Hung H, Hsiao S, Chih S, Lin H, Tsauo J. Effect of Pelvic-Floor Muscle Strengthening on Bladder Neck Mobility: A Clinic al Trial

Pelvic Physiotherapy Think Tank

December 7, 2011

Michelle Spicka

Objective:  The aim of the study was to investigate the effect of PFM strengthening on bladder neck mobility for women with stress UI or mixed UI.

Subjects: 23 patients between 18 and 65 who had at least one episode of SUI or MUI during the previous month.  .

Study Design/Method:  Each participant underwent a PFM strengthening program for 4 months.  Participants were asked to perform 3-5 sets of 6 near-maximal contractions daily (hold for 10 seconds and relax for at least 10 seconds).  Fast contractions (1 second contraction with 1 second relaxation) were added after the sustained contractions, with a target of 10 reps in every set.  Bladder neck position at rest and during a cough, the Valsalva maneuver, and a PFM contraction was assessed by transperineal ultrasonography before and after the intervention.  There was no blinding of subjects or evaluators in this study.

Oxford Levels of Evidence: This study was a single-group pretest-posttest design - Level 3

Outcome: All 23 subjects completed the 4 month exercise program.  13 made appointments for additional instruction throughout the study (this was made available to all participants and was optional).  The mean number of PFM contractions per day by the group was 26.5.  One patient noted she was cured and the other 22 (95.7%) reported improvement.

Results:

1)      After the 4 month strengthening program, both the angle of bladder neck rotation on PFM contraction and the bladder neck mobility of maximal incursion from rest to PFM contraction increased (See Table 2)

2)      Bladder neck position was not changed at rest or during a cough or Valsalva maneuver

Conclusion:

1)      This study demonstrated that a 4-month PFM  strengthening program for women with SUI or MUI could improve the ability of the pelvic floor to elevate the bladder neck, improve urinary continence and enhance PFM strength but not reduce the caudal displacement of the bladder neck during a cough or the Valsalva maneuver

2)      Study Limitations: Study design; measurements, true exercise adherence. 

Thought Questions:

1)      What role does bladder neck mobility have in continence and what other techniques could be used to improve bladder neck stiffness? 

2)      Is bladder neck stiffness more important than pelvic floor strength?  What about the other segments of the urethral structures? 

a.       Kruger et al (2007) concluded that mid-urethral mobility rather than bladder neck or proximal urethral mobility is a factor in SUI

b.      El Sayed et al (2008) concluded that SUI is associated with structural defects in the urethral support rather than bladder neck descent

c.       Pipiris et al (2009) and Erdmann et al (2010) found mid-urethral mobility significantly predicts the symptom of SUI but not proximal urethral mobility

3)      Currently there is no consensus in the literature regarding the effects of PFM strengthening on bladder neck position at rest and during the Valsalva maneuver or on downward displacement of the bladder neck during the Valsalva.

4)      Given the different findings in literature, wouldn’t it be best to just generalize that increasing pelvic floor strength is beneficial in decreasing SUI regardless of which structures are actually affected (since different studies conclude that different structures are key in maintaining continence without any consensus)