasound

Abstract

Background The aims of physiotherapy in stress incontinent women are to improve pelvic floor function and the continence mechanism including bladder neck support and urethral closure pressure. In Germany, traditional conservative treatment often includes gymnastic exercises with unclear effects on the bladder neck. The aim of this study was to sonographically assess bladder neck movements during selected exercises.

Methods Fifteen healthy, continent women without previous vaginal births, who were able to voluntarily contract their pelvic floor muscels performed the shoulder bridge, the abdominal press, tiptoe and the Pilates clam exercises. The first set was performed without any additional instructions. During the second set directions were given to activate the pelvic floor before beginning each exercise and to maintain the contraction throughout the exercise. Bladder neck movement was measured on perineal ultrasound using a validated method with the pubic symphysis as a reference point.

Results The median age of participants was 32 years, median BMI was 23. Eight women were nulliparous and seven had given birth to 1 – 2 children via caesarean section. When exercises were performed without voluntary pelvic floor contraction the bladder neck descended on average between 2.3 and 4.4 mm, and with pelvic floor contraction prior to the exercise only between 0.5 and 2.1 mm (p > 0.05 except for abdominal press p = 0.007). The Pilates clam exercise and toe stand stabilised the bladder neck most effectively.

Discussion Bladder neck descent often occurs during pelvic floor gymnastic exercises as traditionally performed in Germany, and a voluntary pelvic floor contraction during the exercises does not necessarily prevent this.

Key words

pelvic floor training - pelvic floor rehabilitation - bladder neck - perineal ultrasound - pelvic floor contraction

• References

• 1 DeLancey JO. Structural support of the urethra as it relates to stress urinary incontinence: the hammock hypothesis. Am J Obstet Gynecol 1994; 170: 1713-1720 discussion 1720–1723
• 2 Delancey JO, Ashton-Miller JA. Pathophysiology of adult urinary incontinence. Gastroenterology 2004; 126: S23-S32
• 3 DeLancey JO, Trowbridge ER, Miller JM. et al. Stress urinary incontinence: relative importance of urethral support and urethral closure pressure. J Urol 2008; 179: 2286-2290 discussion 2290
• 4 Dietz HP, Clarke B, Herbison P. Bladder neck mobility and urethral closure pressure as predictors of genuine stress incontinence. Int Urogynecol J Pelvic Floor Dysfunct 2002; 13: 289-293
• 5 Thompson JA, OʼSullivan PB, Briffa NK. et al. Assessment of voluntary pelvic floor muscle contraction in continent and incontinent women using transperineal ultrasound, manual muscle testing and vaginal squeeze pressure measurements. Int Urogynecol J Pelvic Floor Dysfunct 2006; 17: 624-630
• 6 Peschers U, Schaer G, Anthuber C. et al. Changes in vesical neck mobility following vaginal delivery. Obstet Gynecol 1996; 88: 1001-1006
• 7 Thompson JA, OʼSullivan PB, Briffa NK. et al. Comparison of transperineal and transabdominal ultrasound in the assessment of voluntary pelvic floor muscle contractions and functional manoeuvres in continent and incontinent women. Int Urogynecol J Pelvic Floor Dysfunct 2007; 18: 779-786
• 8 van Delft K, Thakar R, Sultan AH. Pelvic floor muscle contractility: digital assessment vs. transperineal ultrasound. Ultrasound Obstet Gynecol 2015; 45: 217-222
• 9 Howard D, Miller JM, Delancey JO. et al. Differential effects of cough, valsalva, and continence status on vesical neck movement. Obstet Gynecol 2000; 95: 535-540
• 10 Schaer GN, Koechli OR, Schuessler B. et al. Perineal ultrasound: determination of reliable examination procedures. Ultrasound Obstet Gynecol 1996; 7: 347-352
• 11 Miller JM, Ashton-Miller JA, DeLancey JO. A pelvic muscle precontraction can reduce cough-related urine loss in selected women with mild SUI. J Am Geriatr Soc 1998; 46: 870-874
• 12 Miller JM, Perucchini D, Carchidi LT. et al. Pelvic floor muscle contraction during a cough and decreased vesical neck mobility. Obstet Gynecol 2001; 97: 255-260
• 13 Junginger B, Seibt E, Baessler K. Bladder-neck effective, integrative pelvic floor rehabilitation program: follow-up investigation. Eur J Obstet Gynecol Reprod Biol 2014; 174: 150-153
• 14 Braekken IH, Majida M, Engh ME. et al. Can pelvic floor muscle training reverse pelvic organ prolapse and reduce prolapse symptoms? An assessor-blinded, randomized, controlled trial. Am J Obstet Gynecol 2010; 203: 170.e1-170.e7
• 15 Bo K, Stien R. Needle EMG registration of striated urethral wall and pelvic floor muscle activity patterns during cough, Valsalva, abdominal, hip adductor, and gluteal muscle contractions in nulliparous healthy females. Neurourol Urodyn 1994; 13: 35-41
• 16 Hodges PW, Richardson CA. Inefficient muscular stabilization of the lumbar spine associated with low back pain. A motor control evaluation of transversus abdominis. Spine (Phila Pa 1976) 1996; 21: 2640-2650
• 17 Sapsford RR, Hodges PW, Richardson CA. et al. Co-activation of the abdominal and pelvic floor muscles during voluntary exercises. Neurourol Urodyn 2001; 20: 31-42
• 18 Smith MD, Coppieters MW, Hodges PW. Postural response of the pelvic floor and abdominal muscles in women with and without incontinence. Neurourol Urodyn 2007; 26: 377-385
• 19 Smith MD, Coppieters MW, Hodges PW. Postural activity of the pelvic floor muscles is delayed during rapid arm movements in women with stress urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct 2007; 18: 901-911
• 20 Junginger B, Baessler K, Sapsford R. et al. Effect of abdominal and pelvic floor tasks on muscle activity, abdominal pressure and bladder neck. Int Urogynecol J 2010; 21: 69-77
• 21 Baessler K, Junginger B. Why do women leak urine? Which continence mechanism(s) fail(s)?. Int Urogynecol J 2013; 24: 90-91
• 22 Fischer W, Baessler K. Postpartum pelvic floor conditioning using vaginal cones: not only for prophylaxis against urinary incontinence and descensus. Int Urogynecol J Pelvic Floor Dysfunct 1996; 7: 208-214
• 23 Thompson JA, OʼSullivan PB. Levator plate movement during voluntary pelvic floor muscle contraction in subjects with incontinence and prolapse: a cross-sectional study and review. Int Urogynecol J Pelvic Floor Dysfunct 2003; 14: 84-88
• 24 Amaro JL, Moreira EC, De Oliveira Orsi Gameiro M. et al. Pelvic floor muscle evaluation in incontinent patients. Int Urogynecol J Pelvic Floor Dysfunct 2005; 16: 352-354
• 25 Baessler K, Kempkensteffen C. [Validation of a comprehensive pelvic floor questionnaire for the hospital, private practice and research]. Gynakol Geburtshilfliche Rundsch 2009; 49: 299-307
• 26 Dietz HP, Bennett MJ. The effect of childbirth on pelvic organ mobility. Obstet Gynecol 2003; 102: 223-228
• 27 Dietz HP, Lanzarone V. Levator trauma after vaginal delivery. Obstet Gynecol 2005; 106: 707-712
• 28 Reddy AP, DeLancey JO, Zwica LM. et al. On-screen vector-based ultrasound assessment of vesical neck movement. Am J Obstet Gynecol 2001; 185: 65-70
• 29 Dietz HP. Ultrasound imaging of the pelvic floor. Part I: two-dimensional aspects. Ultrasound Obstet Gynecol 2004; 23: 80-92
• 30 Schaer GN, Koechli OR, Schuessler B. et al. Perineal ultrasound for evaluating the bladder neck in urinary stress incontinence. Obstet Gynecol 1995; 85: 220-224
• 31 Bo K. Pelvic floor muscle exercise for the treatment of stress urinary incontinence: an exercise physiology perspective. Int Urogynecol J 1995; 6: 282-291
• 32 Bo K, Kvarstein B, Nygaard I. Lower urinary tract symptoms and pelvic floor muscle exercise adherence after 15 years. Obstet Gynecol 2005; 105: 999-1005
• 33 Hides JA, Jull GA, Richardson CA. Long-term effects of specific stabilizing exercises for first-episode low back pain. Spine (Phila Pa 1976) 2001; 26: E243-E248
• 34 Delancey JO. Why do women have stress urinary incontinence?. Neurourol Urodyn 2010; 29 (Suppl. 01) S13-S17
• 35 Howard D, Miller JM, Delancey JO. et al. Differential effects of cough, valsalva, and continence status on vesical neck movement. Obstet Gynecol 2000; 95: 535-540
• 36 Dietz HP, Wilson PD, Clarke B. The use of perineal ultrasound to quantify levator activity and teach pelvic floor muscle exercises. Int Urogynecol J Pelvic Floor Dysfunct 2001; 12: 166-168 discussion 168–169
• 37 de Jong TP, Klijn AJ, Vijverberg MA. et al. Effect of biofeedback training on paradoxical pelvic floor movement in children with dysfunctional voiding. Urology 2007; 70: 790-793
• 38 Jedrzejczak A, Chipchase LS. The availability and usage frequency of real time ultrasound by physiotherapists in South Australia: an observational study. Physiother Res Int 2008; 13: 231-240