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Research Studies

Digital assessment of pelvic floor muscle function should be part of the primary clinical evaluation of elderly women with urinary incontinence

Talasz H, Jansen SC, Kofler M, Lechleitner M. High prevalence of pelvic floor muscle dysfunction in hospitalized elderly women with urinary incontinence.  Int Urogynecol J 2012; 23 (9): 1231-12371.

Why they did the study

Physical evaluation is generally considered as important part of urinary incontinence (UI) assessment in women that should routinely include visual inspection of the uro-genital region, vaginal palpation and testing pelvic floor muscle (PFM) function.  Although different methods exist to verify PFM function, digital vaginal palpation is considered to be simple and the gold standard procedure in primary clinical assessment. The choice of conservative therapeutic interventions such as PFM and bladder training in elderly women with UI is primarily based on the detection of normal muscle function. Numerous studies about PFM function in younger women have been published; however, less information about the elderly is available and these data have often been obtained by questionnaires only. This study was performed to determine PFM function in elderly women with UI by means of digital clinical assessment and to identify possible correlations between PFM dysfunction and age-related conditions, common medical symptoms and subjective burden of disease.

How they did it

This was a cross-sectional Austrian study conducted in a general hospital in Innsbruck between November 2000 and June 2009 on women aged older than 65 years who were admitted to the hospital for various medical reasons. Routine clinical UI assessment was performed within 1 week after admission in patients who complained about UI with high associated subjective burden of disease or in patients with symptoms of UI based on the nurses’ notes.

PFM function testing was carried out by the same person in all patients by a physician experienced in pelvic floor assessment and re-education. After positioning the index finger into the distal part of the vagina, the investigator asked patients to contract the PFM, to lift inward, and to squeeze around the finger. When necessary, instructions were repeated up to 3 times, and the women were also asked to squeeze the PFM as they would when feeling acute urinary urgency. Constriction and elevation of the vaginal wall and strength of PFM contraction were graded according to the modified Oxford grading scale. To determine involuntary PFM contractions, women were asked to cough without changing position. Each circular constriction of PFM before or during coughing was defined as involuntary PFM contraction, regardless of additional cranial movement of the vagina or not.

Other variables studied included age, body mass index, subjective burden of UI, predominant UI symptoms, number of childbirths, history of hysterectomy, history of previous PFM training, vulvo-vaginal mucosal status, ultrasound-measured post-void residual, Tinetti score and Mini-Mental State Examination (MMSE) score. Subjective burden of UI was estimated by asking the women to rate the subjective negative impact of UI on quality of life (0= no burden; 1= little burden; 2= high burden). Predominant UI symptoms were evaluated by means of a non-validated questionnaire for screening UI symptoms from the medical history obtained by the examiner. The Tinetti performance test was used to assess patients’ mobility, balance, and gait and to predict falls. With a maximum score of 16 points for evaluating balance, 12 points for evaluating gait, and a cut-off score of 20 points; this test is recommended as gold standard for testing mobility in the elderly. Mini-mental state examination (MMSE) was used to evaluate cognitive function. This brief screening test with a maximum score of 30 points and a cut-off score of 24 points is widely used for detecting presence and global severity of cognitive impairment in the elderly.
Complete data sets of 704 patients were available for statistical analysis.

What they found

Among the 704 elderly women, 280 presented with predominant urge UI symptoms, 269 with mixed stress/urge UI symptoms, and 55 with predominant stress UI symptoms. In 100 patients, more than100 ml post-void residual volume was registered by ultrasound. Mean age was 78.2±6.3 years (range, 65–96 years).

Only 25.5% (n= 180) of the patients were able to perform normal or strong PFM contractions with noticeable contraction and elevation of the vagina (Oxford Grades 3 and 4); 39.2% (n= 276) showed only weak PFM activity without circular contraction and elevation of the vagina (Oxford Grades 1 and 2), and 35.2% (n=248) were not aware of their pelvic floor and could not voluntarily influence PFM (Oxford Grade 0). None of the patients was able to perform a strong PFM contraction (Oxford Grade 5). Before and during coughing, palpable involuntary PFM contraction was noted in only 5 patients. Most patients presented with considerable downward displacement of the pelvic floor during coughing.

Significant positive correlation of PFM function was found to higher MMSE score (r=0.177; p<0.001), higher Tinetti score (r=0.110; p<0.05) and history of PFM training (r=0.155; p<0.001). Negative correlation was found between PFM function and patients’ age (r=−0.139; p<0.001) and extent of vaginal mucosal dystrophy (r=−0.090; p<0.05). No significant correlation was found between PFM function and body mass index, parity and history of hysterectomy. Notably, subjective burden did not correlate to PFM function (r=0.017; p=0.685), nor to MMSE (r=−0.069; p=0.084).

Mean Oxford grading score was significantly lower (p< 0.05) in patients with increased residual volume (mean Oxford score, 1.2±1.3 SD) as compared to those without residual volume (mean Oxford score, 1.5 ±1.3 SD). No significant difference was noted between patients with predominant symptoms of stress UI (mean Oxford score, 1.5±1.4 SD) and those with predominant symptoms of urge UI (mean Oxford score 1.7±1.4 SD).

Why it matters

Epidemiologic and clinical studies reveal that the highest prevalence of UI is in elderly women. In this group, UI is considered to be not a single diagnosis but rather a consequence of different underlying conditions and age-related factors, such as PFM dysfunction, cognitive decline, psychological changes, neurological disorders and lower genitourinary diseases, other co-morbidities and side effects of drugs. Routine clinical evaluation of elderly women with UI should include assessment of PFM function as PFM dysfunction is considered to be a fundamental patho-physiological mechanism in development of the condition as well as the principal cause of conservative treatment failure. The rationale for prescribing PFM training in women with stress UI is to improve PFM contraction strength and to learn timed PFM contraction before and during increase in intra-abdominal pressure. In women with urge UI, voluntary PFM contractions can be used as possible deferral technique to inhibit urgency to void during bladder training based on the physiological observation that a detrusor muscle contraction can be inhibited by PFM contractions.

This large cross-sectional study revealed that the great majority of hospitalized elderly incontinent women were unable to contract PFM voluntarily or involuntarily when requested during digital clinical assessment with a negative relationship to age. There was a positive correlation between PFM function and cognitive and mobility status. There was also poor awareness of the pelvic region in this group of women. These results clearly indicate that age-related changes may play an important role in the pathogenesis of PFM dysfunction in incontinent women.

An interesting finding of this study was that PFM function did not correlate with the subjective burden of UI. Also, the strength of PFM contraction was not significantly lower in women with the predominant symptom of stress UI than in those with predominant urge UI symptom, as expected. PFM strength was assessed in this study according to the modified Oxford grading score. This test is helpful in clinical settings for planning treatment strategies but may not be suitable for clinical research purposes due to its subjective quantification and moderate intra- and inter- observer reliability. Assessment of involuntary PFM contraction before and during coughing by digital vaginal palpation is more difficult to perform and is known for its low inter-observer reliability. A further possible explanation could be that both the burden of UI and the predominant UI symptom were evaluated by non-validated questionnaires that focused mainly on patients reporting and/or the medical history obtained by the examiner. Some of these results could have been biased by inaccuracies due to certain patient’s impaired cognitive status that was related to PFM dysfunction. Additional limitations of the present study include uncontrolled design and the highly selective population. Further research in this field should, therefore, include a controlled sample of elderly incontinent women randomized to digital versus no digital vaginal examination using standardized tools for PFM function assessment. To ensure comparability across studies conducted in different settings, it is also important to use validated and objective outcome evaluation measures for the burden of UI and more discriminative indicators of incontinence symptomatology.

Next question

Behavioral interventions such as PFM and bladder training are recommended as first-line treatment of UI in elderly women. Both interventions require awareness of the pelvic floor and the ability to voluntarily perform a PFM contraction. This hospital-based study clearly shows that using simple digital vaginal palpation of PFM, almost three quarters of elderly women with UI who were hospitalized for various medical reasons, have PFM dysfunction. Only those with normal or perhaps mildly weak PFM contraction are likely to be able to carry out subsequent PFM training instructions and thus able to train muscles and correct coughing patterns by themselves. In fact, previous studies have shown that even a high proportion of younger women were unable to control their PFM muscles properly. Therefore, especially in older women with anticipated poor PFM function, routine digital vaginal palpation is mandatory during the primary clinical assessment to confirm correct PFM contraction before deciding PFM training programs. Further studies could clarify if digital clinical assessment of PFM function in this group of women will also improve compliance to training programmes and/or treatment outcome in the subgroup with normal or near normal muscle function.

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