Intra-abdominal Pressure with pelvic Floor Dysfunction: Do Postoperative Restrictions Make Sense?

Yamasato KS, Oyama IA, Kaneshiro B. The Journal of Reproductive Medicine 2014 Jul-Aug;59 (7-8):409-13

Trisha Jenkyns PT, DPT, WCS

11-5-2014  Pelvic PT Distance Journal Club

 

OBJECTIVE: To quantify and compare intraabdominal pressures (IAPs) in women with pelvic floor dysfunction… during standard activities.

STUDY DESIGN:

Prospective, descriptive study done at the University of Hawaii between 2007-2008.  Women were sequentially recruited when presenting for urodynamic testing with dysfunctions of POP and /or UI 

Exclusion criteria:  younger than 18 years old, Pregnancy, mental o physical disability, or inability to safely perform the activities in the study.

PROCEDURE STARTED WITH CATHING TO EMPTY THE BLADDER, THEN…

Bladder & vaginal pressure catheters were placed. 

Bladders were filled until the women reported a strong urge to void. 

With the vaginal pressure catheter in place to measure IAP, each subject performed certain tasks in the same order.

1. Standing up from a chair
2. Coughing once
3. Lifting 10 lbs by bending & grasping a handle with one hand & standing
4. Lifting 20 lbs, 10 lbs in each hand
5. Pushing 20 lbs on wheels for 3-4  feet

Net IAP was recorded along with age, height, weight, indication for Urodynamic testing and degree of POP for 147 women ( but the degree of POP was not included in the findings)

 Mean age was 57 with ages spanning 36-83 years), SUI was the most common reason for urodynamics

68.7% had SUI,

18.4% for POP, and

6.8% POP & SUI

6.1 % urinary urgency was

RESULTS:

Table I has more specific demographic data

Table II looks at the IAP (CM H2O) generated by each activity. 

Standing up and coughing produced greatest IAP

What I find very interesting here is not just the pressure induced by the coughing and standing up, but also the tremendous variation.  For example with standing, in some women it was as little as 5 cm H2O  or as high as 89 cm H2O …and with coughing the minimum was 14 cm H2o and the maximum of 150 cm H2O.  I wonder if the participants with higher IAPs were  holding their breath & bearing down as they stood up.

When looking at Table III, where they make comparisons between activities

you can see there was a significant difference between lifting 10 lbs and 20 lbs, but there was still more IAP generated with coughing and standing up

Table IV describes the IAP according to BMI.  They found that IAP was significantly greater for overweight women in all activities, except with standing. 

Because BMI was shown to be a significant factor … the authors concluded that this population may benefit from stricter post-op restrictions then women with lower BMI’s.

IN Table V…they looked at different age groups and amount of IAP generated

 Age was associated with a difference in IAP only for standing.  The 70-89 year group generated significantly less IAP the younger than those younger than 70 years old.

 IAP during lifting did not vary by age group, so the authors concluded that age might not be a factor in post-op restrictions.

They also pointed out that IAP did not differ with the presence of POP for any of the activities

LIMITATIONS:  Things not factored in: hx of pelvic surgery, menopausal state and parity, IAP during the activities was not different in women with POP, but degree of POP was not identified when comparing data.

DISCUSSION:

• This study presents helpful quantitative data to consider when advising pre and post-op gyne repairs and for promoting PT pre & post op
• Reminder that patients would likely benefit from education & training with breathing during all functional activities to avoid excessive increased IAP.
• In particular the activity of sit to stand should be discussed with patients
• What is the significance of this article compared to other studies we have previously discussed looking at post gyne surgery guidelines?
• It would be beneficial to study if IAP can be reduced by altering techniques for lifting, pushing or standing up and can we impact IAP with training & education?