May 6th, 2015
Pelvic Physical Therapy Distance Journal Club
Description: Pelvic
floor muscle exercises have been found to help with post-prostatectomy urinary
incontinence in men but there is a lack of consistency of the instructions used
to teach men to activate the pelvic floor muscles. Because the efficacy of a pelvic floor muscle
exercise program for treatment of incontinence after prostatectomy is likely to
depend on if and how the muscles of urinary continence are activated, optimal
methods to achieve activation have received limited attention.
The aim of this study is to investigate the effect of
instruction on activation of pelvic floor muscles in men as quantified by
transperineal ultrasound imaging and to validate these measures with invasive
EMG recordings.
Methods: Fifteen
men aged 28-44 with no history of urological or neurological disease were
included. No participant had undergone
previous training for the pelvic floor muscles.
Participants sat upright on a plinth with knees
extended. Three repetitions of voluntary
pelvic floor contractions were performed with guidance of specific verbal
instructions. Contractions were
sustained for 3 seconds and separated by 10 seconds rest.
Four instructions were tested (and performed in random
order, separated by 2 minutes rest):
1.
Tighten around the anus (predicted to target the
anal sphincter)
2.
Elevate the bladder (predicted to target
pubrorectalis)
3.
Shorten the penis (predicted to target striated
urethral sphincter)
4.
Stop the flow of urine (predicated to target
striated urethral sphincter and puborectalis)
Results: Displacement
at the mid-urethra differed between instructions.
1)
Peak mid-urethral displacement was greater
during “shorten the penis” than “elevate the bladder” and “tighten the anus”
but not “stop the flow of urine”
2)
Instruction had no differential effect on
displacements at ventral urethral-vesical junction.
3)
The instruction that achieved maximum
displacement of puborectalis for individual participants was distributed
between “elevate the bladder”, “shorten the penis” and “stop the flow of
urine”.
4)
Most participants achieved maximum displacement
of ano-rectal junction with “tighten around the anus” and “stop the flow of
urine”.
5)
The greatest movement at the bulb of penis was
most commonly observed for “tighten around the anus”.
6)
Instruction to “elevate the bladder” induced the
greatest increase in abdominal EMG and intra-abdominal pressure.
Discussion:
1)
Verbal instructions used to encourage voluntary
contraction of different pelvic floor muscles influences the pattern of
urethral movement observed with ultrasound.
2)
Optimized activation of the striated urethral
sphincter with limited increase in intra-abdominal pressure is best achieved
with “shorten the penis” or “stop the flow of urine”.
3)
“Tighten around the anus” targets activation of
the anal sphincter muscle, although there is co-concomitant activation of the
muscles that can affect the urethra but the activation of those muscles was
less than for other instructions.
4)
The instruction that emphasized “elevation”
caused a counter-productive increase in abdominal muscle activity and IAP that
was greater than the other instructions.
5)
The relationship between movement on ultrasound
and EMG provides evidence for the validity of interpretation of activity of
specific pelvic floor muscles from motion of pelvic landmarks which supports
the potential clinical use of US.
6)
The optimal instructions to activate pelvic
floor muscles are likely those that induce the greatest amplitude of pelvic
floor muscle shortening with minimal increase in abdominal muscle activity and
IAP but one instruction does not achieve the same pattern of activation for all
men.
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