Análise Da Distribuição Multivetorial De Cargas Do Assoalho Pélvico Feminino Em Diferentes Populações / Licia Pazzoto Cacciari -- São Paulo, 2017

LICIA PAZZOTO CACCIARI

Análise da distribuição multivetorial de cargas do assoalho

pélvico feminino em diferentes populações

Tese apresentada à Faculdade de Medicina da Universidade de São Paulo para obtenção do título de Doutora em Ciências Programa de Ciências da Reabilitação Orientadora: Profa. Dra. Isabel de Camargo Neves Sacco

SÃO PAULO

2017

LICIA PAZZOTO CACCIARI

Análise da distribuição multivetorial de cargas do assoalho

pélvico feminino em diferentes populações

SÃO PAULO

2017

Dados Internacionais de Catalogação na Publicação (CIP) Preparada pela Biblioteca da Faculdade de Medicina da Universidade de São Paulo

©reprodução autorizada pelo autor

Cacciari, Licia Pazzoto Análise da distribuição multivetorial de cargas do assoalho pélvico feminino em diferentes populações / Licia Pazzoto Cacciari -- São Paulo, 2017. Tese (doutorado)--Faculdade de Medicina da Universidade de São Paulo. Programa de Ciências da Reabilitação. Orientadora: Isabel de Camargo Neves Sacco.

Descritores: 1.Biomecânica 2.Assoalho pélvico. 3.Cargas internas 4.Mulheres 5.Treinamento

USP/FM/DBD-228/17

19 20 21 Aos meus pais e ao Gui, 22 com muito amor 23 24 iii

ACKNOWLEDGEMENTS 25

Agradeço a todos que me acompanharam, apoiaram e incentivaram ao longo 27 destes quatro anos de estudo, dedicação e aprendizado. 28

Ao Gui, que se debruçou e se aprofundou comigo em cada conquista e desafio, 29 que tornou possível e prazerosa cada superação que vivenciamos juntos. Foi ele o 30 responsável por suavizar, com carinho, amor e leveza, muitos momentos de angústia e 31 incerteza, mas também de muita felicidade e descoberta. 32

Agradeço aos meus pais, que me apresentaram a vida acadêmica desde cedo. 33

Com eles aprendi a ser curiosa, criteriosa, a desconfiar, a testar hipóteses, a discutir 34 ciência, a acreditar nos meus sonhos e a valorizar minhas realizações. Sou muito grata 35 por ter tido todas as oportunidades e facilidades que reconheço hoje como 36 fundamentais para a minha trajetória. Sei que não foi fácil, que em muitos momentos 37 eles se desdobraram e se privaram de tudo em nome dos meus desejos. Aprendi 38 também com meus pais a valorizar os amigos e a família, a amar todos que me cercam, 39 a conhecer o mundo e reconhecer as diferenças com humildade, me deslumbrando a 40 cada nova descoberta. Agradeço ao meu irmão, que sempre foi meu grande 41 companheiro, mas que me surpreendeu também como um exemplo de disciplina 42 acadêmica. Sempre fomos considerados muito diferentes física e emocionalmente, 43 mas por coincidência e muita sorte (minha) acabamos seguindo caminhos parecidos e 44 estudando temas “idênticos”. Como fisioterapeuta precisei inúmeras vezes do seu 45 olhar teórico e físico, e foi com ele que escolhi variáveis, que construí gráficos e que 46 entendi o canal vaginal como um túnel flexível, passível de mensurações mecânicas 47

como uma verdadeira obra da engenharia. 48

Agradeço à minha orientadora, Isabel, por me inspirar como cientista. Eu serei 49 sempre grata por ter teimado em fazer parte do seu laboratório e grupo de pesquisa. 50

Por muito tempo fui carinhosamente apelidada de adotiva, mas nunca deixei de me 51 sentir parte integrante do grupo, mesmo antes de ser oficialmente vinculada, por 52 sempre encontrar ali um ambiente acolhedor e incansavelmente a postos para todas 53 as minhas inúmeras questões, pendências e confusões. Sempre muito mais do que 54 uma coordenadora de um grupo de pesquisa, sempre mais do que uma orientadora 55 acadêmica, encontrei na Isabel uma verdadeira companheira, e um exemplo de 56 dedicação aos alunos e à ciência que me enchem de orgulho e admiração. 57

Agradeço muito à Dr. Simone, que se envolveu desde o começo neste projeto, foi 58 essencial desde as nossas primeiras elocubrações. Sempre muito generosa, abriu as 59 portas da sua prática clínica e me possibilitou uma experiência inesquecível, da qual 60 sou muito grata, de acompanhar lado a lado o trabalho de excelência da 61 uroginecologia no hospital universitário. Com ela aprendi a importância da pesquisa 62 clínica e sistematizada, e aprendi também a trabalhar de forma humana e apaixonada, 63 transformando, segundo constantes relatos de suas pacientes, uma avaliação por 64 vezes considerada desconfortável, em um momento de atenção e acolhimento. 65

Este trabalho seria impossível sem o grupo uro, sem nossa bolha de amor. A 66

Anice sempre foi minha inspiração. Desde o estágio, como profissional impecável e 67 apaixonante, que deslumbra os alunos com as maravilhas da saúde da mulher. Sempre 68 sonhei em trabalhar com ela, e foi com base no que ela me ensinou, e em nossas 69 inúmeras conversas e desabafos que resolvi mudar o rumo da minha vida e me 70

embrenhar no desenvolvimento de uma linha de pesquisa que somasse a sistemática 71 da biomecânica ao conhecimento quantitativo e de qualidade do assoalho pélvico 72 feminino. A Anice sempre foi meu olho clínico e engajado, que não me deixava desviar 73 do meu objetivo, e que atribuiu conteúdo a todos os meus devaneios. Agradeço 74 também à Amanda, parte indispensável do nosso subgrupo de pesquisa, que chegou 75 no primeiro ano da graduação com determinação e empolgação para desbravar o 76 mundo acadêmico. Descobri com ela o foco e a organização que nunca tive, e que até 77 hoje me servem de exemplo, e agradeço pela oportunidade de assistir de perto, do 78 empenho incansável, o surgimento de uma brilhante pesquisadora e companheira de 79 batalhas e conquistas. 80

Agradeço a todos os integrantes do LABIMPH pelo companheirismo, em especial 81 a todas AS integrantes que se dispuseram a inúmeros testes e pilotos intermináveis 82 com o novo equipamento, que era uma inovação para todas nós, e que construíram 83 comigo esse sonho de pesquisa. No LABIMPH posso dizer que somos um verdadeiro 84 grupo, que aprendemos uns com os outros e nos apoiamos nas dificuldades assim 85 como compartilhamos conhecimentos e vitórias. Eu sempre gostei de trabalhar em 86 equipe, e especialmente sempre tive o maior prazer e orgulho de fazer parte dessa 87 equipe. Amo muito e admiro cada um de vocês, como profissionais criativos e 88 competentes, e também como verdadeiros amigos. Em especial agradeço à Yuri, que 89 foi minha guia desde a matrícula, sempre dez passos na minha frente ela iluminou meu 90 caminho, e sempre impecável me instigou a exigir um pouco mais, e a ir além do que 91 eu achava que conseguiria. Agradeço também especialmente ao Ricky, que me 92 inspirou a seguir meu sonho, me mostrou que existe um mundo para ser descoberto, e 93

mesmo a distância segue me ajudando, sempre as pressas, nas correções de papers e 94 inclusive pela leitura atenta desta tese. Sempre trabalhamos bem juntos, e sempre 95 conseguimos aprender com humor e entusiasmo, o que torna minha vida muito mais 96 divertida. 97

Agradeço enormemente a todos os meus queridos amigos que adoçam os meus 98 dias, aos que foram me encontrar no polo norte, e aos que me esperaram e me 99 fizeram querer voltar correndo para casa. Agradeço à Maia que me motivou nesse 100 projeto, que me incentiva desde sempre a realizar meus sonhos, e que me encanta há 101 mais de 15 anos, abrindo meus olhos para o mundo e para as ousadias e prazeres da 102 vida. Agradeço ao Fred, que segue me surpreendendo, pela descoberta do mise en 103 place e das frases viúvas, mas também pelo modelo de determinação e superação, me 104 mostrando que devemos e merecemos escolher nossos próprios caminhos, mesmo em 105 casos de completa instabilidade. 106

Sou muito grata aos professores Patrícia Driusso, Jeffereson Loss e Elisabete 107

Ferreira que compuseram minha banca de qualificação e nortearam esse projeto, com 108 brilhantes apontamentos e generosas contribuições que me ajudaram a entender 109 melhor clínica e mecanicamente o foco deste estudo. 110

Agradeço às mais de 100 voluntárias que participaram intimamente desse 111 estudo, muitas vezes mais de uma vez, apostando na importância do auto 112 conhecimento, e do estudo da biomecânica do assoalho pélvico feminino. 113

Especialmente gostaria de agradecer à Lu Riva, por abrir as portas da sua escola e 114 dessa forma confiar a nós a sua experiência, o que possibilitou essa importante e 115 necessária parceria entre a prática e a academia 116

vii

Esse estudo também não seria possível sem a constante participação dos 117 desenvolvedores da Novel, em especial Peter, Axel e Manfred, que abraçaram a ideia 118 desde o primeiro esboço de projeto, e seguiram nos ajudando, incentivando e 119 premiando em todas as etapas. 120

Obrigada às secretárias da pós-graduação, Ana e Aninha, pela prontidão 121

(mesmo em casos de urgência e total desorganização pessoal) e por sempre estarem 122 de sorriso aberto dispostas a esclarecer e ajudar os alunos. 123

I also would like to thank to the research group that I had the great opportunity 124 to meet in Montreal. At the Laboratoire Incontinence et Veillissement I’ve learned 125 another way to think and develop science. Chantale Dumoulin and her team are the 126 kindest and one of the most generous people I ever met, patiently teaching me how to 127 make cutting-edge science from scratch, but also showing me that it is possible, and 128 reasonable, to work and have a healthy and sometimes magical life. At the same time 129

I’ve learned how systematic science can be, but also how beautiful and kind life is in 130 the lovely Montreal. 131

Por fim, obrigada à Fundação de Amparo à Pesquisa do Estado de São Paulo – 132

FAPESP, pela bolsa de doutorado (processo nº 2013/13820-6), pela bolsa de estágio de 133 pesquisa no exterior (University of Montreal, Canada) (processo nº 2015/19679-9) e 134 pelo auxílio ao projeto de pesquisa (processo nº 2013/19610-3). 135

viii

NORMATIZAÇÃO ADOTADA 136

137

138

Esta tese está de acordo com as seguintes normas, em vigor no momento desta 139 publicação: 140

141

Referências: adaptado de International Committee of Medical Journals Editors 142

(Vancouver). 143

144

Universidade de São Paulo. Faculdade de Medicina. Divisão de Biblioteca e 145

Documentação. Guia de apresentação de dissertações, teses e monografias. Elaborado 146 por Anneliese Carneiro da Cunha, Maria Julia de A. L. Freddi, Maria F. Crestana, 147

Marinalva de Souza Aragão, Suely Campos Cardoso, Valéria Vilhena. 3a ed. São Paulo: 148

Divisão de Biblioteca e Documentação; 2011. 149

150

Abreviaturas dos títulos dos periódicos de acordo com List of Journals Indexed in Index 151

Medicus. 152

153

SUMMARY 154

155

156

LIST OF FIGURES 157

LIST OF TABLES 158

RESUMO 159

ABSTRACT 160

1. INTRODUCTION ...... 1 161

1.1. Assessment of pelvic floor muscle function ...... 7 162

1.1.1. Manometry ...... 8 163

1.1.2. Dynamometry ...... 13 164

1.1.3. Electomyography ...... 19 165

1.1.4. Imaging techniques ...... 21 166

1.2. Rational for the development of a new measurement device of PFM 167

function ...... 24 168

2. OBJECTIVES ...... 27 169

2.1. Specific aims ...... 27 170

2.2. Hypotheses ...... 28 171

3. METHODS ...... 29 172

4. ACCEPTED PAPER 1 ...... 31 173

5. ACCEPTED PAPER 2 ...... 56 174

6. GENERAL DISCUSSION ...... 82 175

6.1. Advantages and applicabilities of the new device ...... 82 176

6.2. Effects of Pompoir practice for PFM training on the 3D pressure profile 177

map of the vaginal canal ...... 87 178

6.3. Clinical Implications ...... 92 179

6.4. General considerations and limitations ...... 93 180

7. CONCLUSIONS ...... 96 181

8. ANNEX – ABSTRACTS TO BE PRESENTED IN THE ICS 2017 ...... 97 182

9. REFERENCES ...... 101 183

APPENDICES 184

185

LIST OF FIGURES 186

187

188

Paper 1: 189

Figure 1. A- pliance System (Novel, Munich, Germany) intravaginal instrumented 190

probe: hard plastic cylinder covered by capacitive transducers placed in a 191

matrix configuration (10x10). B- Sensor matrix diagrams representing three 192

major areas: caudal (first three lines of sensors), medial (four mid sensor 193

lines), and cranial (last three lines of sensors)...... 36 194

Figure 2. Temperature test setup for assessing the uniformity and linearity of the 195

pressure measurement along the instrumented probe in a controlled 196

condition. Figure on the left- 1-meter column of water. Detail – location of 197

probe insertion to be tested and digital thermometer...... 37 198

Figure 3. 3D diagram of the matrix peak pressure mean among participants (n=26) 199

for maximum pelvic floor contraction (A) and valsalva maneuver (B). For 200

both graphs, x and y planes represent latero-lateral and antero-posterior 201

planes of the pelvis, respectively (C). The z axis represent the depth of the 202

vaginal canal, being 7 the hymenal caruncle, and 1 the most cranial portion 203

achieved by the instrumented probe (D)...... 41 204

Figure 4. Peak pressure comparisons between tasks: maximum contraction (in grey) 205

and valsalva maneuver (in orange). Mean and standard errors (n=26), 206

differences between tasks (univariate ANOVAs) highlighted in pink 207

(P<0.05). A- peak pressures among planes (sum vector of pressures from 208

xii

two 10-sensor lines diametrically opposed along the vaginal depth). B- 209

peak pressures among rings (10-sensor perimeters surrounding the vaginal 210

circumference). C- onset of peak pressure-time series for each ring (instant 211

in % time that each sensor ring achieved a pressure value higher than 2 212

standard deviations from baseline)...... 43 213

Paper 2: 214

Figure 1. A- Pliance System (Novel, Munich, Germany). Intravaginal probe: 215

Ertacetal® cylinder covered with capacitive transducers placed in a matrix 216

configuration (10x10). B- Variables calculated from the peak pressure time- 217

series. Sustained contraction: peak pressure and pressure instant. “Wave” 218

contraction: peak pressure, pressure instant, contractions rate and 219

relaxation rate...... 65 220

Figure 2. Mean total pressure-time integrals (standard error) for each one of the 5 221

planes for endurance (sustained contraction) and wave tasks normalized by 222

the total pressure-time integral of the matrix (relative values %). On the 223

right two representative plots illustrate the pressure-time integral window 224

used for each task. CG= control group, PG= Pompoir group. Differences 225

between groups (univariate ANOVAs) highlighted in pink (P<0.05)...... 70 226

Figure 3. Mean total pressure-time integrals (standard error) for each one of the 10 227

rings for endurance (sustained contraction) and wave tasks normalized by 228

the total pressure-time integral of the matrix (relative values %). CG= 229

control group, PG= Pompoir group. Differences between groups (univariate 230

ANOVAs) highlighted in pink (P <0.05)...... 71 231

xiii

Figure 4. Onset mean of the peak pressure-time series (standard error) for each one 232

of the 10 rings during the wave contraction task. CG= control group, PG= 233

pompoir group. Differences between groups (univariate ANOVAs) 234

highlighted in pink (P <0.05)...... 73 235

236

xiv

LIST OF TABLES 237

238

239

Paper 1: 240

Table 1. Peak pressure (kPa) mean and standard deviation in three major areas and 241

in the total matrix area during Valsalva and maximum contraction. Intra 242

class correlation coefficients and standard error of measurement and 243

prediction between raters and trials of the maximum contraction task. ... 45 244

Paper 2: 245

Table 1. Mean (standard-deviation) of the pressure-related variables of the time 246

series of the entire matrix for endurance and wave tasks...... 68 247

Table 2. Mean (standard-deviation) of the peak pressure-time integral by planes 248

and rings of endurance (kPa*s) and wave tasks (normalized in time, 249

kPa*%t)...... 72 250

251

252

RESUMO 253

254

255

Cacciari LP. Análise da distribuição multivetorial de cargas do assoalho pélvico feminino 256 em diferentes populações [tese]. São Paulo: Faculdade de Medicina, Universidade de 257 São Paulo; 2017. 258 259 Apresentamos nesta tese a compilação de dois artigos científicos aceitos para 260 publicação, que serão reproduzidos e discutidos em diferentes sessões apresentadas a 261 seguir. Os objetivos gerais desta tese são desenvolver um instrumento inovador para a 262 análise biomecânica do assoalho pélvico (AP) , capaz de fornecer um perfil preciso da 263 distribuição de pressões ao longo do canal vaginal, e caracterizar o potencial de 264 coordenação espacial desse grupo muscular em uma população de mulheres treinadas 265 na técnica de Pompoarismo. Para o primeiro objetivo, nós desenvolvemos um sensor 266 com alta resolução tridimensional para a avaliação do perfil espaço-temporal de 267 pressões no canal vaginal. Para isso, o mapeamento obtido da distribuição intravaginal 268 de pressões foi (i) testado entre avaliadores, tentativas e sessões de avaliação para 269 verificação da confiabilidade e repetitividade do instrumento e protocolo de coleta; (ii) 270 comparado à avaliação digital da força do AP, e (iii) caracterizado e diferenciado entre 271 duas tarefas opostas: a contração máxima do AP e manobra de Valsalva (considerada 272 como um esforço máximo de expulsão com movimento caudal do AP). Para o segundo 273 objetivo, com o novo sensor nós comparamos dois grupos de mulheres: praticantes e 274 não praticantes de uma técnica específica de coordenação da musculatura do AP, o 275 Pompoarismo. O sensor consiste em um cilindro de Ertacetal® não deformável 276 envolvido por uma matriz de sensores capacitivos calibrados individualmente (MLA-P1, 277 pliance System; novel; Munique, Alemanha). O cilindro, com 23,2 mm de diâmetro e 8 278 cm de comprimento, contém uma área sensora de 50 cm2 (10x10 elementos de 7,07 279 mm2, com gap de 1,79 mm entre cada sensor). Cada sensor apresenta amplitude de 280 medida entre 0,5 e 100 kPa, e resolução de 0,42 kPa, o que possibilita mensurações 281 unidirecionais com alta resolução espacial e testada baixa e uniforme resposta à 282 temperatura. O perfil de pressão intravaginal foi descrito com base em duas diferentes 283 abordagens considerando: (i) o pico de pressão da matriz inteira e (ii) a distribuição da 284 pressão ao longo de diferentes sub-regiões do canal vaginal, obtidas por divisões da 285 matriz sensora em “anéis”, “planos”, ou subáreas (caudal, média e cranial). 286 Coeficientes de correlação intraclasse indicaram excelente repetitividade inter e intra 287 avaliador para a área total e medial, com confiabilidade moderada para as áreas 288 cranial e caudal. A correlação entre os picos de pressão e a força obtida pela avaliação 289 digital do AP foi moderada [coeficiente de Spearman r=0,55 (p<0,001)]. O Perfil 290 espaço-temporal de pressões do canal vaginal foi completamente diferente entre a 291 contração máxima do AP e a Valsalva (ANOVA medidas repetidas, dois fatores), com a 292 contração muscular resultando em pressões notavelmente maiores na porção 293 anteroposterior média do canal vaginal. Considerando o potencial de coordenação e 294 distribuição espacial da pressão intravaginal, observamos no grupo de mulheres 295

xvi

praticantes de pompoarismo uma maior capacidade de sustentação da força muscular 296 (40% maior, efeito moderado, p=0,04), além de menores contribuições relativas da 297 porção média e plano anteroposterior, e maiores contribuições das porções caudal e 298 cranial e planos latero-laterais da pressão intravaginal, que se mostrou de modo geral 299 mais simetricamente distribuída em relação ao grupo controle. Com este protocolo e 300 instrumento inovador foi possível obter um mapeamento de alta resolução, confiável e 301 capaz de distinguir o perfil de distribuição de pressões ao longo de diferentes porções 302 do canal vaginal, e caracterizar tarefas e padrões de coordenação muscular em 303 diferentes grupos de mulheres. 304 305 Descritores: biomecânica; assoalho pélvico; cargas internas; mulheres; treinamento 306 307

xvii

ABSTRACT 308

309

310

Cacciari LP. Investigation of the multivectorial load distribution of the pelvic floor in 311 different female populations [thesis]. São Paulo: Faculdade de Medicina, Universidade 312 de São Paulo; 2017. 313 314 This thesis is presented as a compilation of two scientific papers accepted for 315 publication, reproduced in different sections. The general purpose of this thesis is to 316 develop a novel instrumented probe for pelvic floor muscle (PFM) biomechanics 317 assessment, capable of providing a precise high spatial 3D resolution pressure profile 318 of the vaginal canal, and to map the spatial coordination potential of these muscles in 319 a trained female population. For the first objective, we developed a novel device for 320 assessing the spatiotemporal pressure profile of the vaginal canal. The pressure profile 321 was (i) tested for reliability and repeatability, (ii) compared to the PFM digital 322 assessment, and (iii) characterized and compared between two opposite tasks: 323 maximum contraction and Valsalva maneuver (maximum intra-abdominal effort with 324 downward movement of the pelvic floor). For the second objective, we assessed and 325 compared two groups of asymptomatic women using the newly developed device: 326 practitioners and non-practitioners of a specific coordination training of the PFM, the 327 Pompoir technique. The developed probe consists of a non-deformable Ertacetal® 328 cylinder, covered by a matrix of individually calibrated capacitive sensors (MLA-P1, 329 pliance System; Novel, Munich, Germany). The cylinder is 23.2 mm in diameter and 8 330 cm in length, and its sensing area is 70.7 mm2 (10x10 matrix of sensing elements, each 331 with 7.07 mm2 in size and 1.79 mm gap between them). The capacitive sensors have a 332 measurement range of 0.5‒100kPa, and a measurement resolution of 0.42 kPa, 333 enabling unidirectional measurements with high spatial resolution, and tested low 334 uniform and linear response to temperature variations. The pressure profile was 335 described based on two different approaches, either considering the peak pressure of 336 the entire sensor matrix or the pressure distribution along different sub-regions of the 337 vaginal canal, obtained by divisions of the sensor matrix in “rings”, “planes” or major 338 areas (caudal, mid and cranial) throughout the vaginal length. Intraclass correlation 339 coefficients indicated excellent inter- and intra-rater reliability and intra-trial 340 repeatability for the total and mid-areas, with moderate reliability for the cranial and 341 caudal areas. There was a moderate correlation between peak pressure and PFM 342 digital palpation [Spearman’s coefficient r=0.55 (p<0.001)]. Spatiotemporal profiles 343 were completely different between the maximum contraction tasks compared to 344 Valsalva (2-way ANOVAs for repeated measures), with contraction resulting in notably 345 higher pressures in the mid-anteroposterior portion of the vaginal canal. Regarding the 346 effect of Pompoir training, the trained group presented better ability to sustain the 347 achieved pressure for a longer period (40% longer, moderate effect, P=0.04) also 348 having smaller relative contributions from the mid-region rings and anteroposterior 349 plane, and greater contributions from the caudal and cranial rings and latero-lateral 350

xviii

plane, with more symmetrical pressure distribution patterns in comparison to the 351 control group. With this protocol and novel instrument, we obtained a high-resolution 352 and highly reliable innovative 3D pressure distribution map of the pelvic floor, capable 353 of distinguishing vaginal sub-regions, planes, rings, tasks and characterizing 354 coordination patterns of the PFM following a specific training protocol. 355 356 Descriptors: biomechanics; pelvic floor; internal loads; woman; training 357 358

1. INTRODUCTION 359

360

361

The pelvic floor is defined as the structures located within the bony pelvis, 362 including the urogenital and anorectal viscera, the pelvic floor muscles (PFM) and their 363 connective tissues, nerves and blood vessels (Bø et al. 2017a). PFM, especially the 364 levator ani muscle, are critical to protect the pelvic connective tissues from overloads, 365 interacting to the endopelvic fascia to maintain continence and provide pelvic organ 366 support (Ashton-Miller and DeLancey 2007). 367

The levator ani muscle is a complex structure with five origin-insertion pairs and 368 three basic sub-regions: (i) the iliococcygeus, consisting in a flat layer that connects the 369 pelvic sidewalls near the sacrum; (ii) the pubovisceral, comprised itself of three origin- 370 insertion pairs, that attaches the walls of the pelvic organs and the perineal body to 371 the pubic bone on either side of the symphysis (puboperineal, the pubovaginal and the 372 puboanal), and (iii) the puborectalis, that form a sling around and behind the rectum, 373 just above the external anal sphincter (Kearney et al. 2004; Ashton-Miller and 374

DeLancey 2007). 375

The normal function of the PFM is defined as a level of constant resting tone 376

(except just before and during voiding and defecation), that should be symmetrical and 377 with the ability to voluntarily and involuntarily contract and relax (Bø et al. 2017a). This 378 constant resting tone keeps the urogenital hiatus closed by compressing the vagina, 379 urethra, and rectum against the pubic bone, pulling the pelvic floor structures in a 380 ventro-cephalic direction (Ashton-Miller and Delancey 2009). 381

Rises in intra-abdominal pressure, which occur during coughing, lifting, or other 382 physical exercises, exert a caudal (downward) force on both the bladder and the 383 urethra. To counterbalance this force, further voluntary or reflex contraction of the 384

PFM result in a constriction and inward (ventro-cephalic) movement of the pelvic 385 openings (Bø et al. 2017a), increasing the compression force to maintain continence 386 and support of the pelvic floor structures (Ashton-Miller and DeLancey 2007). During a 387 cough, for example, normal PFM function was shown to produce a timely compression 388 of the pelvic floor and additional external support to the urethra, reducing its 389 displacement, velocity, and acceleration (Jones et al. 2010). 390

More precisely, during maximum voluntary contraction the pubovisceral and 391 puborectalis portions of the levator ani muscle increase the vaginal closure force by 392

46%, further compressing the rectum, distal vagina, and urethra behind the pubic bone 393 distally, to elevate these structures and close the genital hiatus, accounting for the 394 constriction and inward components of the PFM function (Kearney et al. 2004; Ashton- 395

Miller and Delancey 2009). Finally, the iliococcygeus portion of the levator ani muscle 396 elevates the central region of the posterior pelvic floor, acting mainly as a support 397 diaphragm, having a small contribution to the ventral displacement of the pelvic 398 organs (Ashton-Miller and Delancey 2009). When both constriction and lifting 399 components are combined, a resultant force in the ventro-cephalic direction helps to 400 compress the rectum, vagina, and urethra, from back to front, balancing the caudal 401 force that is naturally exerted by the gravity, and further augmented by effort tasks 402 that result in increases in intra-abdominal pressure (Ashton-Miller and Delancey 2009). 403

404

In addition to maintaining pelvic organ support, and bowel and bladder 405 continence, pelvic floor structures have a critical role in sexual satisfaction 406

(Rosenbaum 2007). Female sexual function is defined not only by physical health, but 407 also by emotional, mental and social wellbeing in relation to sexuality (World Health 408

Organization 2015). Although acknowledging its multifactorial etiology, some authors 409 related the PFM tonus and voluntary contraction capacity to genital arousal and 410 orgasmic functions, describing the vagina as a contractile organ, exhibiting electrical 411 activity in the form of slow waves, which together with active contractions of the PFM 412 stimulates sexual excitement and pleasure for both men and women (Shafik 2000; 413

Shafik et al. 2004). PFM contractions have also been hypothesized to lead to genital 414 responses that would facilitate sexual performance, such as (i) vaginal constriction, 415 which helps to maintain penile rigidity, and promote clitoral and cervical stimulation; 416

(ii) vaginal elongation together with uterine elevation, which contribute to the 417 adequate adaptation of the penis in the vaginal canal (Shafik 2000), and (iii) increase in 418 vulvovaginal blood flow, which contribute to a better arousal, lubrication and orgasm 419

(Lavoisier et al. 1995). All these responses are related to PFM functionality, therefore 420 biomechanical capabilities of the PFM such as cranial-caudal coordination, 421 spatiotemporal symmetry of action, along with strength and resistance, are necessary 422 for targeting sexual function. 423

Several pelvic floor symptoms have been described, and can be classified into (i) 424 urinary incontinence symptoms, (ii) bladder storage symptoms, (iii) sensory symptoms, 425

(iv) voiding and postmicturition symptoms, (v) pelvic organ prolapse symptoms, (vi) 426 symptoms of sexual dysfunction, (vii) symptoms of anorectal dysfunction, (viii) pelvic 427

pain and (ix) lower urinary tract infection (Haylen et al. 2010). Most of those symptoms 428 are associated to PFM dysfunctions (Messelink et al. 2005), wherein the force- 429 generating capacity of the PFM seem to be related to symptoms of urinary 430 incontinence (Jones et al. 2010; Luginbuehl et al. 2015), fecal incontinence (Lewicky- 431

Gaupp et al. 2010; Tibaek and Dehlendorff 2014), pelvic organ prolapse (DeLancey et 432 al. 2007; Friedman et al. 2012) or sexual dysfunctions (Lowenstein et al. 2010; 433

Martinez et al. 2014; de Menezes Franco et al. 2016). Besides the magnitude of PFM 434 force-generating capacity, other force/pressure related parameters have been found 435 to be different between symptoms or treatment protocols, such as force velocity and 436 endurance (Morin et al. 2004a), symmetry (Deindl et al. 1994), coordination between 437 superficial and deep PFM contractions (Devreese et al. 2007) and overall spatial 438 distribution of pressures along the vaginal wall (Peng et al. 2007). Altogether these 439 variables other than maximum strength should be added to the PFM assessment in 440 both clinical and research settings. 441

Pelvic floor symptoms are common conditions affecting more than one fourth 442

(MacLennan et al. 2000; Kepenekci et al. 2011; Wu et al. 2014) of adult women. 443

Particularly urinary and anal incontinence are common in the female population, with 444 a prevalence of about 16–17% and 9%, respectively (Nygaard et al. 2008; Wu et al. 445

2014), although depending on the definition and study population, the prevalence can 446 be much higher. Female sexual dysfunction is also age-related, progressive, and highly 447 prevalent, with 40 to 45% of adult women presenting at least one symptom including 448 low sexual interest, desire or arousal (sexual excitement and sexual pleasure); 449 lubrication problems; orgasmic dysfunctions (inability to achieve an orgasm, markedly 450

diminished intensity of orgasmic sensations, or marked delay of orgasm during any 451 kind of sexual stimulation); and dyspareunia (persistent or recurrent pain during sexual 452 activity) among others (Lewis et al. 2010). Up to one in seven women have surgery for 453 pelvic organ prolapse (POP) or urinary incontinence in their lifetime (Olsen et al. 1997; 454

Smith et al. 2010; Løwenstein et al. 2015). Furthermore, as the population ages, the 455 number of women suffering from pelvic floor symptoms is expected to increase, 456 resulting in a large social, medical and economic burden (Wu et al. 2011). 457

Kegel (1948) was the first to report training of the PFM to be effective in the 458 management of urinary incontinence in women. Though PFM motor-capacity training 459 has been an important part of Chinese Taoism exercises for more than 6,000 years, 460 aiming to stimulate circulation in the sexual organs, energize the pubic region and 461 promote self-awareness (Chang 1986). Up to date, PFM exercises are widely 462 recommended as first line conservative management for women with all types of 463 urinary incontinence (Dumoulin et al. 2015). Some studies also indicated that PFM 464 training have a positive impact on sexual functions by increasing self-confidence, 465 desire, lubrication, orgasm, and satisfaction (Bø et al. 2000; Beji et al. 2003; Dean et al. 466

2008; Zahariou et al. 2008), although it has been suggested that more high quality 467 clinical trials would be necessary to confirm these findings (Bø 2012; Ferreira et al. 468

2015). Most recently, benefits of PFM training were reported for anal incontinence 469

(Johannessen et al. 2017), and for the prevention and reduction of symptoms and 470 severity of pelvic organ prolapse (Hagen and Stark 2011; Hagen et al. 2017), pointing 471 out that intervention for treatment and prevention of these dysfunctions should be 472 encouraged on the basis of it being safe and done easily by most women. 473

Moreover, a recent study (Alperin et al. 2016) found that aging itself results in 474 substantial decrease in the predicted force production and fibrosis in all PFM, 475 suggesting that PFM training should be prescribed as a preventive strategy for all 476 women, as means for mitigating the impact of aging before the development of 477 significant fibrotic changes. However, no study investigated the effects of PFM training 478 in asymptomatic women, which could be of great interest to better understand the 479 potential of this muscle group, and clarify the advantages of recommending PFM 480 training as a preventive measure for several pelvic floor symptoms. 481

Therefore, an objective evaluation of PFM, assessing its physical and mechanical 482 capabilities – such as strength, coordination, resistance, symmetry, relaxation and 483 contraction rates, among others – is necessary to be able to properly intervene and 484 give feedback regarding a woman’s ability to contract their PFM and to document 485 changes in PFM function and biomechanical capabilities throughout an intervention 486 protocol (Bø and Sherburn 2005). However, there is still no gold standard method for 487 this purpose and measuring tools are still a topic of debate. 488

We believe that PFM assessments with clinical relevance should be made by an 489 objective, reliable, and multidimensional mechanical tool capable of measuring the 490 magnitude and spatiotemporal distribution of pressures along the vaginal canal, taking 491 into account the PFM 3D flexible structure, the directions of PFM contractions and, 492 more precisely, its ventro-cephalic resultant force. 493

In the following sections, some of the available measuring tools, as well as their 494 strengths and limitations will be described, and the rationale for building a new 495 measuring tool will be presented, proposing a method for objectively distinguishing 496

PFM contractions from intra-abdominal pressure increases, and to assess the PFM’s 497 biomechanical capabilities, such as force, pressure, coordination, resistance, 498 symmetry, relaxation and contraction rates in different regions of the vaginal canal. 499

500

1.1. Assessment of pelvic floor muscle function 501

502

In clinical practice, PFM function is commonly assessed by digital palpation scales 503

(e.g., PERFECT scheme proposed by Laycock and Jaerwood (2001)), which remains the 504 first choice of assessment among clinicians, mainly because it is fast, requires no 505 equipment, and selectively depicts PFM activity (Peschers et al. 2001b). Furthermore, 506 most validated digital palpation scales have the advantage of providing information on 507 both the squeeze and lift components of the PFM contraction (Laycock and Jerwood 508

2001), with some of them also accounting for muscle tone, endurance (Devreese et al. 509

2004), and left-right and anteroposterior symmetry of contraction (Slieker-ten Hove et 510 al. 2009). 511

However, the digital palpation assessment has the disadvantage of being a 512 subjective method with limited reproducibility. Digital palpation scales have been 513 considered less sensitive than objective techniques to quantify sustained contractions 514

(Frawley et al. 2006) and to differentiate variations in discrete force (Morin et al. 515

2004b). Additionally, although substantial agreement have been reported between 516 two raters in one study (Van Delft et al. 2013), others reported limited reliability even 517 for experienced examiners (Bø and Finckenhagen 2001; Ferreira et al. 2011; Sartori et 518 al. 2015). Bo and Finckenhagen (2001) reported that an available definition of “weak”, 519

“moderate”, “good”, and “strong” muscle contractions does not seem to be specific 520 enough to reliably reproduce the evaluation of PFM strength, concluding that vaginal 521 palpation can be mandatory when teaching correct PFM function, but may not be 522 reproducible, sensitive or valid enough for scientific purposes. 523

For the objective assessment of the PFM function, the existing (defined) devices 524 can be classified as manometers, dynamometers, electromyographers (EMG) or 525 imaging techniques, such as ultrasound and magnetic resonance imaging (MRI) (Bø and 526

Sherburn 2005; Bø et al. 2017a). So far, there is no perfect instrument or gold standard 527 for the PFM strength assessment; however, each method has its advantages and 528 disadvantages, and some of them will be discussed in the following sections. 529

530

1.1.1. Manometry 531

532

Manometers are among the most popular devices of PFM function assessment, 533 mainly because they are easy to handle, there are several commercially available 534 options, and they are considered an inexpensive alternative to obtain objective 535 measures of PFM function. The first “air balloon type” manometer designed to 536 measure PFM function has been presented by Kegel (1948). At that time, the new 537 device was named “perineometer”, and was considered an instrument devised to 538 register muscle contraction. Perineometers offered great value as a visual aid for 539 guiding patients during PFM exercises, functioning mainly as a biofeedback tool, 540 encouraging patients to continue the exercises until the desired result was attained. 541

However, the use of perineometers as an objective measuring tool of PFM 542 strength has been widely discussed, mostly because intra-abdominal pressure 543 variations might interfere with the validity of measurements. For example, it has been 544 shown that during tasks that raise intra-abdominal pressure the recorded vaginal 545 pressure increases regardless of PFM contraction, suggesting that the obtained 546 measures may not be specifically related to PFM strength (Bø et al. 1990b; Peschers et 547 al. 2001b; Thompson et al. 2006a). 548

Nevertheless, a degree of imprecision does not preclude its value as a simple, 549 inexpensive, and painless way to reliably assess general PFM function (Hundley et al. 550

2005). One of the suggested techniques described to avoid misleading measurements 551 is to assure that PFM contraction is simultaneously accompanied by an observable 552 inward movement of the balloon catheter (which is considered to be a sign of correct 553

PFM contraction) (Bø et al. 1990a, 1990b). Previous studies have found substantial 554 agreement of vaginal squeeze pressure measured by perineometers with digital 555 assessment of the PFM function (Isherwood and Rane 2000; Riesco et al. 2010), and 556 also with morphometric parameters assessed by transperineal ultrasound during 557 maximal voluntary PFM contraction (Volløyhaug et al. 2016). However, the 558 concordance of measurements with different commercially available perineometers 559 ranged from poor to moderate, which makes it hard to compare results acquired with 560 different equipments (Barbosa et al. 2009). One possible explanation is that pressure 561 measurements of vaginal squeeze differ depending on the size of the vaginal probe 562 used (Bø et al. 2005). Therefore, results from published studies using various probes 563 are hard to be compared or combined (Bø et al. 2005). 564

One of the main concerns about the commercially available perineometers is 565 that their intravaginal balloon catheters are made of highly pliable materials, which 566 can be problematic since their radial compliance hinders isometric measurements of 567

PFM contraction (Ashton-Miller and Delancey 2009). Furthermore, not only PFM force 568 is highly related to vaginal canal distension, but PFM length affects the reliability of 569 those measurements, with vaginal apertures of 24-40 mm being considered ideal for 570 reducing the standard error of measurement (Dumoulin et al. 2004a; Verelst and 571

Leivseth 2004b). 572

Several variations of perineometers have been applied to differentiate PFM 573 contraction among women with a range of pelvic floor symptoms. Specifically, when 574 comparing women with and without symptoms of urinary incontinence, it has been 575 found that these symptoms are related to (i) lower vaginal squeeze pressure during 576 maximal PFM contraction (Mørkved et al. 2004; Amaro et al. 2005; Thompson et al. 577

2006b; Hilde et al. 2013); or (ii) lower PFM endurance, defined either as the duration 578 of a sustained maximal contraction (Amaro et al. 2005; Thompson et al. 2006b) or the 579 pressure-time integral (Hilde et al. 2013). Also, the amount of vaginal pressure 580 obtained during maximum PFM contraction was considered a strong predictor of stress 581 urinary incontinence (Baracho et al. 2012). Nevertheless, some of these findings are 582 not unanimous in the literature. For instance, (i) peak pressure was not different 583 between young continent and incontinent women (da Roza et al. 2013), and also (ii) 584 when comparing PFM contraction to a Valsalva maneuver (maximum intra-abdominal 585 pressure effort with downward movement of the pelvic floor) vaginal squeeze 586 pressure increased during both tasks, with no difference in the pressure measured 587

either between tasks or when comparing continent and incontinent women 588

(Thompson et al. 2006a). 589

Considering other PFM symptoms, reduced vaginal squeeze pressure assessed by 590 perineometers was also related to (i) symptoms of anal incontinence, (ii) pelvic organ 591 prolapse (Friedman et al. 2012), (iii) levator ani structural damages caused by after 592 vaginal delivery (Hilde et al. 2013), and (iv) symptoms of sexual dysfunction (e.g., 593 satisfaction and lubrication) either in young nulliparous (Martinez et al. 2014) or in 594 post menopausal women (de Menezes Franco et al. 2016). Therefore, perineometers 595 do not seem to be the instrument of choice to distinguish PFM contractions from intra- 596 abdominal pressure rises, or to describe the pressure profile along different portions of 597 the vaginal canal as they do not have adequate precision or resolution to evaluate 598 symmetry, coordination or the lift component of the PFM function. 599

600

Improved manometry devices and prototypes 601

A completely different methodology to improve precision in the pressure 602 assessments was presented by three different research groups. In the first case 603

(Guaderrama et al. 2005), a four-channel water-perfused manometry catheter (4.5 604 mm) was used to map the pressure profile of the vaginal canal. As a solution to 605 measure pressures along the depth of the vagina, the proposed device was motor- 606 driven pulled through the vagina at constant withdrawal speed of 8 mm/s. In the 607 second case (Raizada et al. 2010), the proposed device consisted of a high-definition 608 manometry probe (10 mm diameter with a pressure sensitive part of 64mm), 609 instrumented with 256 tactile sensitive microtransducers forming a continuous grid in 610

both the axial and circumferential directions, with the advantage of mapping the 611 vaginal canal all at once, without the need to be pulled through. Finally, the last 612 mentioned proposed instrument (Egorov et al. 2010) was designed to measure the 613 elastic properties of the vaginal wall through a “tactile imaging” technique (considered 614 a translation of manual palpation into a digital image). For that a tactile array probe 615 prototype was developed, comprising 120 capacitive sensors, and “computerized 616 palpations” of the vaginal canal were achievable by pressing the probe head against 617 different portions of the vaginal wall (Egorov et al. 2010). However, these devices are 618 either not commercially available, or have limited accessibility and high cost. 619

From the results of these studies, one can easily conclude that the vaginal 620 pressure profile is more complex than what was previously described, with an 621 asymmetry of force/pressure distribution in both the longitudinal and the 622 circumferential directions of the vaginal wall (Guaderrama et al. 2005; Raizada et al. 623

2010), highlighting the importance of a spatial-temporal assessment of the PFM 624 function. More specifically, at rest or during PFM contraction, the anteroposterior 625 maximum pressures were found to be 50-65% greater than the lateral ones 626

(Guaderrama et al. 2005), and image findings support that PFM contraction result in a 627 high-pressure zone of 3-4 cm length that compresses the pelvic organs against each 628 other from back to front and also against the back of the symphysis pubis (Jung et al. 629

2007). Furthermore, (i) the anterior peak pressure was found to be greater than the 630 posterior one, especially during PFM contractions; (ii) the vaginal high-pressure zone 631 was also found to be longer in the posterior portion of the vaginal wall, compared to 632 the anterior and lateral directions; (ii) the size of the vaginal high-pressure zone was 633

found to increase in all directions with PFM contraction, with this increase being 634 maximal in the posterior wall; and (iv) the posterior peak pressure point was reported 635 to move together with the anorectal angle, around 7 mm in the ventro-cephalic 636 direction during PFM contraction (Raizada et al. 2010). 637

Most recently, a new pressure device was proposed (Schell et al. 2016), 638 consisting of an array of eight pressure sensors mounted onto a flexible printed circuit 639 board (80 mm length and of 20 mm width), which allow the device to conform to the 640 anatomy of the vagina. In addition to its flexibility and flat-shape that seems to 641 conform to the anatomy of the vagina, this device has the advantage of being wireless, 642 with data transmitted via Bluetooth to an Android tablet with reported real-time 643 display and user feedback, which appears to allow data acquisition in different body 644 positions in a more ecological environment. However this device is still under testing 645 and validation, and it is also not yet commercially available. 646

647

1.1.2. Dynamometry 648

649

Dynamometers are found to be capable of providing a precise measure of vaginal 650 force and its derivative variables, which are considered to be a more direct assessment 651 of the PFM strength (Morin et al. 2004; Constantinou and Omata 2007). At least five 652 dynamometer prototypes have been proposed by different research groups from 653 different countries, proven to be reliable and also tested either across groups of 654 women with and without pelvic floor symptoms or following PFM treatment 655

protocols (Dumoulin et al. 2003; Verelst and Leivseth 2004b; Constantinou and Omata 656

2007; Nunes et al. 2011; Ashton-Miller et al. 2014). 657

Some other instruments have been proposed, but they are still under 658 development or have not been tested across pelvic floor symptoms or treatments, 659 with only reliability studies found in the literature so far (Saleme et al. 2009; Jean- 660

Michel et al. 2010; Arora et al. 2015; Kruger et al. 2015; Martinho et al. 2015; Schell et 661 al. 2016). Therefore, in the following paragraphs, the first dynamometers, mentioned 662 in the beginning of this sub-section, will be discussed. 663

Most of the initially proposed dynamometer devices can be categorized as 664

“speculum type dynamometers” (Dumoulin et al. 2003; Verelst and Leivseth 2004b; 665

Nunes et al. 2011; Ashton-Miller et al. 2014), and some of them have the advantage of 666 being suitable to measure the intravaginal force along different apertures of the 667 vaginal canal (Verelst and Leivseth 2004b; Nunes et al. 2011). 668

Dumoulin et al. (2003), in Canada, developed an instrumented speculum 669 comprised of two aluminum branches. While the upper branch is fixed, the other can 670 be slowly opened allowing the pelvic floor forces to be measured at different introital 671 vaginal anteroposterior diameters (from 19 to 54 mm). Here, the resultant force 672 exerted by the PFM on the speculum is recorded by two pairs of strain gauges, and the 673 difference between them is acquired and used for analysis. 674

Verelst and Leivseth (2004b), in Norway, proposed a prototype consisting of two 675 semi-round branches meant to shift mutually parallel to each other, so the opening 676 can be changed from 30 to 50 mm. Strain gauges were glued to one of the branches, 677 with no specifications of number or arrangements. The main difference between this 678

and the aforementioned device is that the first, on one hand, is fixed to a metal base, 679 which can make it uncomfortable to the patient if not properly adjusted to the vaginal 680 canal angle; while the second, on the other hand, seems to require someone to hold it 681 during the evaluation, which could also be a source of random artifacts in the measure. 682

A third speculum type dynamometer was designed by Nunes et al. (2011), in 683

Brazil. This prototype consists of a stainless steel speculum instrumented with two 684 pairs of strain gauges (fixed on the inferior and lateral sides of the branches) in a way 685 that both the anteroposterior (sagittal plane) and left-right (frontal plane) directions of 686 the intravaginal force could be assessed. Likewise, the first two previously described 687 prototypes, this device was designed to perform measurements under variable- 688 openings of the vaginal canal, although the aperture range was not specified. 689

One of the main limitations of the three previously described devices is that only 690 the resultant force of the whole vaginal canal is measured, even though it is in both 691 directions (anteroposterior and left-right), which makes it unlikely to depict PFM 692 contractions from other artifacts, such as intra-abdominal pressure rises. To overcome 693 this limitation, Ashton-Miller et al. (2014), in United States, designed a fourth 694 dynamometer without evidence of crosstalk from intra-abdominal pressure, while 695 retaining acceptable discriminant validity and repeatability for the assessment of PFM 696 strength. This device is an improved model that evolved from an original instrumented 697 speculum developed by the same group (Ashton-Miller et al. 2002), which was similar 698 in size and shape to a Pederson speculum. The difference is that the upper bill of the 699 speculum was divided in two along its length. The proximal “short” portion of the 700 upper bill, closest to the handle, was designed to be positioned immediately dorsal to 701

the inferior aspect of the symphysis pubis, thereby minimizing the net force across the 702 modified lower bill originated from intra-abdominal pressure variations. This device, 703 however, only measures the resultant force of the PFM in a fixed aperture of the 704 vaginal canal (25 mm). 705

Finally, in a different approach, a directional multi-sensor vaginal probe was 706 designed by Constantinou and Omata (2007), also in United States. This probe is 707 completely different from the speculum type dynamometers presented until now. 708

Here, the force transducer is supported by a leaf spring, which can be compressed by 709 the force applied by PFM contractions, incorporating the measurement of both force 710 and displacement of the vaginal wall. For that, four pairs of force/displacement 711 transducers were assembled to enable the measurement of anterior, posterior, left 712 and right vaginal wall movement with reference to a fixed central axis. Another novelty 713 of this sensor is that it was designed to be manually pulled through (2 cm/s) the 714 vaginal canal while simultaneously recording the position of the probe and the 715 force/displacements along the vaginal walls in the four mentioned directions. The 716 advantage of this approach is the possibility to acquire the force and displacement 717 across the whole length of the vaginal canal, as with some of the pressure devices 718 presented before (Guaderrama et al. 2005; Raizada et al. 2010). The main 719 disadvantage of this device is that it does not allow acquirements of the pressure-time 720 profile of the vaginal canal all at once, requiring it to be pulled through, which can be 721 considered a source of bias when describing pressure patters in different portions of 722 the vaginal length. 723

Because PFM maximum strength increases depending on the vaginal introitus 724 opening, dynamometers apertures and diameters directly affect the reliability of PFM 725 measurements (Dumoulin et al. 2004a; Verelst and Leivseth 2004b). Therefore, it is 726 particularly hard to combine findings from different studies using different devices 727 formats and openings. Regarding this matter, intravaginal force measurements at 24 728 mm of anteroposterior vaginal-opening presented a higher reliability with lower 729 standard error of measurements (Dumoulin et al. 2004a) compared to narrower or 730 wider opening options; while for the transverse plane, a left-right 40 mm vaginal 731 opening provided the most reliable outcome (Verelst and Leivseth 2004b). 732

In regards to the relationship between dynamometer measurements and digital 733 palpation, the magnitude of mean forces increased proportionally to increments in 734 digital palpation scores with moderate correlation between the two techniques (Morin 735 et al. 2004b). According to the authors, this result reveals a relevant sensitivity of the 736 objective assessment provided by dynamometry, which seems to be a better option to 737 detect discrete changes of PFM strength over time and/ or after treatments than 738 digital palpation. Most of the presented dynamometer devices have several 739 advantages when compared to pliable perineometers, but lack in precision or 740 resolution to assess symmetry, coordination or even the lift component of the pelvic 741 floor function. Furthermore, none of the abovementioned devices are capable of 742 mapping the spatio-temporal pressure distribution across different portions of the 743 vaginal canal, which would be recommended considering the reported asymmetric 744 distribution of forces along the vaginal length (Jung et al. 2007). 745

746

Description of force parameters in women with pelvic floor dysfunctions 747

All of these dynamometers were used to investigate the effect of some pelvic 748 floor symptoms and dysfunctions in PFM force parameters (Morin et al. 2004a; Verelst 749 and Leivseth 2004a, 2007; Peng et al. 2007; Shishido et al. 2008; Lewicky-Gaupp et al. 750

2010; Chamochumbi et al. 2012; Miller et al. 2015; Cyr et al. 2017), with most of the 751 studies focusing on symptoms of urinary incontinence (Morin et al. 2004a; Verelst and 752

Leivseth 2004a, 2007; Peng et al. 2007; Shishido et al. 2008; Chamochumbi et al. 2012). 753

When compared to a control group, women with symptoms of urinary 754 incontinence presented similar time to fatigue (defined as time to 10% decline of the 755 initial reference force) (Verelst and Leivseth 2004a) and vaginal cavity aperture value 756

(maximum vaginal opening that the volunteer could tolerate, without discomfort or 757 pain); but lower (i) PFM force normalized by the body weight as a function of the 758 transverse diameter of the vagina (Verelst and Leivseth 2004a); (ii) endurance 759

(considered as the area under the force-curve from 10 to 60 s of PFM contraction); (iii) 760 rate of force development; and (iv) number of rapidly repeated contractions (taken 761 during 15s) (Morin et al. 2004a). 762

For the passive force (tonus) and the maximum PFM force, the reports are 763 conflicting. Two studies did not find differences in tonus between controls and women 764 with urinary incontinence symptoms (Verelst and Leivseth 2004a; Chamochumbi et al. 765

2012) and three others reported lower tonus in the incontinent group (Morin et al. 766

2004a; Peng et al. 2007; Shishido et al. 2008). Similarly, one study did not find 767 differences in the PFM maximum force between groups (Morin et al. 2004a), while 768 four others reported lower force in the incontinent group (Verelst and Leivseth 2004a; 769

Peng et al. 2007; Shishido et al. 2008; Chamochumbi et al. 2012). These conflicting 770 findings could be explained by the fact that each study used a different measuring 771 device, for which the force was considered in different portions or orientations of the 772 vaginal canal. Therefore, we can conclude that the assessment of PFM should not be 773 restricted to maximal force, and should definitely acknowledge the asymmetry of the 774 force spatial distribution along different portions of the vaginal wall. 775

776

1.1.3. Electomyography 777

778

Surface electromyography (EMG) assessing the neuromuscular function of the 779

PFM is widely used as a biofeedback tool, with many commercially available options, 780 guiding clinical practice during PFM treatment protocols (Aksac et al. 2003; Aukee et 781 al. 2004; Auchincloss and McLean 2009). This feedback is thought to help isolating 782 specific PFMs and to motivate the participants by displaying the PFM activity and 783 progress. Bipolar electrodes are usually placed on the surface of the perineum or 784 inside the urethra, vagina or rectum (Bø et al. 2017a). However, it is important to 785 acknowledge that the large surface area of the available electrodes may result in cross- 786 talk from adjacent muscles and other artifacts (Bø et al. 2017a). This limitation is 787 particularly relevant when assessing PFM, considering that the pelvic floor is a complex 788 structure, comprised of multiple innervation zones with large inter-individual 789 variability (Enck et al. 2004; Cescon et al. 2014), several muscle layers and muscle 790 insertions, contained in a concave three-dimensional (3D) architecture (Ashton-Miller 791 and DeLancey 2007). 792

Between-trials and between-days reliability findings performed with two 793 commercially available intravaginal EMG devices suggested that, although it is 794 acceptable to use PFM surface EMG as a biofeedback tool for training purposes, it is 795 not recommended as an objective PFM function assessment for between-subject 796 comparisons or as an outcome measure between-days (Auchincloss and McLean 797

2009). In addition, when surface EMG was compared to other assessment techniques, 798 such as perineometers, digital evaluation or perineal ultrasound, both EMG and 799 pressure perineometers did not to selectively depict PFM activity from intra-abdominal 800 pressure rises (Peschers et al. 2001a). 801

Nevertheless, recent high-density surface EMG prototypes have presented 802 reliable measurements of the PFM activity in different regions of the vaginal canal 803

(Voorham-van der Zalm et al. 2013), and showed to be capable of providing a 804 comprehensive mapping of innervation zones of the pelvic floor and sphincter muscles 805

(Peng et al. 2016). These devices have yet to be tested either across patients or 806 following treatments. However, it is interesting to mention that a different asymmetry 807 pattern was found in the PFM activation, with women presenting significantly higher 808 average EMG values on the right side of the pelvic floor compared to the left side 809

(Voorham-van der Zalm et al. 2013). In addition, innervation zones were also found not 810 to be strictly left–right symmetric, with up to 10 motor units detected by the vaginal 811 probe, which varied in location and number among individuals (Peng et al. 2016). 812

Surface EMG is usually recommended to measure the activity of large, superficial 813 muscles, and it is important to take into consideration the signal-to-noise ratio, which 814 is inversely related to the thickness of the tissue between the sensor and the muscle 815

fibers, and highly related to the EMG sensor direction relative to muscle fibers 816

(Merletti et al. 2009). As previously described, PFM are a complex structure with 817 multiple origins and insertions, therefore, having multipennate fiber patterns (with 818 angles ranging from 41° to −43° relative to the horizontal (Betschart et al. 2014)), 819 which makes reliable and reproducible acquisition of muscular activity signal patterns 820 a real challenge, specially when considering comparisons across individuals with 821 different muscular trophisms, or following interventions. Another important 822 consideration to be made is that pre and post treatment comparisons using EMG are 823 compromised due to changes in trophism and to inevitable changes in the position of 824 electrodes, altering the muscle sample that is being assessed, and therefore, 825 compromising the reliability of the method for this purpose. 826

827

1.1.4. Imaging techniques 828

829

Imaging techniques such as magnetic resonance imaging (MRI) or ultrasound 830

(US) have been increasingly used in the evaluation of pelvic floor disorders (Dietz 2010; 831

Pontbriand-Drolet et al. 2015). MRI presents an advantage of providing clear and 832 detailed images of pelvic floor anatomy, remaining the most promising tool for 833 studying details of urethral movement (Perez et al. 1999); whereas US enables 834 dynamic measurements of the pelvic floor morphometry and function (Dietz et al. 835

2002), which could further elucidate the etiology and pathophysiology of pelvic floor 836 symptoms. 837

Some of the main advantages of transperineal US compared to MRI are the lower 838 cost, better visualization of moving structures, convenience for real time visual 839 biofeedback of PFM contractility (Dietz et al. 2001). Additionally, it is a non-invasive 840 assessment, which is an advantage compared to other objective assessments of PFM 841 function, especially for older women, or women with sexual dysfunction symptoms 842

(van Delft et al. 2015). 843

Three-dimensional or four-dimensional transperineal US can measure the 844 reduction in the area and in the anteroposterior diameter of the levator hiatus, which 845 result mainly from the ventral component of PFM contraction (Brækken et al. 2008; 846 van Delft et al. 2015). Although other morphometry parameters, such as cranio-ventral 847 shift of the bladder neck or the pelvic floor organs (Dietz et al. 2001, 2002; Thompson 848 et al. 2006b) may not reflect PFM strength strictly, they account for the result of both 849 the constriction and inward components of PFM action (Peschers et al. 2001b; 850

Brækken et al. 2009). 851

Studies comparing assessments of PFM contraction by transperineal US and 852 digital palpation presented moderate-to-strong correlations between PFM strength 853 and morphometric parameters of the pelvic floor structure. PFM strength was, for 854 example, associated to a higher bladder neck cranio-ventral displacement (Dietz et al. 855

2002; Thompson et al. 2005), thicker pubovisceral muscles (Brækken et al. 2014) and 856 smaller levator hiatus dimensions (Brækken et al. 2014; Albrich et al. 2016; Volløyhaug 857 et al. 2016). However, up to date, only one classification scale was recently proposed 858 for the PFM strength assessment using ultrasound measurements (Volløyhaug et al. 859

2016). 860

Nevertheless, US morphometric parameters may not be sensitive enough to 861 discriminate subtle variations in PFM function, mainly because the measures of 862 displacement are crucially dependent on tissue compliance or elasticity rather than 863 only muscle strength or resistance (Chen et al. 2011). In support of this hypothesis, a 864 reduced PFM contractility detected by digital palpation was better related to levator 865 ani muscle injuries (Guzmán-Rojas et al. 2014), and to subjective and objective 866 measures of pelvic floor organ descent (Oversand et al. 2015) than any sonographic 867 morphometric parameter of PFM function. 868

When imaging measurements were done prior to and after PFM treatment 869 protocols, pelvic floor morphometric changes were often accompanied by symptoms 870 or function improvements. More specifically, although it cannot directly assess 871 strength improvements, imaging studies provided some insights into the possible 872 anatomical mechanisms through which physiotherapy enables the PFM to minimize 873 urine leakage, or prolapse symptoms. US images were capable of detecting some 874 changes in the morphology and anatomy of some structures post PFM treatment, such 875 as (i) reduction in levator ani muscle surface area at rest, and during contraction, 876 suggesting increase in levator ani passive tone and strength (Dumoulin et al. 2007); (ii) 877 reduction in the anorectal angle and increase in the bladder neck height at rest, during 878 contractions or Valsalva maneuvers, suggesting improved pelvic organ support (Madill 879 et al. 2013); (iii) hypertrophy of the striated urethral sphincter (Madill et al. 2015); (iv) 880 increases in PFM volume and reduction of the levator hiatus dimension, elevating the 881 resting position of the bladder and rectum (Brækken et al. 2010), suggesting changes 882 in the strength and resistance of these muscles. 883

1.2. Rational for the development of a new measurement device of PFM function 884

885

From this brief literature review, we conclude that an objective assessment of 886

PFM physical and functional capacities are indubitably necessary, for clinicians and 887 researchers, when choosing treatment orientation or evaluating outcomes. However, 888 up to date, there is no gold standard method of evaluation, and although different 889 measuring prototypes have been recently proposed, comparisons between them are 890 challenging, and their results are hard to be compared or combined. 891

Most authors suggest assessing PFM strength using vaginal dynamometers, 892 considering it a better method as they measure force directly (Dumoulin et al. 2003; 893

Verelst and Leivseth 2004a; Constantinou and Omata 2007; Saleme et al. 2009; Nunes 894 et al. 2011; Ashton-Miller et al. 2014; Parkinson et al. 2016; Romero-Cullerés et al. 895

2017). However, none of the aforementioned dynamometer prototypes are available 896 to be commercialized, and they appear to be used only in a research scenario. 897

Among the commercially available options, manometers and EMG are not the 898 best choice for an objective PFM assessment, since they do not selectively depict PFM 899 activity from confounding artifacts effectively (Peschers et al. 2001a). In addition, both 900 options lack the ability to adequately evaluate the spatiotemporal differentiation of 901

PFM function along the vaginal canal, providing only a single univectorial 902 measurement of the resultant force acting on the vaginal walls, which reveal little 903 about the quality, symmetry or different biomechanical capabilities of the PFM (Bø and 904

Sherburn 2005; Guaderrama et al. 2005; Shishido et al. 2008). 905

Imaging techniques seem to be the most effective way to investigate both the 906 constriction and inward mechanisms of PFM action (Brækken et al. 2009), but they 907 have limited accessibility and high cost. Also, as discussed previously, they are not the 908 best option to discriminate subtle variations in PFM function, mainly because the 909 measures of displacement are crucially dependent on tissue compliance or elasticity 910 rather than just muscle strength or endurance (Chen et al. 2011; Guzmán-Rojas et al. 911

2014; Oversand et al. 2015). 912

Ideally, a device designed to assess the PFM function should take into account its 913 flexible, 3-D, deformable surface and should analyze both the force distributed 914 through various regions of the vaginal canal (latero-lateral and anteroposterior 915 directions; caudal, mid and cranial areas) (Devreese et al. 2004) and the capacity to 916 coordinate contractions in a symmetrical way and with proper spatial distribution. 917

One of the main goals of the present study was to develop a PFM assessment 918 device that (i) is specific enough to provide force and pressure parameters in order to 919 distinguish between patients and follow-up on treatment outcomes; (ii) could precisely 920 map the pressure profile along the entire vaginal canal; and (iii) could be 921 commercialized and used by researchers and clinicians in a simple and easy way. 922

We chose to start from a sensor matrix of capacitive transducers that was 923 already commercially available for other purposes rather than intravaginal measures 924

(pliance sensor mat, Novel; Munich, Germany). To be sure it was suitable for PFM 925 assessments, the device was extensively tested and had to be adapted to the specific 926 characteristics of this particular application, considering parameters such as sensor 927 length, format, and diameter; range of pressure measurement across the sensor 928

matrix; sampling frequency; spatial and temporal resolution; electronic resolution; and 929 sensitivity. It was a great advantage to start from something that is already highly 930 precise, with low sensitivity to temperature variations (Kernozek et al. 2002; Janura et 931 al. 2009) and with a commercially available and easy to use software, with a friendly 932 interface that does not require special training to be handled. 933

The idea of building this equipment won a prize in the University of Sao Paulo 934 contest for innovative ideas (Olímpiada USP Inovação), promoted by the Agência USP 935

Inovação, and also won the most promising proposal award in an international 936 conference (Expert Scientific Meeting- Cambridge, USA 2014) specifically aimed at 937 investigations of load distribution on the human or animal bodies. 938

In the following conference, in 2016 (Expert Scientific Meeting- Lisbon, Portugal 939

2016), a full-length paper presenting the results obtained with this new instrument on 940 a Pompoir trained population was selected by a prominent panel of experts as the Art 941 in Science Award winner, which was the main prize given in this event. This paper was 942 accepted by the Clinical Biomechanics journal and it is presented in a separate section 943 of this thesis. 944

945

2. OBJECTIVES 946

947

948

The general purpose of this study is to develop a novel instrumented probe for 949

PFM biomechanics assessment, capable of providing a precise high spatial 3D 950 resolution pressure profile of the vaginal canal, to distinguish PFM contractions from 951 intra-abdominal pressure rises, and to map the spatial coordination potential of these 952 muscles in a trained asymptomatic female population. 953

954

2.1. Specific aims 955

956

Our specific aims were to: 957

(i) verify the association between the PFM functional assessment score by 958

a digital assessment scale (Oxford grading) and the biomechanical 959

parameters measured by the new device; 960

(ii) verify the reliability (intra- and inter-rater) and repeatability (among 961

trials) of the new device and assessment protocol; 962

(iii) characterize the spatiotemporal pressure profile along the entire vaginal 963

canal of healthy women during the performance of two opposite tasks: 964

PFM maximum contraction, and a Valsalva maneuver (maximum intra- 965

abdominal pressure effort with downward movement of the pelvic 966

floor); 967

(iv) investigate the potential coordination of the different portions of the 968

PFM in asymptomatic women trained in the Pompoir technique. 969

970

2.2. Hypotheses 971

972

Our hypotheses were that with this novel instrument would be able: 973

(I) to reliably map the pressure profile along the vaginal canal, 974

differentiating the PFM contraction from intra-abdominal pressure rises, 975

(II) and to describe the potential capabilities of the PFM function in an 976

asymptomatic trained population, distinguishing spatial symmetry and 977

coordination patterns along the length of the vaginal canal. 978

979

980

3. METHODS 981

982

983

The results of this study will be published in two accepted papers. Therefore, this 984 thesis is being presented as a compilation of scientific papers, reproduced in the 985 following sections. 986

The first study was accepted and published online by the Journal of Biomechanics 987

(impact factor of 2.43, https://doi.org/10.1016/j.jbiomech.2017.04.035) and presents 988 the results of the test-retest reliability study of the novel instrumented device, 989 together with differentiation of the 3-D pressure distribution map of the vaginal canal 990 during two tasks, PFM maximum voluntary contraction and Valsalva maneuver 991

(Cacciari et al. 2017). 992

The second study was accepted by the Clinical Biomechanics journal in may 2017 993

(impact factor of 1.64) and presents the potential capabilities of the PFM function, 994 comparing asymptomatic women with and without experience on a specific training 995 program for the PFM strength and coordination, the Pompoir technique 996

Additionally, a research internship was included as part of the PhD project 997 development, which took place at the Laboratoire Incontinence et Veillissement 998

(Montreal, Canada). During the internship, data on an investigation using imaging 999 technique as a tool to assess PFM functionality and responses of two types of PFM 1000 training protocols in the management of female urinary incontinence was analyzed. 1001

Along with the experience in assessing PFM characteristics and properties using US 1002 imaging, the results of a randomised clinical trial with women aged 60 years or older 1003

suffering from urinary incontinence symptoms are still to be published, but one 1004 abstract containing some of these findings will be presented in the International 1005

Continence Society meeting (Florence, 2017). This internship and learning experience, 1006 supervised by Dr. Chantal Dumoulin, also resulted in a Cochrane review aiming to 1007 determine the effectiveness of training in the management of female urinary 1008 incontinence, which is also to be published in the first semester of 2017. A second 1009 abstract containing a summary of this Cochrane review update will also be presented 1010 in the International Continence Society meeting (Florence, 2017). These results are in 1011 the annex section of this thesis. 1012

1013

4. ACCEPTED PAPER 1 1014

1015

Abstract 1016

We developed an intravaginal instrumented probe (covered with a 10x10 matrix of 1017 capacitive sensors) for assessing the three-dimensional (3D) spatiotemporal pressure 1018 profile of the vaginal canal. The pressure profile was compared to the pelvic floor (PF) 1019 digital assessment, and the reliability of the instrument and repeatability of the 1020 protocol was tested. We also tested its ability to characterize and differentiate two 1021 tasks: PF maximum contraction and Valsalva maneuver (maximum intra-abdominal 1022 effort with downward movement of the PF). Peak pressures were calculated for the 1023 total matrix, for three major sub-regions, and for 5 planes and 10 rings throughout the 1024 vaginal canal. Intraclass correlation coefficients indicated excellent inter- and intra- 1025 rater reliability and intra-trial repeatability for the total and medial areas, with 1026 moderate reliability for the cranial and caudal areas. There was a moderate correlation 1027 between peak pressure and PF digital palpation [Spearman’s coefficient r=0.55 1028 (p<0.001)]. Spatiotemporal profiles were completely different between tasks (2-way 1029 ANOVAs for repeated measures) with notably higher pressures (above 30kPa) for the 1030 maximum contraction task compared to Valsalva (below 15kPa). At maximum 1031 contraction, higher pressures occurred in the mid-antero-posterior zone, with earlier 1032 peak pressure onsets and more variable along the vaginal depth (from rings 3 to 10- 1033 caudal). During Valsalva, the highest pressures were observed in rings 4 to 6, with peak 1034 pressure onsets more synchronized between rings. With this protocol and novel 1035 instrument, we obtained a high-resolution and highly reliable innovative 3D pressure 1036 distribution map of the PF capable of distinguishing vaginal sub-regions, planes, rings 1037 and tasks. 1038 1039 Keywords: pelvic floor, reliability, pressure distribution, vaginal closure force, levator 1040 ani, strength. 1041

Introduction 1042

1043

The pelvic floor (PF) has been poorly studied from a biomechanical perspective 1044 probably because of its complex structure comprised of many muscle layers, multiple 1045 muscle insertions in endopelvic organs and fascia (Ashton-Miller and DeLancey 2007) 1046 with concave format in a three-dimensional (3D) architecture. 1047

Although objective assessment of PF muscles (PFM) physical and functional 1048 capacities is highly recommended (Abrams et al. 2010), a gold standard method and 1049 equipment are still topics of debate. PFM assessments of clinical relevance should be 1050 made by an objective, reliable, and multidimensional mechanical tool capable of 1051 measuring the magnitude and spatiotemporal distribution of pressures inside the 1052 vaginal canal, taking into account the PF 3D flexible structure, and the relative 1053 direction of PFM contractions. 1054

In clinical practice, digital palpation is the technique most often used to evaluate 1055 the quality of PFM function (Laycock and Jerwood 2001). However, palpation is less 1056 sensitive than other techniques for quantifying sustained contractions (Frawley et al. 1057

2006), for differentiating variations in discrete force (Morin et al. 2004b), and has 1058 limited reliability even for experienced examiners (Sartori et al. 2015). The most 1059 regularly used quantitative methods include EMG, manometers, and dynamometers 1060

(Bø and Sherburn 2005). In particular, manometers and dynamometer measurements 1061 are considered more direct and objective assessments of PF function than digital 1062 palpation (Bø and Finckenhagen 2001; Barbosa et al. 2009; Rahmani and Mohseni- 1063

Bandpei 2011; Ribeiro et al. 2016) and have been used for several purposes 1064

(Theofrastous et al. 2002; Dorey et al. 2004; Quartly et al. 2010; Friedman et al. 2012; 1065

Middlekauff et al. 2016; Torelli et al. 2016; Bø et al. 2017b). 1066

Dynamometers are capable of providing precise maximum force and its 1067 derivative variables (Morin et al. 2004; Constantinou and Omata 2007); whereas 1068 manometers are usually made of highly pliable materials, which can be problematic. 1069

Furthermore, univectorial measurements obtained by manometers or by 1070 dynamometers reveal little about the quality, symmetry, or cranial movement 1071 direction of PFM contractions (Schaer et al. 1995; Bø and Sherburn 2005; Haylen et al. 1072

2010). Moreover, surface EMG does not provide an objective measurement of force, 1073 endurance, or symmetry, and assessment is rather questionable and difficult to 1074 perform reliably because PFM architecture includes multiple innervation zones 1075

(Peschers et al. 2001b; Enck et al. 2004; Cescon et al. 2014). 1076

In general, the literature points out that all aforementioned methods lack the 1077 proper spatiotemporal differentiation of PF functions along the vaginal canal and do 1078 not effectively differentiate PFM contractions from intra-abdominal pressure increases 1079 or adjacent muscle contractions (Peschers et al. 2001b; Guaderrama et al. 2005; 1080

Shishido et al. 2008). 1081

Recently, new equipment has emerged, such as a pressure sensor developed by 1082 van Raalte and Egorov (2015) to record tissue deformation patterns from the vaginal 1083 walls. However, it does not cover the entire vaginal canal, the resulting pressure maps 1084 are merely tactile images (a translation of the digital sensation of touch in to a digital 1085 image), and it is necessary to rotate the probe to get spatial pressure distribution; 1086

therefore, one cannot measure spatial and time distribution simultaneously, reducing 1087 repeatability. 1088

To improve the understanding of PF function and the pathophysiology of 1089 urogynecological dysfunctions, we propose a novel instrumented non-deformable 1090 probe (pliance sensor mat type: MLA-P1; novel; Munich, Germany) for PF assessment 1091 and test (i) its association with a clinical evaluation scale (Oxford grading); (ii) its 1092 reliability (intra- and inter-rater) and repeatability (among trials); and (iii) its ability to 1093 characterize the spatiotemporal pressure profile along the entire vaginal canal and to 1094 differentiate between a PFM maximum contraction, which is clinically relevant to 1095 investigate, and a Valsalva maneuver (maximum intra-abdominal pressure effort with 1096 downward movement of the PF), which can be performed by women instead of a 1097 proper PFM contraction in clinical evaluations (inward movement). 1098

1099

Methods 1100

Participants 1101

This cross-sectional study included 26 healthy women [37.0 (10.8) years, 62.6 1102

(9.0) kg, 162.4 (7.2) cm, 23.8 (3.9) kg/m2] with regular menstrual cycles, median 1103

(Interquartile range): 0 parity (number of children- 0–1), 3 (from 0 to 5) modified 1104

Oxford grading scheme (Laycock and Jerwood 2001). Exclusion criteria included body 1105 mass index higher than 30kg/m2; history of pregnancy within the past year; history of 1106 urogynecological or neurological dysfunctions, untreated urinary tract infections or 1107 surgery for urinary incontinence or pelvic organ prolapse; pelvic organ prolapse stage 1108 higher than II (most distal portion of the prolapse situated between 1cm above and 1109

below the hymen) (Haylen et al. 2016). This study was approved by the Ethics 1110

Committee of the School of Medicine of the University of São Paulo (protocol 1111 n.023/14), and all subjects provided informed consent. 1112

1113

Biomechanical assessment 1114

The spatiotemporal pressure distribution of the vaginal canal was evaluated 1115 using a fully instrumented non-deformable probe, consisting of an Ertacetal® cylinder 1116

[tensile modulus of elasticity of 2,800 MPa (according to ISO 527-1/-2)], covered by a 1117

10 x 10 matrix of individually calibrated capacitive sensors (MLA-P1, pliance System; 1118 novel; Munich, Germany). The cylinder is 23.2mm in diameter and 8cm in length, and 1119 its sensing area is 70.7x70.7mm (10x10 sensing elements of 7.07x7.07mm, with 1120

1.79mm gap between them). The capacitive sensors have a measurement range of 1121

0.5‒100kPa, and a measurement resolution of 0.42kPa, enabling unidirectional 1122 measurements with high spatial resolution (Fig.1). This equipment and software are 1123 easy to use, with a friendly interface that do not require special training to handle. 1124

1125

Figure 1. A- pliance System (Novel, Munich, Germany) intravaginal instrumented probe: 1126 hard plastic cylinder covered by capacitive transducers placed in a matrix 1127 configuration (10x10). B- Sensor matrix diagrams representing three major areas: 1128 caudal (first three lines of sensors), medial (four mid sensor lines), and cranial (last 1129 three lines of sensors). 1130 1131

Capacitive sensors are notoriously highly precise, with low temperature variation 1132

(Kernozek et al. 2002; Janura et al. 2009). However, when it comes to measuring 1133 pressures inside the body we considered it necessary to test its uniformity and linearity 1134 in response to temperature. Therefore, we built a 1-meter water column instrumented 1135 with a thermometer (Fig. 2). To better understand the effect of the temperature in 1136 which the instrumented probe was calibrated, we tested it under two conditions: (1) 1137 probe calibration under room temperature (around 20oC) and (2) probe calibration 1138 under body temperature (around 37oC). The instrumented probe was covered with 1139 two non-lubricated condoms, and data collection was performed with water 1140

temperatures ranging from 15 to 40oC in 5–10oC increments. We observed that at 1141

9.81kPa (1-m water column) all sensors were active, measuring uniformly equal 1142 pressures for both conditions. Nevertheless, for the condition in which the sensor was 1143 calibrated under body temperature, we could observe more linearity of peak pressure 1144 changes (regression equation y=10.09–0.06*x; R2=0.88; Pearson correlation r=0.94;), 1145 compared to the condition in which the probe was calibrated under room temperature 1146

(regression equation y=10.86–0.06*x; R2=0.79; Pearson correlation r=0.89), with peak 1147 pressure changing linearly and only slightly in temperatures varying from 20 to 40o. 1148

1149

Figure 2. Temperature test setup for assessing the uniformity and linearity of the pressure 1150 measurement along the instrumented probe in a controlled condition. Figure on 1151 the left- 1-meter column of water. Detail – location of probe insertion to be tested 1152 and digital thermometer. 1153 1154

Pressure-related variables were acquired at 50Hz as the women performed two 1155 tasks while breathing normally, with a 1-min rest period between trials and tasks. The 1156 first task— maximum contraction—was similar to the POWER assessment from the 1157

PERFECT scheme (Laycock and Jerwood 2001), and consisted of two trials of PF 1158

maximum contractions maintained for 3 seconds each, where the participants had to 1159

“lift” and “squeeze” their PF as hard as possible (Bø 2003); the second task—the 1160

Valsalva maneuver—consisted of two trials of maximum intra-abdominal pressure 1161 effort leading to a downward movement of the PF, maintained for 5 seconds each. The 1162 start of the measurements was manually synchronized just after the verbal command 1163 given for each tasks. Later, during the data processing, each signal was cut-in a custom- 1164 written MATLAB function to isolate the pressure time-series corresponding to the 1165 beginning of PF contraction. 1166

The instrumented probe was warmed to body temperature and covered with a 1167 hypoallergenic, non-lubricated condom, which was marked at a length of 7cm to 1168 ensure standardized depth of insertion. A second condom was placed over the first to 1169 prevent skin contact with the ink used for the marking. The probe was sterilized and 1170 cleaned according to the manufacturer’s instructions and the requirements of the 1171

University Hospital Infection Commission. The instrumented probe was always 1172 inserted into the vaginal canal with the same orientation, following the marks, 7cm 1173 from the hymeneal caruncle. 1174

To test the reliability and repeatability (intra- and inter-raters and trials), a subset 1175 of 15 participants were tested twice. At the first visit, participants were assessed by 1176 two trained physiotherapists (evaluators 1 and 2) with an hour interval between 1177 assessments. One week later, at a second visit, volunteers were re-assessed by 1178 evaluator 1. 1179

1180

1181

Data analysis 1182

Data were filtered (8Hz low pass, 4th order), and analyzed using a custom- 1183 designed math function. From the peak pressure-time series, we calculated peak 1184 pressures [kPa] (highest pressure value in a subset of sensors): (A) in 5 planes – 20 1185 sensors each, with each plane (36o apart from each other) representing a sum vector 1186 of pressures from two 10-sensor lines diametrically opposed along the cylinder (Peng 1187 et al. 2007); (B) in 10 rings, each one composed by the 10-sensor perimeters 1188 surrounding the cylinder; and (C) in three major areas: cranial (corresponding to the 1189 first 3 lines of sensors from the vaginal opening), medial (4 mid-lines of sensors), and 1190 caudal (3 last lines of sensors) (Fig.1B). Regarding the variables described in A and B 1191 above, our rational was based on the anatomy and biomechanics of the pelvic floor 1192 muscles. Normal forces measured along the circumference of the vaginal canal are 1193 thought to act together (i.e. to constrict and lift the pelvic floor structures during the 1194

PFM contraction), regardless of the orientation of each individual force. By this means, 1195 we considered that adding together the pressures from opposite sides of the vaginal 1196 wall would provide a better directional overview of the resultant forces acting on the 1197 vaginal canal. Similar approaches were proposed by Peng et al. (2007) and Shishido et 1198 al. (2008), however, in both cases the sensor device used consisted of only four force 1199 transducers that were manually pulled thought the vaginal canal. In our study, when 1200 analyzing together the pressure matrix divided by planes and axes, it is possible to 1201 have a complete map of the load distribution along the vaginal length, differentiating 1202 the pressure patters on the two opposite tasks. 1203

Peak pressure onset in each ring was also determined from the instant (% time 1204 series) at which the peak pressure-time series of each sensor ring achieved a pressure 1205 value higher than 2 standard deviations from its baseline pressure. The mean value for 1206 each task (from 2 trials) was considered for statistical purposes. 1207

1208

Statistical analysis 1209

Given the sample size evaluated (n=26), an alpha error of 5%, and a moderate 1210 effect size of 0.45 (d) (based on peak pressure in the total area), the statistical power 1211

(1-β) obtained was 0.77 for the t-test used. For all variables, normal distribution 1212

(Shapiro Wilk test) and homoscedasticity (Levene Test) were achieved. For 1213 comparisons of peak pressure between tasks (Valsalva and maximum contraction) and 1214 among rings (10), planes (5), or major areas (3), we used 2-way ANOVAs for repeated 1215 measures. For comparisons of the peak pressure onset among rings within each task, 1216 we used ANOVAs for repeated measures, and for comparisons between tasks in each 1217 ring, we used paired t-tests. For reliability testing, we calculated (a) the Intra-class 1218

Correlation Coefficient2,1 (ICC); (b) the standard error of prediction (SEP) for inter-rater 1219 comparisons; for intra-rater and intra-trial comparisons, we used (c) ICC3,1; and (d) 1220 standard error of measurements (SEM). An alpha error of 5% was adopted for all 1221 comparisons. For the correlation between the peak pressure from the entire matrix 1222 and the Oxford grading scheme we used the Spearman correlation. 1223

1224

1225

1226

Results 1227

1228

Fig.3 shows different pressure profiles for both tasks. For the maximum contraction, 1229 the highest pressures (above 30kPa) were observed in the mid-antero-posterior zone (2– 1230

4cm from the vaginal introitus), whereas for the Valsalva, the highest pressures were 1231 markedly lower (below 15kPa) and in the upper portion of the antero-posterior zone (4– 1232

5cm from the vaginal introitus), with notably high pressures along the whole cranial 1233 circumference of the vaginal wall compared to other regions, although not significant. 1234

1235

Figure 3. 3D diagram of the matrix peak pressure mean among participants (n=26) for maximum 1236 pelvic floor contraction (A) and valsalva maneuver (B). For both graphs, x and y planes 1237 represent latero-lateral and antero-posterior planes of the pelvis, respectively (C). The z 1238 axis represent the depth of the vaginal canal, being 7 the hymenal caruncle, and 1 the 1239 most cranial portion achieved by the instrumented probe (D). 1240

Peak pressure by planes and rings 1241

There was a significant interaction effect between tasks and planes (p<0.001, 1242

F=14.87), with higher pressures in all 5 planes during maximum contraction as opposed 1243 to those that occurred during the Valsalva. Intra-task comparisons between planes 1244 showed, for the maximum contraction, higher pressures in planes 2 and 3 1245

(corresponding to the antero-posterior plane), and for the Valsalva, higher pressures 1246 also in plane 2 compared to planes 1, 4-5, and plane 3 compared with plane 5 (Fig.4a). 1247

For the analysis by rings, there was a significant interaction effect between the 1248 tasks (maximum contraction and Valsalva) and rings (p<0.001, F=17.34), with higher 1249 pressures in rings 4 to 8 during maximum contraction as opposed to Valsalva. For the 1250 maximum contraction, intra-task comparisons between rings showed higher pressures 1251 in rings 4 to 8, with the highest in ring 6. For the Valsalva, higher pressures were 1252 observed in rings 4 to 6 compared to rings 1, 8, 9, and 10 (Fig.4b). 1253

1254

Peak pressure by major areas 1255

There was an interaction effect between tasks and major areas in peak pressure 1256

(F=42.267, p<0.001). In both tasks, the medial area presented higher peak pressures 1257 than the cranial and caudal areas (p<0.001), which were different for the medial and 1258 caudal areas between tasks (Table 1). 1259

1260

Figure 4. Peak pressure comparisons between tasks: maximum contraction (in grey) and 1261 valsalva maneuver (in orange). Mean and standard errors (n=26), differences 1262 between tasks (univariate ANOVAs) highlighted in pink (P<0.05). A- peak pressures 1263 among planes (sum vector of pressures from two 10-sensor lines diametrically 1264 opposed along the vaginal depth). B- peak pressures among rings (10-sensor 1265 perimeters surrounding the vaginal circumference). C- onset of peak pressure- 1266 time series for each ring (instant in % time that each sensor ring achieved a 1267 pressure value higher than 2 standard deviations from baseline). 1268

Peak pressure onset by rings 1269

Peak pressure onset was always later in the Valsalva compared to the maximum 1270 contraction for rings 3 to 10 (p<0.05) and we observed contractions with more 1271 synchronicity in the activation of the rings in the Valsalva. For maximum contraction, 1272 rings were different from each other in 21 out of 45 possible comparisons (F=12.443; 1273 p<0.001); for instance, ring 1 was different from rings 3 to 8, ring 2 was different from 1274 rings 4 to 8, ring 3 was different from ring 10, rings 4 to 7 were different from rings 9 1275 to 10, and ring 8 was different from ring 10. In contrast, in the Valsalva, only rings 1 1276 and 2 were different from rings 9 and 10, respectively (F=3.681; p=0.0005). Only 3 1277 differences were found among 45 possible differences. There were clearly three blocks 1278 of rings contracting at similar times in the Valsalva: rings 1, 2, 6, and 7 were the first 1279 block; rings 5, 4, and 3 were the second block; and rings 8, 9, and 10 were the third and 1280 last block, in order of contraction. Whereas for the maximum contraction task, three 1281 different blocks were identified: rings 5, 6, 7, 8, and 3, in this order, in the first block; 1282 rings 9, 2, and 1 in the second block; and finally, ring 10 (Fig.4c). 1283

1284 Correlation of total peak pressure and Oxford grading 1285

We observed a significant moderate correlation between digital palpation 1286 assessment and biomechanical assessment (peak pressure) [Spearman’s coefficient of 1287

Þ=0.5477 (p<0.001)]. Out of the 26 participants, 3 presented a score of 1 [peak 1288 pressure mean (95% confidence interval) [27.1kPa (16.50–37.78)], 2 presented a score 1289 of 2 [33.2kPa (-0.33–66.68)], 10 presented a score of 3 [54.1kPa (43.58–64.60)], 3 1290 presented a score of 4 [61.1kPa (36.93–85.21)], and 8 presented a score of 5 [74.8kPa 1291

(61.52–88.15)]. 1292

Inter- and intra-rater reliability and inter-trial repeatability of peak pressure in major 1293

areas in the maximum contraction task 1294

The intra-rater reliability for the maximum contraction task was excellent for the 1295

peak pressure in the total and medial areas. For the cranial area, the reliability was 1296

modest, and it was poor for the caudal area. The intra-trial repeatability was excellent 1297

for the peak pressure in the total, cranial, and medial areas (ICC3,1 >0.86), however, we 1298

observed moderate reliability for the caudal area. The inter-rater reliability was 1299

excellent in the total and medial areas. For the cranial and caudal areas, the reliability 1300

was modest (Table 1). 1301

1302

Table 1. Peak pressure (kPa) mean and standard deviation in three major areas and in the total 1303 matrix area during Valsalva and maximum contraction. Intra class correlation coefficients and 1304 standard error of measurement and prediction between raters and trials of the maximum 1305 contraction task. 1306

Reliability Reliability Reliability Peak Pressure (kPa) Intra-rater Intra-trials Inter-rater

Maximum Tasks SEP SEP Areas Valsalva ICC3,1 SEM ICC3,1 SEM ICC2,1 force comparison rater1 rater2

Cranial 8.2 (4.3) 12.5 (8.5) 0.69 4.5 0.86 2.9 0.72 3.2 5.6

Medial 18.6 (11.7)*& 45.0 (22.4)*& p1<0.001 0.94 7.6 0.95 6.6 0.92 10.6 12.1

Caudal 6.4 (4.9)# 12.2 (9.7)# F=42.267 0.12 11.6 0.70 6.2 0.50 10.7 10.7

Total 20.3 (13.2) 52.0 (24.2) 0.94 7.4 0.97 5.1 0.96 8.0 8.5

1 ANOVA 2-way (repeated measures), bonferroni post-hoc test. * represents the medial area 1307 different from the others in maximum contraction and valsalva; & represents the difference 1308 between tasks in medial area; # represents the difference between tasks in caudal area. 1309

1310

Discussion 1311

1312

The proposed instrumented probe provided a precise 3D map of the pressure 1313 distribution profile of different areas, rings, and planes throughout the vaginal canal, 1314 and enabled a distinctive and high-resolution spatiotemporal analysis, enhancing the 1315 understanding of the function of the PF in dynamic tasks. This novel device also 1316 provided reliable measurements of PFM contractions for intra- and inter-rater and 1317 intra-trial comparisons. 1318

The intra-rater, inter-rater, and intra-trial reliability for the medial and total areas 1319 of the vaginal canal were excellent, whereas for the cranial area, we found modest 1320 intra- and inter-rater reliability, but excellent intra-trial reliability. Although the caudal 1321 area showed moderate inter-rater and intra-trial reliability, intra-rater reliability was 1322 poor suggesting a greater individual variability in achieving maximum PF force, mainly 1323 because of the anatomical location of the PFMs (Jung et al. 2007); however, when 1324 comparing trial averages between sessions (intra-rater reliability), this variability was 1325 attenuated and the reliability became excellent. Peak pressures were slightly 1326 susceptible to changes, which were linearly predictable when the sensor was 1327 calibrated under body temperature. 1328

Among clinicians, the most typical method for quantification of PF function is 1329 digital palpation because it is fast, requires no equipment, and selectively depicts PFM 1330 activity better than most available biofeedback devices (Peschers et al. 2001b). The 1331 moderate correlation observed between clinical and biomechanical assessment can be 1332 attributed to a possible lack of sensitivity of the clinical evaluation that could fail to 1333

differentiate discrete changes over time or treatments. Although peak pressures have 1334 increased accordingly with digital palpation rates, pressure value confidence intervals 1335 overlap between adjacent clinical grades. For instance, among 10 participants scored 1336 as 3 in Oxford grading (Laycock and Jerwood 2001) the peak pressure confidence 1337 interval could be attributed to both grades 2 and 4. 1338

Several manometers (Barbosa et al. 2009; van Raalte and Egorov 2015; Ribeiro et 1339 al. 2016), dynamometers (Dumoulin et al. 2004a; Constantinou and Omata 2007; 1340

Saleme et al. 2009; Chamochumbi et al. 2012; Romero-Cullerés et al. 2017) and EMG 1341 techniques (Halski et al. 2013; Ptaszkowski et al. 2015) have been proposed to 1342 objectively quantify PF function. However, most of these methods were developed for 1343 research purposes, in contrast to the proposed sensor, which is already commercially 1344 available and has the advantage of differentiate the effects of maximum contraction of 1345

PFMs as opposed to an increase in intra-abdominal pressure (Valsalva) along the 1346 vaginal canal (Fig.3). Pressure profiles were completely different between tasks with 1347 notably higher pressures (above 30kPa) for the maximum contraction and lower 1348 pressures (below 15kPa) for the Valsalva, with an entirely different spatiotemporal 1349 pressure distribution pattern. 1350

Furthermore, most of the assessment devices described in the literature 1351 measure only the resultant load of the entire vaginal canal; with this new device, it was 1352 possible to precisely map the vaginal spatiotemporal pressure profile with a high- 1353 resolution, distinguishing 5 planes and 10 rings (Fig.4). One major advantage of our 1354 proposed 100 capacitive sensors instrumented probe is the ability to measure the 1355 entire vaginal depth, which definitely provides a better spatiotemporal pressure profile 1356

and facilitates comparisons between anatomical regions. We consider a limitation of 1357 this study, and a suggestion for future studies, the lack of comparison of the new 1358 proposed device with other available measuring tools. More studies are now needed 1359 to confirm our results and compare the instrument with dynamometers or 1360 perineometers. 1361

When comparing both tasks, we observed for the maximum contraction, higher 1362 pressures in the mid-antero-posterior zone (2–4cm from the vaginal introitus), 110– 1363

126% higher for all 5 planes, whereas in the Valsalva, the highest pressures were in the 1364 upper portion of the antero-posterior zone (4–5cm from the vaginal introitus). Along 1365 the rings, higher-pressures were again observed for the maximum contraction in the 1366 mid-portion [rings 4–8], and were even higher in rings 6–8 (130–197% above the 1367 obtained Valsalva pressure). Accordingly, the mid-region achieved higher-pressure 1368 rates for both tasks when the sensors were divided into the three major areas (caudal, 1369 medial, and cranial). These results detail the specific region of PFM force action and 1370 confirm previous findings of a mid-antero-posterior high-pressure zone in the vaginal 1371 canal (Guaderrama et al. 2005; Jung et al. 2007; Peng et al. 2007; Shishido et al. 2008). 1372

In our study we observed a latero-lateral asymmetry during PFM contraction, 1373 with higher-pressure values shown in the 2nd plane (left anterior to right posterior) 1374 compared to the 4th plane (right anterior to left posterior). In healthy women the PFM 1375 have been thought to contract bilaterally as a functional unit (Shafik 1998), with no 1376 differences reported on vaginal pressure (Guaderrama et al. 2005) or ultrasound 1377 images between right or left sides (Weinstein et al. 2007). However latero-lateral 1378 asymmetries of the PFM were reported in a recent study using a multiple array EMG 1379

probe (Voorham-van der Zalm et al. 2013), with higher average EMG values obtained 1380 for the right side of the PF compared to the left side. Considering that PFM form a U- 1381 shaped loop around the urethra, vagina, and anus, the reported higher activation of 1382 the PFM left portion corroborates with the higher-pressure pattern observed here in 1383 the 2nd plane. This is the first time that the pressure profile of the vaginal canal has 1384 been evaluated with a high spatial 3D resolution probe, and it is possible that this 1385 slight symmetry difference was not reported before due to lack of resolution of the 1386 majority of the equipment’s used to date. 1387

Peak pressure onsets were different from rings 3 to 10 in the maximum 1388 contraction; the ring onsets were always late in the Valsalva compared to the 1389 maximum contraction, with more synchronicity in the activation of the rings in the 1390

Valsalva. 1391

A limitation of our study is that we did not standardize the length of the vagina 1392 among women and the instrumented probe has a fixed length. Nevertheless, 1393 anthropometric factors such as height, weight, and body mass index cannot predict the 1394 anatomical configuration of the vaginal canal (Luo et al. 2016) and there are no 1395 correlations between vaginal length and these parameters. Here we made sure to 1396 cover the mid-portion of the vaginal canal for all participants (around 3.5 cm from the 1397 vaginal introitus), which was previously described as the most relevant region for PF 1398 muscle contraction (Guaderrama et al. 2005). With 100 sensors, we can be confident 1399 that the high-pressure zone observed in the mid-antero-posterior portion of the 1400 vaginal canal, would not be influenced by the size of either the vagina or the device 1401 length. Another limitation of our instrument is that it can only be used when the 1402

subject is lay down, and therefore it is not possible to assess the PFM in dynamic 1403 conditions such walking, jumping or running, what could provide more information 1404 about the continence mechanism. 1405

With this protocol and novel instrument, we can obtain highly reliable 1406 measurements and high-resolution recording of the dynamic responses of the PFMs 1407 along the entire vaginal canal, as well as in different areas, planes, and rings, enabling 1408 an innovative 3D pressure distribution map for the female PF; this method has 1409 advantages among other commercially available instruments for measuring pressure in 1410 the vaginal canal, considering its high spatial 3D resolution. From a clinical perspective, 1411 this new device allows accurate and selective measurement of PFM performance and 1412 could have positive implications for clinical assessment and rehabilitation. In further 1413 studies, this novel instrument allows us to measure the load distribution in pregnant 1414 woman; to differentiate patterns of load distribution in different populations, training 1415 effect and tasks, leading us to a new era of measuring loads distribution of the pelvic 1416 floor muscles. 1417

1418

Conclusion 1419

1420

The novel instrumented probe has an excellent reliability and repeatability, is 1421 moderately associated with PFM digital assessment, and provides a high-resolution 1422 map of the dynamic and spatiotemporal pressure profile throughout the vaginal canal, 1423 differentiating the action of PFMs from intra-abdominal pressure increases. 1424

1425

Acknowledgement 1426

The authors are grateful to the National Council for Scientific and Technological 1427

Development (CNPq) for Sacco´s scholarship (Process: 305606/2014-0) and Amorim’s 1428 scholarship (478332/2013-0), to the São Paulo State Research Foundation (FAPESP) for 1429 funding this project (process 2013/19610-3), and for Cacciari’s scholarship (process 1430

2013/13820-6, 2015/19679-9). 1431

1432

Conflict of interest statement 1433

The research has been co-funded by CNPQ, CAPES and FAPESP. The fourth 1434 author (M.G.) works in novel gmbh and conducts this research supervised by Dr Isabel 1435

CN Sacco. All other authors are not associated to novel gmbh. Data were collected, 1436 analyzed and the paper written with no influence from the funding agencies or novel 1437

Company and no author will receive anything of value from the commercial product 1438 included in this paper. 1439

1440

References 1441

Abrams P, Andersson KE, Birder L, Brubaker L, Cardozo L, Chapple C, et al. Fourth International 1442 Consultation on Incontinence Recommendations of the International Scientific 1443 Committee: Evaluation and treatment of urinary incontinence, pelvic organ prolapse, 1444 and fecal incontinence. Neurourol Urodyn [Internet]. 2010;29(1):213–40. 1445 Ashton-Miller JA, DeLancey JOL. Functional anatomy of the female pelvic floor. Ann N Y Acad 1446 Sci. 2007;1101:266–96. 1447 Barbosa PB, Franco MM, de Oliveira Souza F, Antônio FI, Montezuma T, Ferreira CHJ. 1448 Comparison between Measurements Obtained with three Different Perineometers. 1449 Clinics. 2009;64(6):527–33. 1450 Bø K. Pelvic floor muscle strength and response to pelvic floor muscle training for stress 1451 urinary incontinence. Neurourol Urodyn. 2003;22(January):654–8. 1452

Bø K, Finckenhagen HB. Vaginal palpation of pelvic floor muscle strength: inter-test 1453 reproducibility and comparison between palpation and vaginal squeeze pressure. Acta 1454 Obstet Gynecol Scand. 2001;80(6):883–7. 1455 Bø K, Hilde G, Tennfjord MK, Engh ME. Does episiotomy influence vaginal resting pressure, 1456 pelvic floor muscle strength and endurance, and prevalence of urinary incontinence 6 1457 weeks postpartum? Neurourol Urodyn [Internet]. 2017 Mar;36(3):683–6. 1458 Bø K, Sherburn M. Evaluation of female pelvic-floor muscle function and strength. Phys Ther. 1459 2005;85(3):269–82. 1460 Cescon C, Riva D, Začesta V, Drusany-Starič K, Martsidis K, Protsepko O, et al. Effect of vaginal 1461 delivery on the external anal sphincter muscle innervation pattern evaluated by 1462 multichannel surface EMG: results of the multicentre study TASI-2. Int Urogynecol J. 1463 2014; 1464 Chamochumbi CCM, Nunes FR, Guirro RRJ, Guirro ECO. Comparison of active and passive 1465 forces of the pelvic floor muscles in women with and without stress urinary incontinence 1466 [Internet]. Vol. 16, Revista Brasileira de Fisioterapia. 2012. p. 314–9. 1467 Constantinou CE, Omata S. Direction sensitive sensor probe for the evaluation of voluntary and 1468 reflex pelvic floor contractions. Neurourol Urodyn. 2007;26(February):386–91. 1469 Dorey G, Speakman M, Feneley R, Swinkels A, Dunn C, Ewings P. Randomised controlled trial of 1470 pelvic floor muscle exercises and manometric biofeedback for erectile dysfunction. Br J 1471 Gen Pract. 2004;54(November):819–25. 1472 Dumoulin C, Gravel D, Bourbonnais D, Lemieux MC, Morin M. Reliability of Dynamometric 1473 Measurements of the Pelvic Floor Musculature. Neurourol Urodyn. 2004;23(July 1474 2003):134–42. 1475 Enck P, Hinninghofen H, Wietek B, Becker HD. Functional asymmetry of pelvic floor innervation 1476 and its role in the pathogenesis of fecal incontinence. Digestion. 2004;69:102–11. 1477 Frawley HC, Galea MP, Phillips BA, Sherburn M, Bø K. Reliability of pelvic floor muscle strength 1478 assessment using different test positions and tools. Neurourol Urodyn. 2006;25(August 1479 2005):236–42. 1480 Friedman S, Blomquist JL, Nugent JM, McDermott KC, Muñoz A, Handa VL. Pelvic Muscle 1481 Strength After Childbirth. Obstet Gynecol. 2012;120(5):1. 1482 Guaderrama NM, Nager CW, Liu J, Pretorius DH, Mittal RK. The vaginal pressure profile. 1483 Neurourol Urodyn. 2005;24:243–7. 1484 Halski T, Ptaszkowski K, Słupska L, Dymarek R. The evaluation of bioelectrical activity of pelvic 1485 floor muscles depending on probe location: a pilot study. Biomed Res Int [Internet]. 1486

2013;2013:238312. 1487 Haylen BT, Maher CF, Barber MD, Camargo S, Dandolu V, Digesu A, et al. An International 1488 Urogynecological Association (IUGA) / International Continence Society (ICS) Joint 1489 Report on the Terminology for Female Pelvic Organ Prolapse (POP). Neurourol Urodyn 1490 [Internet]. 2016 Feb;35(2):137–68. 1491 Haylen BT, de Ridder D, Freeman RM, Swift SE, Berghmans B, Lee J, et al. An International 1492 Urogynecological Association (IUGA)/International Continence Society (ICS) joint report 1493 on the terminology for female pelvic floor dysfunction. Int Urogynecol J [Internet]. 2010 1494 Jan [cited 2016 Jan 3];21(1):5–26. 1495 Janura M, Peham C, Dvorakova T, Elfmark M. An assessment of the pressure distribution 1496 exerted by a rider on the back of a horse during hippotherapy. Hum Mov Sci. 1497 2009;28(3):387–93. 1498 Jung S-A, Pretorius DH, Padda BS, Weinstein MM, Nager CW, den Boer DJ, et al. Vaginal high- 1499 pressure zone assessed by dynamic 3-dimensional ultrasound images of the pelvic floor. 1500 Am J Obstet Gynecol. 2007;197(July):1–7. 1501 Kernozek TW, Wilder PA, Amundson A, Hummer J. The effects of body mass index on peak 1502 seat-interface pressure of institutionalized elderly. Arch Phys Med Rehabil. 1503 2002;83(6):868–71. 1504 Laycock J, Jerwood D. Pelvic Floor Muscle Assessment: The PERFECT Scheme. Physiotherapy. 1505 2001;87(12):631–42. 1506 Luo J, Betschart C, Ashton-Miller JA, DeLancey JOL. Quantitative analyses of variability in 1507 normal vaginal shape and dimension on MR images. Int Urogynecol J [Internet]. 2016 1508 Jul;27(7):1087–95. 1509 Middlekauff ML, Egger MJ, Nygaard IE, Shaw JM. The impact of acute and chronic strenuous 1510 exercise on pelvic floor muscle strength and support in nulliparous healthy women. Am J 1511 Obstet Gynecol [Internet]. 2016;215(3):1–7. 1512 Morin M, Dumoulin C, Bourbonnais D, Gravel D, Lemieux M-C. Pelvic floor maximal strength 1513 using vaginal digital assessment compared to dynamometric measurements. Neurourol 1514 Urodyn [Internet]. 2004;23(4):336–41. 1515 Peng Q, Jones RCL, Shishido K, Omata S, Constantinou CE. Spatial distribution of vaginal closure 1516 pressures of continent and stress urinary incontinent women. Physiol Meas. 1517 2007;28(11):1429–50. 1518 Peschers UM, Gingelmaier A, Jundt K, Leib B, Dimpfl T. Evaluation of pelvic floor muscle 1519 strength using four different techniques. Int Urogynecol J Pelvic Floor Dysfunct. 1520

2001;12(1):27–30. 1521 Ptaszkowski K, Paprocka-Borowicz M, Słupska L, Bartnicki J, Dymarek R, Rosińczuk J, et al. 1522 Assessment of bioelectrical activity of synergistic muscles during pelvic floor muscles 1523 activation in postmenopausal women with and without stress urinary incontinence: a 1524 preliminary observational study. Clin Interv Aging [Internet]. 2015 Jan 23 [cited 2015 Oct 1525 26];10:1521–8. 1526 Quartly E, Hallam T, Kilbreath S, Refshauge K. Strength and endurance of the pelvic floor 1527 muscles in continent women: An observational study. Physiotherapy. 2010;96(4):311–6. 1528 van Raalte H, Egorov V. Tactile Imaging Markers to Characterize Female Pelvic Floor 1529 Conditions. Open J Obstet Gynecol [Internet]. 2015 Aug;5(9):505–15. 1530 Rahmani N, Mohseni-Bandpei MA. Application of perineometer in the assessment of pelvic 1531 floor muscle strength and endurance: A reliability study. J Bodyw Mov Ther. 1532 2011;15(2):209–14. 1533 Ribeiro J dos S, Guirro ECO, Franco M de M, Duarte TB, Pomini JM, Ferreira CHJ. Inter-rater 1534 reliability study of the PeritronTM perineometer in pregnant women. Physiother Theory 1535 Pract [Internet]. 2016;32(3):209–17. 1536 Romero-Cullerés G, Peña-Pitarch E, Jané-Feixas C, Arnau A, Montesinos J, Abenoza-Guardiola 1537 M. Intra-rater reliability and diagnostic accuracy of a new vaginal dynamometer to 1538 measure pelvic floor muscle strength in women with urinary incontinence. Neurourol 1539 Urodyn [Internet]. 2017 Feb;36(2):333–7. 1540 Saleme CS, Rocha DN, Del Vecchio S, Silva Filho AL, Pinotti M. Multidirectional Pelvic Floor 1541 Muscle Strength Measurement. Ann Biomed Eng. 2009;37(8):1594–600. 1542 Sartori DVB, Gameiro MO, Yamamoto HA, Kawano PR, Guerra R, Padovani CR, et al. Reliability 1543 of pelvic floor muscle strength assessment in healthy continent women. BMC Urol 1544 [Internet]. 2015 Dec;15(1):29. 1545 Schaer GN, Koechli OR, Schuessler B, Haller U. Perineal ultrasound for evaluating the bladder 1546 neck in urinary stress incontinence. Obstet Gynecol [Internet]. 1995 Feb;85(2):220–4. 1547 Shafik A. A new concept of the anatomy of the anal sphincter mechanism and the physiology 1548 of defecation: Mass contraction of the pelvic floor muscles. Int Urogynecol J Pelvic Floor 1549 Dysfunct. 1998;9(1):28–32. 1550 Shishido K, Peng Q, Jones RCL, Omata S, Constantinou CE. Influence of Pelvic Floor Muscle 1551 Contraction on the Profile of Vaginal Closure Pressure in Continent and Stress Urinary 1552 Incontinent Women. J Urol. 2008;179(5):1917–22. 1553 Theofrastous JP, Wyman JF, Bump RC, McClish DK, Elser DM, Bland DR, et al. Effects of pelvic 1554

floor muscle training on strength and predictors of response in the treatment of urinary 1555 incontinence. Neurourol Urodyn [Internet]. 2002;21(5):486–90. 1556 Torelli L, de Jarmy Di Bella ZIK, Rodrigues CA, Stüpp L, Girão MJBC, Sartori MGF. Effectiveness 1557 of adding voluntary pelvic floor muscle contraction to a Pilates exercise program: an 1558 assessor-masked randomized controlled trial. Int Urogynecol J [Internet]. 2016;1–10. 1559 Voorham-van der Zalm PJ, Voorham JC, Van den Bos TWL, Ouwerkerk TJ, Putter H, Wasser 1560 MNJM, et al. Reliability and differentiation of pelvic floor muscle electromyography 1561 measurements in healthy volunteers using a new device: The Multiple Array Probe 1562 Leiden (MAPLe). Neurourol Urodyn. 2013;32(4):341–8. 1563 Weinstein MM, Jung S-A, Pretorius DH, Nager CW, den Boer DJ, Mittal RK. The reliability of 1564 puborectalis muscle measurements with 3-dimensional ultrasound imaging. Am J Obstet 1565 Gynecol [Internet]. 2007 Jul;197(1):68.e1-6. 1566 1567

5. ACCEPTED PAPER 2 1568

1569

Abstract 1570 1571 Background: Pompoir is a technique poorly studied in the literature that claims to 1572 improve pelvic floor strength and coordination. This study aims to investigate the 1573 pelvic floor muscles´ coordination throughout the vaginal canal among Pompoir 1574 practitioners and non-practitioners by describing a high resolution map of pressure 1575 distribution. 1576 Methods: This cross-sectional, study included 40 healthy women in two groups: control 1577 and Pompoir. While these women performed both sustained and “waveform” pelvic 1578 floor muscle contractions, the spatiotemporal pressure distribution in their vaginal 1579 canals was evaluated by a non-deformable probe fully instrumented with a 10x10 1580 matrix of capacitive transducers. 1581 Findings: Pompoir group was able to sustain the pressure levels achieved for a longer 1582 period (40% longer, moderate effect, P=0.04). During the “waveform” contraction task, 1583 Pompoir group achieved lower, earlier peak pressures (moderate effect, P=0.05) and 1584 decreased rates of contraction (small effect, P=0.04) and relaxation (large effect, 1585 P=0.01). During both tasks, Pompoir group had smaller relative contributions by the 1586 mid-region and the anteroposterior planes and greater contributions by the caudal and 1587 cranial regions and the latero-lateral planes. 1588 Interpretation: Results suggest that specific coordination training of the pelvic floor 1589 muscles alters the pressure distribution profile, promoting a more-symmetric 1590 distribution of pressure throughout the vaginal canal. Therefore, this study suggests 1591 that pelvic floor muscles can be trained to a degree beyond strengthening by focusing 1592 on coordination, which results in changes in symmetry of the spatiotemporal pressure 1593 distribution in the vaginal canal. 1594 1595 Keywords: pelvic floor muscle function, pelvic floor muscle training, muscle strength, 1596 vaginal pressure, women, biomechanics. 1597 1598

Introduction 1599

1600

Pelvic floor (PF) muscle training is widely recommended as first-line, conservative 1601 management for women with any type of urinary incontinence (Dumoulin et al. 2014) 1602 and as a treatment or prevention option for a variety of urogynecological dysfunctions 1603

(Freeman 2013) because these disorders have been linked to anatomical defects in 1604 structures that support the pelvic organs, including the levator ani muscle (Heilbrun et 1605 al. 2010). Urogynecological dysfunctions affect up to 67% of adult women (Kepenekci 1606 et al. 2011), depending mostly on age, childbirth status, body mass index (BMI), and 1607 family history (MacLennan et al. 2000; Swift et al. 2005; Wood and Anger 2014). 1608

In addition to improving PF coordination and strength, PF muscle exercises are 1609 believed to improve sexual function by increasing self-confidence, desire, lubrication, 1610 orgasm, and satisfaction, although they have mostly been studied in women with 1611 urinary incontinence (Bø et al. 2000). Techniques involving strength and coordination 1612 training were first reported as treatment options for urinary incontinence in the mid- 1613

1900s (Kegel 1948), though reports indicate that PF motor-capacity training has been 1614 an important part of Chinese Taoism exercises for more than 6,000 years, aiming to 1615 stimulate circulation in the sexual organs, energize the pubic region, and promote self- 1616 awareness and sexual satisfaction (Chang 1986). 1617

Although the deep and superficial layers of the PF muscles comprise different 1618 anatomical structures and innervation, clinically, they are assumed to act as a 1619 functional unit simultaneously as a mass contraction, to pull the pelvic floor structures 1620 in a ventro-cephalic direction, (Bø and Sherburn 2005), while Pompoir practitioners 1621

claim they can contract the PF muscles in layers, differentiating these layers as “rings” 1622 along the vaginal canal. If this is true, this practice would reveal patterns of pressure 1623 distribution in the vaginal canal that identify the action of these layers, or discriminate 1624 these rings. Training in the Pompoir technique has recently spread among women 1625 searching for improved self-awareness and sexual satisfaction. However, this practice 1626 has never been properly documented, and its outcomes in terms of pressure 1627 distribution along the PF structures have never been studied. 1628

During the PF muscle contraction, a high-pressure zone is clearly identified at the 1629 mid-anteroposterior portion of the vaginal canal (Guaderrama et al. 2005). Given the 1630 presumed potential of Pompoir training to coordinate, strengthen the capacity of, and 1631 symmetrically distribute loads throughout different portions of the PF, one can assume 1632 that Pompoir practitioners would present a different coordination pattern than those 1633 without training experience that would result in a more homogeneous spatial and 1634 temporal pressure distribution along the vaginal canal. 1635

Speed, timing, endurance, coordination and symmetry of the PF muscle 1636 contraction are thought to be just as important to urogynecological function as is their 1637 capacity to generate force (Bø 2004; Devreese et al. 2004). Therefore, techniques that 1638 favors training these physical capacities could enhance the trainability potential of the 1639

PF muscles in the pursuit of better sexual and continence functioning. 1640

Assessing the PF muscles’ physical and functional capacities is still a matter of 1641 debate in the literature. Because of the complexity of the PF structure, whose format is 1642 concave with a three-dimensional (3-D) architecture, multiple origins and insertions 1643

(Ashton-Miller and DeLancey 2007), and great variability in the locations of its multiple 1644

innervation zones (Cescon et al. 2014), developing a quantitative, 3-D tool to 1645 discriminately assess various regions of the vaginal canal and PF muscle layers and 1646 functions is still ongoing. Digital palpation is the most-used technique to evaluate the 1647 quality of PF muscle function; however, palpation is less sensitive when quantifying 1648 sustained contractions (Frawley et al. 2006) or when differentiating variations in 1649 discrete force (Morin et al. 2004b) and has limited reliability when performed by 1650 different raters (Sartori et al. 2015). 1651

Ideally, assessing the PF should take into account its flexible, 3-D, deformable 1652 surface and should analyze both the force distributed through various regions of the 1653 vaginal canal (latero-lateral, caudal, medial, and cranial) (Devreese et al. 2004) and the 1654 capacity to coordinate contractions in a symmetrical, spatially distributed way. 1655

However, the most regularly used methods in scientific and clinical investigations, 1656 including electromyography (EMG), intravaginal balloon catheters (perineometers), 1657 and dynamometers (Bø and Sherburn 2005), lack adequate spatiotemporal 1658 differentiation of PF functions along the vaginal canal and barely differentiate intra- 1659 abdominal pressure increases from PF-muscle contractions (Guaderrama et al., 2005; 1660

Peschers et al., 2001; Shishido et al., 2008). Perineometers are made of highly pliable 1661 materials, which can be problematic, since it has been shown that PF muscle force is 1662 related with vaginal canal distension (Dumoulin et al. 2004a). In addition, surface EMG 1663 assessments are rather questionable and difficult to perform reliably because PF- 1664 muscle architecture includes multiple innervation zones (Peschers et al. 2001b; Enck et 1665 al. 2004). 1666

PF evaluations using a reliable mechanical tool capable of measuring pressures 1667

magnitude, and their temporal and spatial distribution, would also improve the 1668 understanding of the pathophysiology of urogynecological dysfunctions. Thus, the 1669 purpose of this study was to investigate the potential coordination of the different 1670 portions of the PF in Pompoir practitioners by describing a high spatial (3D resolution) 1671 map of pressure distribution along the vaginal canal among practitioners and non- 1672 practitioners. 1673

1674

Methods 1675

Participants 1676

The eligibility criteria for all participants included age between 20–45 years, 1677 premenopausal status with monthly menstrual cycles, BMI no higher than 30 kg/m2, 1678 not virgins, not currently pregnant, no history of pregnancy within the past year, no 1679 reported urogynecological dysfunction, no history of neurological or psychological 1680 conditions that could interfere with PF muscle function, no history of untreated urinary 1681 tract infections or surgery for urinary incontinence or pelvic organ prolapse, no 1682 pronounced pain or discomfort with pelvic exam, no pelvic organ prolapse stage higher 1683 than II (most distal portion of the prolapse situated between 1cm above and below the 1684 hymen) (Haylen et al. 2016), and the ability to contract the PF muscles correctly 1685 according to digital assessment (≥ 3 on the 0‒5 modified Oxford grading scheme). 1686

This cross-sectional study included 40 healthy adult women divided into two 1687 groups. The control group (CG, n = 23) comprised volunteers without any type of PF 1688 training or urogynecological physiotherapy practice [34.5 (8.9) yrs. old, 23.5 (3.1) 1689 kg/m2, 164.1 (6.8) cm], modified Oxford grading scheme median 4 (IQR 3‒5)]. The 1690

modified Oxford grading scheme defines the ability to contract the PF muscles in six 1691 categories (0-nil, 1-flicker, 2-weak, 3-moderate, 4-good and 5-strong) (Laycock and 1692

Jerwood 2001) and was checked by digital palpation by an experienced 1693 physiotherapist during the clinical assessment. The Pompoir group (PG, n = 17) 1694 comprised volunteers with at least 6 months of Pompoir training taught by the same 1695 professional [34.3 (8.7) yrs. old, 25.5 (4.1) kg/m², 162.1 (9.6) cm], modified Oxford 1696 grading scheme median 4 (IQR 3‒5)]. 1697

This study was approved by the Ethics Committee of the School of Medicine of 1698 the University of São Paulo (protocol n.023/14), and all participants provided written, 1699 informed consent prior to participating. 1700

The two groups were matched to guarantee similarity for features that represent 1701 risk factors for urogynecological dysfunctions (Wood and Anger, 2014), and that could 1702 interfere in the PF-muscle assessment results, including age (t = 0.07; P = 0.95), BMI (t 1703

=-1.05; P = 0.30), height (t=-0.81; P=0.14), modified Oxford grading scheme (z = -0.80; 1704

P = 0.45), parity (median 0, min-max 0‒2, Z = 0.10; P = 0.90), and type of delivery 1705

(vaginal labor, Z=- 0.53; P = 0.74). 1706

1707

Clinical Assessment 1708

The participants were interviewed and then clinically assessed by a trained 1709 physiotherapist (evaluator 1, who had 10 years of experience in women’s health 1710 physiotherapy) to make sure they met the eligibility criteria. For the clinical evaluation, 1711 they were positioned supine with hips and knees flexed and feet flat on a conventional 1712 gynecologist’s table in an isolated, private room with comfortable temperature and 1713

illumination. The participants received detailed instructions about correct PF muscle 1714 contraction with an inward movement of the perineum that tries to “squeeze” and 1715

“lift” the PF as they would to prevent urine or flatus loss (Messelink et al., 2005). The 1716 evaluator assessed the PF muscle function by digital palpation while the women 1717 performed a series of voluntary contractions using Laycock’s PERFECT assessment 1718 scheme (Laycock and Jerwood 2001). PERFECT is an acronym with P representing 1719 power (a measure of strength), E = endurance, R = repetitions, F = fast contractions, 1720 and finally ECT = every contraction timed. The scheme was developed to simplify and 1721 clarify the PF muscle assessment and was used here to quantify and qualify the pelvic 1722 floor muscle function. 1723

1724

Instrument 1725

The spatiotemporal pressure distribution of the vaginal canal was evaluated 1726 using a fully instrumented probe, consisting of an Ertacetal® cylinder [tensile modulus 1727 of elasticity of 2.800 MPa (according to ISO 527-1/-2)], covered by a 10 x 10 matrix of 1728 individually calibrated capacitive transducers (MLA-P1, pliance System; novel; Munich, 1729

Germany). The cylinder is 23.2mm in diameter and 8cm in length, and its sensing area 1730 is 70.7x70.7mm (10x10 matrix of sensing elements, each with 7.07x7.07 mm in size, 1731

0.6 mm in thickness, and 1.79 mm gap between them, coated with a protective layer 1732 of 0.3 mm). The capacitive transducers have a measurement range of 0.5‒100kPa, and 1733 a measurement resolution of 0.42kPa, enabling unidirectional measurements along 1734 the vaginal canal (Figure 1A). All sensors were tested for accuracy before their first use 1735 by the manufacturer. Each individual sensor was checked in regards of measured vs. 1736

applied pressure in a test session with at least 6 different values of pressure covering 1737 the whole range of expected values. 1738

1739

Reliability of the instrument 1740

To ensure the reliability of the instrumented probe and the evaluator, we 1741 designed a test-retest protocol to guarantee the quality of the measurement and 1742 examiner. Prior to the main data acquisition, each participant repeated 3 tasks of 1743 maximum voluntary contraction, twice in the first day with different evaluators, and 1744 once more in a second day, one week apart. In the first visit, participants had their PF 1745 function assessed by a trained physiotherapist (evaluator 1) while performing three 1746 trials of maximally contracting their PF muscles. At least 1h after the first 1747 measurement, the objective PF assessment was repeated by evaluator 2. Both 1748 evaluators were trained physiotherapists specializing in woman’s health and had 10 1749 years of experience (evaluator 1) and 3 years of experience (evaluator 2) in clinical 1750 practice. One week later, at a second visit, volunteers were again assessed by 1751 evaluator 1 while performing the same task. Intra-rater, inter-rater, and inter-trial 1752 reliabilities for peak pressure were excellent (Hallgren 2012). (intra-rater standard 1753 error of measurements (SEM) = 10.54, ICC3,1 = 0.86; inter-rater standard error of 1754 prediction (SEP) = 5.46, ICC2,1 = 0.91; and inter-trials SEM = 9.07, ICC3,1 = 0.907) 1755

1756

Data acquisition 1757

Prior to each test, the instrumented probe was warmed to body temperature 1758 and covered with a hypoallergenic, nonlubricated condom. This condom was marked 1759

at the length of 7 cm to ensure standardized depth of insertion in the vaginal canal. To 1760 prevent skin contact with the ink used for the marking, a second condom was placed 1761 over the first, and it was appropriately lubricated with a warmed, hypoallergenic gel to 1762 minimize discomfort during insertion. Before and after each use, the device was 1763 sterilized and cleaned according to the manufacturer’s instructions and the 1764 requirements of the University Hospital Infection Commission. 1765

The instrumented probe was inserted always with the same orientation, 7 cm 1766 into vaginal canal from the hymeneal caruncle with the content measurement length 1767 of 8 cm. The depth of insertion was carefully ensured by matched anatomical 1768

(hymeneal caruncle and clitoris) references and the mark on the condom and along the 1769 probe. This insertion depth was chosen because the usual length of the vaginal canal of 1770 adult women is 8.9 ± 1.3 cm (Silveira et al. 2015) and we wanted to avoid discomfort 1771 during task performance. In addition, the PF muscles are known to act mainly in the 1772 first 6 cm of the vaginal canal (Shishido et al. 2008). After a 1-min accommodation 1773 period, if no discomfort was reported, the women were instructed to relax their PF 1774 muscles, remain silent and breathe normally for 10 sec while a baseline value was 1775 taken (baseline pressure, calculated as the mean pressure value for each transducer). 1776

Pressure-related variables were acquired at 50 Hz while the women performed 1777 two different tasks with a 1-min rest period between both trials and tasks (Figure 1B). 1778

The first task (the endurance task) consisted of two sustained contractions; the second 1779 task (the wave task) consisted of three waveform contractions. During the endurance 1780 task, participants were asked to contract their PF muscles, as they had done in the 1781 clinical examination, and sustain the contraction for 10 s while breathing normally, 1782

similar to the PERFECT scheme endurance test (Laycock and Jerwood 2001). During the 1783 wave task, women were instructed to contract their PF muscles in a caudal-cranial 1784 direction for 2 s and then relax them in a cranial-caudal direction for 2 s. The cadence 1785 was controlled by a digital metronome. The wave task is usually undertaken in 1786

Pompoir practice and in strengthening training of the PF, and it is a coordination task 1787 in which the actions of all layers and regions of PF muscles must be coordinated to 1788 successfully accomplish the goal. 1789

1790

Figure 1. A- Pliance System (Novel, Munich, Germany). Intravaginal probe: 1791 Ertacetal® cylinder covered with capacitive transducers placed in a matrix 1792 configuration (10x10). B- Variables calculated from the peak pressure time-series. 1793 Sustained contraction: peak pressure and pressure instant. “Wave” contraction: 1794 peak pressure, pressure instant, contractions rate and relaxation rate. 1795 1796

Standardized verbal encouragement was given throughout the efforts (Caldwell 1797 et al. 1974), and only contractions that resulted in an inward movement of the 1798 perineum were recorded (Bø et al. 2009). Tasks were performed in the same sequence 1799 by all women, guaranteeing that the maximum voluntary muscle contraction necessary 1800

for the endurance task was not affected by any fatigue or learning effect produced by 1801 the wave coordination task. 1802

1803

Data analysis 1804

Data was acquired and exported in ASCII format by Pliance System x/E software 1805

(Novel; Munich, Germany), further filtered (8Hz low pass, 4th order) and analyzed in a 1806 custom-designed function written in Matlab (MathWorks; Natick, MA). For the wave 1807 task, data was normalized to time [0‒100%]. 1808

From the recorded pressure values, the following variables were calculated for 1809 the endurance task: (1) peak pressure [kPa] subtracted from the baseline pressure, (2) 1810 time to peak pressure [s] and (3) duration of the plateau [s], which represented the 1811 longest duration of the sustained contraction maintained above 90% of the peak 1812 pressure. For the wave task, the following variables were calculated: (1) peak pressure 1813

[kPa] subtracted from the baseline pressure, (2) time to peak pressure [%t], (3) 1814

!"#$ !"#$$%"#!!"!#!$% !"#$!"!" contraction rate kPa/%t and (4) relaxation rate 1815 !"#$ !" !"#$ !"#$$%"#

!"#$ !"#$$%"#!!"#$% !"#$$%"# kPa/%t . 1816 !!!"#$ !" !"#$ !"#$$%"#

We also analyzed pressure-time integrals of peak pressures and of the sum 1817

(total) of pressures in a) 5 planes (20 sensors each), with each plane (36o apart from 1818 each other) composed by a sum vector of pressures from two 10-sensor lines 1819 diametrically opposed along the cylinder (Peng et al. 2007); and b) 10 rings, each one 1820 composed by 10-sensor perimeters surrounding the cylinder. 1821

For the endurance task, the pressure-time integral was calculated in a fixed 1822 window of 8 s starting from time to peak pressure. For the wave task, the window was 1823

fixed at 50% of the contraction period starting from the instant at which the pressure 1824 rose higher than 2 standard deviations plus the baseline value. To better describe the 1825 relative contribution by each plane and ring to the pressure distribution along the 1826 vaginal canal, the pressure-time integral calculated only for the total pressure was 1827 normalized by the total pressure-time integral of the entire matrix (sum of all 100 1828 sensors) in the same fixed windows used for each task. 1829

Finally, for the wave task, onset of the peak pressure-time series in each ring 1830 was determined from the instant (% time series) at which each ring achieved a 1831 pressure value higher than 2 standard deviations from the baseline pressure. 1832

1833

Statistical analysis 1834

Means of trials (two for the endurance task and three for the wave task) per 1835 subjects were used for statistical purposes. Given the sample size evaluated, an alpha 1836 error of 5%, and an effect size of 0.80 – large effect (d) (based on pressure-time 1837 integral), the statistical power (1- β) obtained was 0.79 with t-test. 1838

For all variables, normal distribution (Shapiro Wilk test) and homoscedasticity 1839

(Levene Test) were achieved. Between-group comparisons of all anthropometric, 1840 clinical, and pressure-related variables (time series, peak pressure, and pressure-time 1841 integral by the entire matrix) were made by t-tests for independent samples, with the 1842 significance level set at 0.05. Between-group comparisons of pressure-time integrals 1843 and peak pressure onsets by planes and rings were conducted by multivariate ANOVAs 1844

(MANOVAs). If a significant difference was found, univariate ANOVAs were performed. 1845

Cohen’s d coefficients were calculated to express the effect size between groups 1846 for each task. We considered d coefficients smaller than 0.40 to be small effects; 1847 between 0.40 and 0.75, moderate effects; and greater than 0.75, large effects. 1848

1849

Results 1850

Peak pressure time series of the entire matrix 1851

For the endurance task, the Pompoir group sustained 90% of the achieved 1852 contraction for a longer period than the control group (40% longer, moderate effect). 1853

No differences between groups were identified for the peak pressure magnitude or the 1854 time to peak pressure (small effects). 1855

For the wave task, the Pompoir group achieved lower, earlier peak pressures 1856 than the control group (moderate effect). The Pompoir group also had decreased 1857 contraction (small effect) and relaxation (large effect) rates (Table 1). 1858

1859

Table 1. Mean (standard-deviation) of the pressure-related variables of the time series of the 1860 entire matrix for endurance and wave tasks. 1861

Peak pressure-time series Control Group (n=23) Pompoir Group (n=17) t 1 P1 Cohen's d ENDURANCE TASK Peak pressure [kPa] 41.7 (21.5) 46.6 (28.8) -0.63 0.53 0.20 (small) Peak pressure instant [s] 2.63 (2.27) 1.85 (1.84) 1.15 0.26 0.38 (small) Plato 90% [s] 1.29 (0.91) 1.90 (1.73) -2.07 0.04 0.43 (moderate) WAVE TASK

Peak pressure [kPa] 40.5 (22.3) 27.4 (16.9) 2.02 0.05 0.67 (moderate) Peak pressure instant [%t] 52.9 (8.9) 45.8 (12.3) 2.11 0.04 0.70 (moderate) Contraction rate [kPa/%t] 0.71 (0.40) 0.57 (0.42) 1.10 0.28 0.35 (small) Relaxation rate [kPa/%t] -0.83 (0.52) -0.46 (0.30) -2.62 0.01 0.86 (large) 1independent samples t-test. Cohen’s d effect size (Thalheimer and Cook 2002). Statistical 1862 differences between groups highlighted (P<0.05). 1863

1864

1865

Pressure-time integrals by planes 1866

Multivariate comparisons between groups and planes showed significant effects 1867 for both pressure-related variables for endurance task: total pressure-time integral 1868

(Wilks’ Lambda = 0.83, F = 4.14, P = 0.004) and peak pressure-time integral (Wilks’ 1869

Lambda = 0.86, F = 2.48, P = 0.039). Both group and planes also significantly affected 1870 the wave task’s total pressure-time integral (Wilks’ Lambda = 0.66, F = 12.25, P < 1871

0.001) and peak pressure-time integral (Wilks’ Lambda = 0.69, F = 8.48, P < 0.001). 1872

Between-group univariate analysis of total pressure-time integrals showed that for 1873 both tasks the Pompoir group had a smaller relative contribution by the 1874 anteroposterior planes and a greater contribution by the latero-lateral planes (Figure 1875

2). 1876

Between-group univariate analysis of the absolute peak pressure-time integrals 1877 showed that Pompoir group achieved higher values in the latero-lateral planes during 1878 the endurance task (33% higher in plane 1) and lower values in the anteroposterior 1879 planes during the wave task (25% lower in plane 3) (Table 2). 1880

1881

Figure 2. Mean total pressure-time integrals (standard error) for each one of the 5 planes 1882 for endurance (sustained contraction) and wave tasks normalized by the total 1883 pressure-time integral of the matrix (relative values %). On the right two 1884 representative plots illustrate the pressure-time integral window used for each 1885 task. CG= control group, PG= Pompoir group. Differences between groups 1886 (univariate ANOVAs) highlighted in pink (P<0.05). 1887 1888

Pressure-time integrals by rings 1889

Multivariate comparisons showed significant effects of groups and rings for both 1890 pressure-related variables for the endurance task: total pressure-time integral (Wilks’ 1891

Lambda = 0.60, F = 5.47, P < 0.001) and peak pressure-time integral (Wilks’ Lambda = 1892

0.78, F = 2.02, P = 0.043). In addition, for the wave task, both groups and rings 1893 significantly affected the total pressure-time integral (Wilks’ Lambda = 0.56, F = 8.14, P 1894

< 0.001) and peak pressure-time integral (Wilks’ Lambda = 0.76, F = 2.84, P = 0.004). 1895

Between-group univariate analysis of total pressure-time integrals showed that for 1896 both tasks, Pompoir group had smaller relative contributions by rings 6 and 7. Trained 1897

women also had greater contributions by the caudal and cranial extremities (rings 1, 9, 1898 and 10) for both the sustained contraction and the wave task (rings 1, 2, and 10) 1899

(Figure 3). 1900

1901

1902

Figure 3. Mean total pressure-time integrals (standard error) for each one of the 10 rings 1903 for endurance (sustained contraction) and wave tasks normalized by the total 1904 pressure-time integral of the matrix (relative values %). CG= control group, PG= 1905 Pompoir group. Differences between groups (univariate ANOVAs) highlighted in 1906 pink (P <0.05). 1907 1908

Between-group univariate analysis of absolute peak pressure-time integral 1909 showed that Pompoir group achieved lower values in the mid-region (67% lower in 1910 ring 7) and higher in the most-caudal region (48% higher in ring 9 and 55% higher in 1911 ring 10), but only during the sustained contraction. For the wave task, Pompoir group 1912 had smaller absolute values in rings 7 and 9 relative to controls (Table 2). 1913

1914

Table 2. Mean (standard-deviation) of the peak pressure-time integral by planes and rings of 1915 endurance (kPa*s) and wave tasks (normalized in time, kPa*%t). 1916

ENDURANCE TASK [kPa*s] Univariate ANOVA WAVE TASK [kPa*%t] Univariate ANOVA CG (n=23) PG (n=17) F P CG (n=23) PG (n=17) F P Plane 1 141.3 (10.3) 187.9 (19.0) 5.4 0.02* 755.8 (71.8) 735.0 (67.6) <0.1 0.83 Plane 2 265.2 (22.6) 336.5 (43.9) 2.5 0.12 1659.8 (174.2) 1200.6 (97.6) 5.2 0.03* Plane 3 297.3 (23.9) 283.1 (30.1) 0.1 0.71 1520.4 (94.7) 1210.8 (103.1) 4.9 0.03* Plane 4 271.4 (30.0) 244.7 (37.3) 0.3 0.58 1355.5 (181.0) 1102.3 (155.0) 1.1 0.29 Plane 5 152.7 (12.8) 188.2 (25.3) 1.9 0.17 755.5 (15.3) 881.5 (121.2) 0.7 0.40 Ring 1 30.9 (4.4) 36.7 (4.9) 0.7 0.39 146.4 (21.2) 171.2 (15.0) 1.3 0.25 Ring 2 45.8 (6.2) 50.9 (7.6) 0.3 0.60 211.8 (33.6) 222.9 (26.9) 0.1 0.74 Ring 3 74.5 (7.8) 92.0 (15.0) 1.4 0.26 366.4 (62.4) 366.9 (45.6) <0.1 0.99 Ring 4 115.3 (12.3) 123.1 (15.8) 0.2 0.70 592.7 (82.2) 595.9 (79.2) <0.1 0.97 Ring 5 156.7 (16.5) 181.6 (21.8) 0.9 0.36 868.9 (56.9) 801.9 (99.8) 0.3 0.60 Ring 6 190.4 (14.0) 189.5 (35.3) <0.1 0.98 855.2 (152.1) 752.2 (86.9) 1.0 0.32 Ring 7 190.2 (19.2) 127.7 (21.7) 4.5 0.04* 1193.9 (95.9) 575.7 (61.2) 13.8 <0.01* Ring 8 93.4 (13.5) 123.0 (27.4) 1.1 0.29 590.9 (92.3) 479.6 (76.7) 0.8 0.37 Ring 9 48.2 (12.3) 64.8 (11.9) 0.9 0.36 425.5 (21.3) 232.0 (23.2) 4.0 0.05* Ring 10 21.7 (2.9) 35.2 (5.7) 5.3 0.02* 156.7 (15.3) 149.0 (13.9) 0.1 0.77 Mean (SD), CP=control group PG=pompoir group. Univariate ANOVAs. Statistical differences 1917 between groups highlighted (*P<0.05). 1918

1919

Onset of peak pressure-time series by rings 1920

Multivariate comparisons showed significant effects of the onset of peak 1921 pressure-time series among groups and rings (Wilks’ Lambda = 0.62, F = 2.15, P = 1922

0.046). Between-group univariate analysis showed for Pompoir group later pressure 1923 increases in the most cranial portions (rings 1 and 2) and earlier in one of the caudal 1924 rings (ring 9) of the vaginal canal. 1925

1926

1927

Figure 4. Onset mean of the peak pressure-time series (standard error) for each one of the 1928 10 rings during the wave contraction task. CG= control group, PG= pompoir group. 1929 Differences between groups (univariate ANOVAs) highlighted in pink (P <0.05). 1930 1931

Discussion 1932

1933

Many studies have investigated the global function, strength, and endurance of 1934

PF muscles. Various equipment have been developed in an attempt to objectively 1935 measure PF muscle function, distinguishing pathologies, and treatment outcomes (Bø 1936 and Finckenhagen 2001; Dumoulin et al. 2003; Ashton-Miller et al. 2014), but no 1937 device has been built to characterize the pressure distribution along various portions 1938 of the vaginal canal. The present study aimed to describe the PF muscles´ capacity to 1939 produce pressure in the vaginal canal in women with experience in the practice of 1940

Pompoir, a technique that has been poorly studied in the literature. This technique 1941 specifically trains the coordinated contraction and relaxation of PF muscles and the 1942 spatiotemporal distribution of pressure along the vaginal canal. Our results indicated a 1943 more-symmetrical pressure-distribution pattern along the vaginal canals of Pompoir 1944

practitioners, which illustrates the effects of PF muscle training in asymptomatic 1945 women and its potential to improve coordination in this muscle group. To our 1946 knowledge, this is the first study to characterize the spatiotemporal pressure 1947 distribution of the PF muscles in a trained population. 1948

For both tasks in both groups, PF muscle contraction resulted in higher 1949 contribution of the anteroposterior (planes 2‒4) mid-pressure zone (rings 4‒7, 1950 corresponding to the first 3‒5 cm from the vaginal introitus) to the total pressure-time 1951 integral (figures 2-3). Similar results have previously been reported (Guaderrama et al. 1952

2005), with the vaginal-pressure profile being described using infusion manometry and 1953 motorized pull-through and with a high-pressure zone of the vaginal canal being 1954 identified at the mid-anteroposterior portion. This pattern can be explained by the 1955 anatomical location of the PF muscles and their function of lifting the anal canal 1956 anteriorly to compress the vagina and urethra against the back of the pubic symphysis 1957

(Jung et al. 2007). Similar pull-through approaches with force transducers have 1958 indicated reduced pressures specifically in the anteroposterior direction of the vaginal 1959 wall, in incontinent women, which has been attributed to poorer PF muscle function 1960 and related to lower urethral-closure pressures, both characteristics of stress urinary 1961 incontinence (Peng et al. 2007; Shishido et al. 2008). 1962

In the present study, Pompoir group displayed a more-homogeneous spatial- 1963 pressure distribution for both the wave and endurance-contraction tasks relative to 1964 the control group, with smaller relative contributions by the anteroposterior planes 1965 and greater participation of the latero-lateral planes while contracting the PF muscles. 1966

In addition, during both tasks, Pompoir group displayed a more-symmetrical 1967

distribution along the 10 rings measured throughout the depth of the vaginal canal, 1968 with less contribution by the mid-region and more by the cranial and caudal regions. 1969

These results suggest that women trained in Pompoir technique produce different 1970 pressures over a broader surface of the vaginal canal when contracting their PF 1971 muscles, distinguishing the contracted regions, which results in an improved capacity 1972 to generate pressures through the entire canal, when compared to controls. 1973

For peak pressure-time series of the entire matrix, Pompoir group sustained the 1974 achieved peak for longer periods during the endurance task. During the wave task, 1975

Pompoir group achieved lower, earlier peak pressures, with a longer relaxation rate. 1976

Apparently, Pompoir practice promoted improved coordination of PF muscle-pressure 1977 production, improving control over gradually contracting and relaxing the PF. For this 1978 task, the participants were asked to contract their PF muscles in a caudal-cranial 1979 direction and then relax them in a cranial-caudal direction in a coordinated manner. 1980

The wave task was chosen to represent the coordination capacity of the PF muscles, 1981 which is usually part of the Pompoir practice. 1982

In addition, for the wave task, differences between groups were observed in the 1983 onset of each ring contraction. It was clear that, for both groups, the mid-pressure 1984 zone of the vaginal canal (rings 4‒7) was activated first, but the trained participants 1985 had earlier pressure increases at the most-caudal portions and later ones at the most- 1986 proximal portions of the vaginal canal, matching the solicited task. Altered contraction 1987 sequence of the PF muscles has previously been observed in incontinent women, with 1988 the majority of asymptomatic women contracting superficial muscles before the deep 1989 muscles, whereas incontinent women presented a reversed sequence (Devreese et al. 1990

2007). In the present study, we observed an overall caudal-to-cranial pattern of 1991 pressure increases along the vaginal canal in both groups, but Pompoir training 1992 seemed to promote a subtle improvement in the separation and sequencing of the 1993 superficial and deep layers of the PF muscles. This could promote a better cranial lift of 1994 the pelvic organs, although this hypothesis needs to be confirmed by imaging studies. 1995

It is not possible to confirm the influence of each muscle layer on the changes in 1996 the pressure profile that were achieved by coordination training, or whether this type 1997 of intervention has any advantages among other PF muscle training techniques, or 1998 would result in functional benefits for continence mechanisms or sexual satisfaction. 1999

We also acknowledge that variations in vaginal length were not taken into account for 2000 this analysis. Whereas there was no difference in body weight, height or BMI between 2001 groups, it was shown in a recent study that these anthropometric parameters are not 2002 correlated to vaginal dimension (Luo et al. 2016). Nevertheless, we made sure to cover 2003 the mid-portion of the vaginal canal for all participants (around 3.5 cm from the 2004 vaginal introitus), which was previously described as the most relevant region for PF 2005 muscle contraction (Guaderrama et al. 2005). With 100 sensors, we can be confident 2006 that the high-pressure zone observed in the mid-anteroposterior portion of the vaginal 2007 canal, would not be influenced by the size of either the vagina or the device length. 2008

This is the first attempt to characterize the status of the pressure distribution in 2009 women that had their PF muscle trained, demonstrating that PF muscles can be 2010 trained to change its coordination capacity, besides improving its strength and 2011 endurance. Future studies should use a longitudinal design and combine investigation 2012 of the pressure profile with imaging techniques to achieve a better understanding of 2013

the effects of different coordination training protocols on urogynecological 2014 functioning. 2015

2016

Conclusion 2017

2018

Specific coordination training of the PF muscles, such as Pompoir practice, alters 2019 the vaginal pressure profile, promoting a more-symmetric pressure distribution 2020 throughout the entire vaginal canal, with greater contributions by the caudal and 2021 cranial extremities and the latero-lateral planes. To our knowledge, this is the first 2022 study to characterize the spatiotemporal pressure distribution of the PF muscle 2023 contraction in a trained population, and it demonstrates that PF muscles can be 2024 trained to a degree beyond strengthening by focusing on coordination, which results in 2025 changes in symmetry of the spatiotemporal pressure distribution in the vaginal canal. 2026

2027

Conflicts of interest 2028

The authors affirm that this study has not received any funding/assistance from a 2029 commercial organization that could lead to a conflict of interest. 2030

2031

Acknowledgements 2032

The authors are grateful to the National Council for Scientific and Technological 2033

Development (CNPq) (MCT/CNPq MCT/CNPq 478332/2013-0) and the State of São 2034

Paulo Research Foundation FAPESP 2013/19610-3) for both grants that funded this 2035 study, and FAPESP scholarship for Cacciari (2013/13820-6), and CNPq scholarship for 2036

Amorim (166104/2013-2). We acklowledge Lu Riva for the crucial support with 2037

Pompoir pratictioners recruitment and for the arrangments for assessment on site. We 2038 also thank Simone B. Silveira, Juliana S. Burti and Ricky Watary for the support in the 2039 subjects’ recruitment, clinical evaluation, and English translation/ discussion, 2040 respectively. 2041

2042

Authors’ contributions 2043

ICNS and LPC are the guarantor of this work and, as such, had full access to all 2044 the data in the study and takes responsibility for the integrity of the data and the 2045 accuracy of the data analysis. LPC, ACP, ACA, and ICNS were responsible for the study 2046 design, analysis and data interpretation and manuscript literature review. LPC, ACP, 2047

ACA were responsible for data collection. All the authors contributed with the 2048 manuscript and approved the final version. The material within has not been and will 2049 not be submitted for publication elsewhere. 2050

2051

References 2052

2053

Ashton-Miller JA, DeLancey JOL. Functional anatomy of the female pelvic floor. Ann N Y Acad 2054 Sci. 2007;1101:266–96. 2055 Ashton-Miller JA, Zielinski R, Miller JM, DeLancey JOL. Validity and reliability of an 2056 instrumented speculum designed to minimize the effect of intra-abdominal pressure on 2057 the measurement of pelvic floor muscle strength. Clin Biomech [Internet]. 2058 2014;29(10):1146–50. 2059 Bø K. Pelvic floor muscle training is effective in treatment of female stress urinary 2060 incontinence, but how does it work? Int Urogynecol J. 2004;15:76–84. 2061 Bø K, Finckenhagen HB. Vaginal palpation of pelvic floor muscle strength: inter-test 2062

reproducibility and comparison between palpation and vaginal squeeze pressure. Acta 2063 Obstet Gynecol Scand. 2001;80(6):883–7. 2064 Bø K, Mørkved S, Frawley HC, Sherburn M. Evidence for benefit of transversus abdominis 2065 training alone or in combination with pelvic floor muscle training to treat female urinary 2066 incontinence: A systematic review. Neurourol Urodyn. 2009;28(November 2008):368– 2067 73. 2068 Bø K, Sherburn M. Evaluation of female pelvic-floor muscle function and strength. Phys Ther. 2069 2005;85(3):269–82. 2070 Bø K, Talseth T, Vinsnes A. Randomized controlled trial on the effect of pelvic floor muscle 2071 training on quality of life and sexual problems in genuine stress incontinent women. 2072 Acta Obstet Gynecol Scand. 2000;79(2):598–603. 2073 Caldwell LS, Chaffin DB, Dukes-Dobos FN, Kroemer KH, Laubach LL, Snook SH, et al. A proposed 2074 standard procedure for static muscle strength testing. Am Ind Hyg Assoc J. 2075 1974;35(4):201–6. 2076 Cescon C, Riva D, Začesta V, Drusany-Starič K, Martsidis K, Protsepko O, et al. Effect of vaginal 2077 delivery on the external anal sphincter muscle innervation pattern evaluated by 2078 multichannel surface EMG: results of the multicentre study TASI-2. Int Urogynecol J. 2079 2014; 2080 Chang ST. The Complete System of Self-healing: Internal Exercises [Internet]. 1st ed. Pub T, 2081 editor. Tao Pub.; 1986. 2082 Devreese A, Staes F, Janssens L, Penninckx F, Vereecken R, de Weerdt W. Incontinent Women 2083 Have Altered Pelvic Floor Muscle Contraction Patterns. J Urol. 2007;178(August):558–62. 2084 Devreese A, Staes F, de Weerdt W, Feys H, Van Assche A, Penninckx F, et al. Clinical evaluation 2085 of pelvic floor muscle function in continent and incontinent women. Neurourol Urodyn 2086 [Internet]. 2004;23(3):190–7. 2087 Dumoulin C, Bourbonnais D, Lemieux M-C. Development of a Dynamometer for Measuring the 2088 Isometric Force of the Pelvic Floor Musculature. Neurourol Urodyn. 2003;22(July 2089 2002):648–53. 2090 Dumoulin C, Gravel D, Bourbonnais D, Lemieux MC, Morin M. Reliability of Dynamometric 2091 Measurements of the Pelvic Floor Musculature. Neurourol Urodyn. 2004;23(July 2092 2003):134–42. 2093 Dumoulin C, Hay-Smith EJC, Mac Habée-Séguin G. Pelvic floor muscle training versus no 2094 treatment, or inactive control treatments, for urinary incontinence in women. Cochrane 2095 Database Syst Rev [Internet]. 2014;5(5):CD005654. 2096

Enck P, Hinninghofen H, Wietek B, Becker HD. Functional asymmetry of pelvic floor innervation 2097 and its role in the pathogenesis of fecal incontinence. Digestion. 2004;69:102–11. 2098 Frawley HC, Galea MP, Phillips BA, Sherburn M, Bø K. Reliability of pelvic floor muscle strength 2099 assessment using different test positions and tools. Neurourol Urodyn. 2006;25(August 2100 2005):236–42. 2101 Freeman RM. Can we prevent childbirth-related pelvic floor dysfunction? BJOG An Int J Obstet 2102 Gynaecol. 2013;120:137–40. 2103 Guaderrama NM, Nager CW, Liu J, Pretorius DH, Mittal RK. The vaginal pressure profile. 2104 Neurourol Urodyn. 2005;24:243–7. 2105 Hallgren KA. Computing Inter-Rater Reliability for Observational Data: An Overview and 2106 Tutorial. Tutor Quant Methods Psychol [Internet]. 2012;8(1):23–34. 2107 Haylen BT, Maher CF, Barber MD, Camargo S, Dandolu V, Digesu A, et al. An International 2108 Urogynecological Association (IUGA) / International Continence Society (ICS) Joint 2109 Report on the Terminology for Female Pelvic Organ Prolapse (POP). Neurourol Urodyn 2110 [Internet]. 2016 Feb;35(2):137–68. 2111 Heilbrun ME, Nygaard IE, Lockhart ME, Richter HE, Brown MB, Kenton KS, et al. Correlation 2112 between levator ani muscle injuries on magnetic resonance imaging and fecal 2113 incontinence, pelvic organ prolapse, and urinary incontinence in primiparous women. 2114 Am J Obstet Gynecol [Internet]. 2010;202(5):488.e1-488.e6. 2115 Jung S-A, Pretorius DH, Padda BS, Weinstein MM, Nager CW, den Boer DJ, et al. Vaginal high- 2116 pressure zone assessed by dynamic 3-dimensional ultrasound images of the pelvic floor. 2117 Am J Obstet Gynecol. 2007;197(July):1–7. 2118 Kegel AH. Progressive resistance exercise in the functional restoration of the perineal muscles. 2119 Am J Obstet Gynecol [Internet]. 1948 Aug;56(2):238–48. 2120 Kepenekci I, Keskinkilic B, Akinsu F, Cakir P, Elhan AH, Erkek AB, et al. Prevalence of pelvic floor 2121 disorders in the female population and the impact of age, mode of delivery, and parity. 2122 Dis Colon Rectum [Internet]. 2011 Jan;54(1):85–94. 2123 Laycock J, Jerwood D. Pelvic Floor Muscle Assessment: The PERFECT Scheme. Physiotherapy. 2124 2001;87(12):631–42. 2125 Luo J, Betschart C, Ashton-Miller JA, DeLancey JOL. Quantitative analyses of variability in 2126 normal vaginal shape and dimension on MR images. Int Urogynecol J [Internet]. 2016 2127 Jul;27(7):1087–95. 2128

MacLennan AH, Taylor AW, Wilson DH, Wilson PD. The prevalence of pelvic floor disorders and 2129 their relationship to gender, age, parity and mode of delivery. BJOG An Int J Obstet 2130 Gynaecol. 2000;107(12):1460–70. 2131 Messelink B, Benson T, Berghmans B, Bø K, Corcos J, Fowler C, et al. Standardization of 2132 terminology of pelvic floor muscle function and dysfunction: Report from the pelvic floor 2133 clinical assessment group of the International Continence Society. Neurourol Urodyn. 2134 2005;24(June):374–80. 2135 Morin M, Dumoulin C, Bourbonnais D, Gravel D, Lemieux M-C. Pelvic floor maximal strength 2136 using vaginal digital assessment compared to dynamometric measurements. Neurourol 2137 Urodyn [Internet]. 2004;23(4):336–41. 2138 Peng Q, Jones RCL, Shishido K, Omata S, Constantinou CE. Spatial distribution of vaginal closure 2139 pressures of continent and stress urinary incontinent women. Physiol Meas. 2140 2007;28(11):1429–50. 2141 Peschers UM, Gingelmaier A, Jundt K, Leib B, Dimpfl T. Evaluation of pelvic floor muscle 2142 strength using four different techniques. Int Urogynecol J Pelvic Floor Dysfunct. 2143 2001;12(1):27–30. 2144 Sartori DVB, Gameiro MO, Yamamoto HA, Kawano PR, Guerra R, Padovani CR, et al. Reliability 2145 of pelvic floor muscle strength assessment in healthy continent women. BMC Urol 2146 [Internet]. 2015 Dec;15(1):29. 2147 Shishido K, Peng Q, Jones RCL, Omata S, Constantinou CE. Influence of Pelvic Floor Muscle 2148 Contraction on the Profile of Vaginal Closure Pressure in Continent and Stress Urinary 2149 Incontinent Women. J Urol. 2008;179(5):1917–22. 2150 Silveira SB, Margarido P, Cacciari LP, Baracat EC. TVL, GH and PB points after a year of surgical 2151 treatment for severe genital prolapse. Neurourol Urodyn [Internet]. 2015 Aug;33(6):194. 2152 Swift SE, Woodman PJ, O’Boyle A, Kahn M, Valley M, Bland DR, et al. Pelvic Organ Support 2153 Study (POSST): The distribution, clinical definition, and epidemiologic condition of pelvic 2154 organ support defects. Am J Obstet Gynecol [Internet]. 2005 Mar [cited 2015 Feb 2155 22];192(3):795–806. 2156 Thalheimer W, Cook S. How to calculate effect sizes from published research: A simplified 2157 methodology. Work Res [Internet]. 2002;(August):1–9. 2158 Wood LN, Anger JT. Urinary incontinence in women. BMJ Br Med J. 2014;349:1–11. 2159 2160

6. GENERAL DISCUSSION 2161

2162

2163

The hypotheses of this study were that with this novel instrument we would be 2164 able to reliably map the pressure profile along the vaginal canal, differentiating the 2165

PFM contraction from intra-abdominal pressure rises, and would be able to describe 2166 the potential capabilities of the PFM function in an asymptomatic trained population, 2167 distinguishing spatial symmetry and coordination patterns along the length of the 2168 vaginal canal. The main findings were that the proposed instrumented probe has an 2169 excellent reliability and repeatability, with outputs that are moderately associated with 2170

PFM digital assessment, and provides a dynamic and high-resolution map of the 2171 spatiotemporal pressure profile throughout the vaginal canal, distinguishing the action 2172 of PFM from intra-abdominal pressure rises. We also verified that specific coordination 2173 training of the PFM, such as the Pompoir practice, alters the vaginal pressure profile, 2174 promoting a more-symmetric pressure distribution throughout the entire vaginal 2175 length, with greater contributions from the caudal and cranial extremities and the 2176 latero-lateral planes of the vaginal canal. 2177

2178

6.1. Advantages and applicabilities of the new device 2179

2180

Ideally, to test the validity or accuracy of a new proposed measurement device, it 2181 would be necessary to analyze how closely the results from the new method 2182 approximate from the current gold standard assessment of the PFM function (Streiner 2183

and Norman 2006). However, as discussed before, there is still no defined gold 2184 standard method for the assessment of PFM strength (Bø et al. 2005). In addition, 2185 among the commercially available devices, neither perineometers nor EMG provide a 2186 precise spatial distribution map of the forces acting along the vaginal canal, measuring 2187 only unspecific resultant forces or muscular activity patterns, which would make 2188 comparisons between the new equipment and other available devices challenging. 2189

Up to date, digital palpation scales of PFM function are still the first choice of 2190 assessment for comparing patients and interventions (Devreese et al. 2004), but 2191 comparisons between digital and dynamometric or manometric assessments of the 2192

PFM strength already showed that objective force/pressure parameters seems to be 2193 more reproducible, sensitive and valid to detect subtle differences across or within 2194 individuals (Bø and Finckenhagen 2001; Morin et al. 2004b). 2195

In our study, we found moderate correlation between the clinical and the 2196 objective assessment of maximum PFM strength [Spearman’s coefficient of ρ=0.5477 2197

(p<0.001)]. While peak pressures increased proportionally with digital palpation rates, 2198 pressure value confidence intervals overlapped between adjacent grades, supporting 2199 findings from previous dynamometric (Morin et al. 2004b) and manometric (Bø and 2200

Finckenhagen 2001) studies, which also reported moderate correlations (0.56 and 0.66 2201 respectively) between these two measurements. 2202

Regarding the reliability of the new device, we observed for the total area 2203

(considering the entire sensor matrix) intraclass correlation coefficients of 0.94 (intra- 2204 rater), 0.97 (intra-trials) and 0.96 (inter-raters), with a standard error of measurement 2205 varying from 5.1 to 8.5, corresponding to 10 to 16% of the mean value pressure 2206

achieved during maximum PFM contractions. Similar results were reported in a 2207 reliability study using a dynamometer (Dumoulin et al. 2004a), with dependability 2208 indexes varying from 0.69 to 0.88, and standard error of measurements ranging from 2209

31 to 33% of the obtained mean force, depending on the number of trials used in the 2210 comparison, or on the opening of the vaginal canal. It is interesting to point out that, 2211 according to the cited study, measurements done at a dynamometer opening of 1 cm 2212

(corresponding to 24 mm of vaginal aperture) reached the best reliability indices and 2213 the lowest error of measurement compared to shorter or wider opening options 2214

(Dumoulin et al. 2004a). Here, we were not able to measure the force-length 2215 relationship of the PFM, but we took into account this reported optimal vaginal 2216 aperture length when building the equipment, choosing a cylinder with matching 2217 length to the previous report (23.2 mm in diameter). 2218

Besides the good sensitivity and reliability of the new proposed device, one of its 2219 main advantages would be its ability to selectively differentiate between the PFM 2220 contraction action in the vaginal canal and intra-abdominal pressure rises. With the full 2221 map of the spatiotemporal distribution of pressures along the vaginal length, it was 2222 possible to observe a high-pressure zone at the anteroposterior mid portion of the 2223 vaginal canal, larger in area and higher in magnitude at the posterior and anterior 2224 vaginal walls, respectively. These results also support previous findings of studies using 2225 either pull-through techniques (Guaderrama et al. 2005; Peng et al. 2007; Shishido et 2226 al. 2008) or a tactile high-definition manometer (Raizada et al. 2010), in which a high- 2227 pressure zone was observed during PFM contraction, and defined as axial and 2228 circumferential asymmetry. According to simultaneous imaging assessment of the 2229

pelvic floor structures, the described pattern represents the resultant force of the PFM 2230 acting to compress the rectum, vagina, and urethra, from back to front, in a ventro- 2231 cephalic direction (Raizada et al. 2010). 2232

This was the first study to map the spatiotemporal distribution of pressures 2233 during a task involving an opposite downward movement of the pelvic floor structures. 2234

A Valsalva maneuver is defined as forced expiration against a closed glottis, requiring 2235 contraction of the diaphragm and abdominal muscles in order to obtain markedly 2236 increased intra-abdominal pressure. When these pressure rises are accompanied by a 2237 relaxation of the PFM, they provoke a caudal force on both the bladder and the 2238 urethra, causing the levator hiatus to increase in length and volume (Ornö and Dietz 2239

2007). During this task, co-activation of the PFM may be a substantial confounder, 2240 reducing pelvic organ descent (Ornö and Dietz 2007). To overcome this limitation it is 2241 recommended to provide digital, auditory or visual biofeedback to the participants, 2242 and to acquire sustained maneuvers held for at least 9s in order to avoid false-negative 2243 results (Ornö and Dietz 2007; Orejuela et al. 2012). With the novel proposed device, 2244 we were able to provide real-time visual and auditory feedbacks to the women during 2245 each assignment, and, within the obtained pressure map, it was easy to distinguish 2246 between contractions of the PFM and a Valsalva effort without any additional 2247 measures. On the other hand, these two opposite movements can hardly be 2248 differentiated by manometers or even EMG, which detect pressure rises or cross-talks 2249 from adjacent muscles indiscriminately (Peschers et al. 2001b), and rely on visual 2250 inspection of an inward movement of the perineum to assure a correct PFM 2251 contraction (Bø et al. 1990a, 1990b). 2252

In our study, we presented several differences in the pressure distribution profile 2253 of these two opposite tasks. For instance, PFM contractions resulted in higher 2254 pressures mainly in the mid-anteroposterior direction of the vaginal canal, 2255 corresponding to 2–4cm from the vaginal introitus, again supporting findings of the 2256

PFM ventro-cephalic action on the pelvic organs (Raizada et al. 2010). Whenever a 2257 high-pressure zone was detected in the mid anteroposterior portion of the vaginal 2258 canal, we were able to recognize a PFM contraction pattern, which can be useful to 2259 better guide clinicians and patients during PFM assessments for training or 2260 comparisons purposes. Also, in our study we followed previous instructions of 2261 providing digital feedback of each task before data acquisition, and opted to ask the 2262 participants to hold their Valsalva maneuver for at least 5 s, in order to minimize their 2263 discomfort without having the risk of assessing sub-maximal efforts. 2264

Ashton-Miller (2014) also presented a device designed to measure the maximum 2265 vaginal closure force without crosstalk from intra-abdominal pressure, but it consisted 2266 in a dynamometer capable of providing only the resultant force of the vaginal canal, 2267 and we believe that being able to map the pressure distribution pattern along the 2268 vaginal length can bring advantages that could objectively help clinicians and 2269 researchers when choosing treatment orientation or evaluating outcomes. In our 2270 study, we were able to differentiate tasks and groups not only by the resultant force, 2271 but also by the pressure distribution pattern from the vaginal canal. Previous studies 2272 also reported that spatial coordination patterns (Devreese et al. 2007) or symmetry 2273 and overall pressure distribution maps (Peng et al. 2007) can be useful when 2274 distinguishing PFM function between symptomatic and asymptomatic women, 2275

suggesting that variables other than resultant strength parameters should be added to 2276 the PFM assessment in both clinical and research settings. 2277

2278

6.2. Effects of Pompoir practice for PFM training on the 3D pressure profile map 2279

of the vaginal canal 2280

2281

PFM training is highly recommended for several pelvic floor dysfunctions (Bø et 2282 al. 2000; Beji et al. 2003; Dean et al. 2008; Zahariou et al. 2008; Hagen and Stark 2011; 2283

Bø 2012; Dumoulin et al. 2015; Ferreira et al. 2015; Hagen et al. 2017; Johannessen et 2284 al. 2017), with some authors recommending it also as a preventive measure for all 2285 women (Hagen and Stark 2011; Hagen et al. 2017), considering the high incidence of 2286 symptoms (MacLennan et al. 2000; Kepenekci et al. 2011; Wu et al. 2014). In addition, 2287 the conservative management is safe, with no contraindications, and easily performed 2288 by most women. 2289

However, up to date, we have not found reports in the literature regarding the 2290 effects of PFM training on asymptomatic women, and the potential capabilities of the 2291

PFM in a trained population, particularly in a practice that claims to improve 2292 coordination, and strengthen the capacity of, and symmetrically distribute loads 2293 throughout the vaginal canal. Devreese et al. (2004) described a coordination pattern 2294 of PFM contraction that varied between continent and incontinent women, with 2295 coordination defined as superficial PFM contraction prior or simutaneously to deep 2296

PFM contraction. Apart from this study, usually only resultant strength parameters are 2297 assessed among individuals or following treatments, with the PFM being assumed to 2298

work as a functional unit (Bø and Sherburn 2005), with little objective information 2299 regarding coordination training techniques and its effects on the pelvic floor capability 2300 to selectively distinguish layers or portions of muscles in a coordinated way. 2301

Considering the studies that evaluated the results of PFM training protocols 2302 specifically designed to treat urinary incontinence symptoms, no changes were 2303 observed between trained and controls for either maximum strength (Sampselle et al. 2304

1998; Dumoulin et al. 2004b) or rapidity of PFM contractions (Dumoulin et al. 2004b). 2305

But improvements were reported for some other strength parameters, reveling that 2306

PFM exercises may result in (i) increased number of PFM contractions in 15 s; (ii) 2307 earlier PFM activation when coughing and (iii) better sustained contractions between 2308 repeated coughs (Madill et al. 2013). These results suggest that the PFM evaluation 2309 should assess, in both clinical and research settings, other parameters besides maximal 2310 strength, such as spatial and temporal force/pressure distribution, symmetry, 2311 endurance, agility, and coordination. However, again, no reports were found on the 2312 spatiotemporal load distribution pattern along the vaginal length, and the possible 2313 effects of the exercise on different regions of the vaginal canal. 2314

The specific training technique studied in the present thesis is called Pompoir, 2315 which is thought to be a millenary practice from India, Japan, or Thailand and consists 2316 of using several exercises to coordinate the contraction and relaxation of various 2317 portions and layers of PFM along the entire vaginal canal in a rhythmic order (Alves 2318

2013). Although for some authors PFM are expected to act simultaneously as a mass 2319 contraction (Bø and Sherburn 2005), Pompoir practitioners claim they can selectively 2320 distinguish PFM layers, called “rings”, along the vaginal length. Training in the Pompoir 2321

technique has recently spread among women searching for improved self-awareness 2322 and sexual satisfaction. However, this practice has never been properly documented, 2323 and its outcomes in terms of pressure distribution along the pelvic floor structures 2324 have never been studied untill today. 2325

In order to differentiate Pompoir practitioners from non-practitioners, we chose 2326 to evaluate an exercise that is commonly taught in this practice, the “wave 2327 contraction”, which is part of the beginners and advanced classes and is considered a 2328 basis for several other exercise variations. During the wave task, women are expected 2329 to contract their PFM in a caudal-cranial direction and then relax them in a cranial- 2330 caudal direction, with it being considered a coordination task, where maximum 2331 contraction is not expected. We also chose to evaluate a commonly assessed task in 2332 clinical practice: a sustained contraction held for 10 s, which is part of the PERFECT 2333 scheme (Laycock and Jerwood 2001), and is considered an important capability for 2334 maintaining continence. 2335

For the data analysis, we opted for two different approaches. Firstly, we 2336 described the pressure-time curve of these two tasks considering the entire sensor. 2337

Secondly, in order to properly map the vaginal canal, we divided the 100-sensor matrix 2338 in rings and planes, aiming to map the spatial distribution pattern along the vaginal 2339 length (10 rings), but also specify the orientation of the normal forces (5 planes) acting 2340 on the vaginal canal. Particularly for the orientation of force assessments, our rational 2341 was based on the anatomy and biomechanics of the PFM. Normal forces measured 2342 along the circumference of the vaginal canal are thought to act together (i.e. to 2343 constrict and lift the pelvic floor structures during the PFM contraction), regardless of 2344

the orientation of each individual force. Therefore, we considered that adding the 2345 pressures from opposite sides of the vaginal wall together would provide a better 2346 directional overview of the vaginal pressure profile. Similar approaches were proposed 2347 by Peng et al. (2007) and Shishido et al. (2008), however, in both cases the adopted 2348 sensor device consisted of only four force transducers that were manually pulled 2349 thought the vaginal canal. In our study, analyzing the pressure matrix divided by planes 2350 and rings simuteneously, we had a complete map of the load distribution along the 2351 vaginal length, which was thought to discriminate the coordination patterns between 2352 tasks and groups with high spatial 3D resolution. 2353

Considering the entire sensor matrix, the main differences found between 2354 practitioners and non-practitioners were not related to the maximal strength, as 2355 reported in previous studies comparing continent and incontinent women, leading us 2356 to conclude that other physical and biomechanical capabilities of the PFM, besides 2357 strength, are more revealing when discriminating symptoms and assessing treatments 2358 effects (Morin et al. 2004a; Madill et al. 2013). We observed in the Pompoir group a 2359 better endurance in the sustained contraction task (time to 10% decline of the initial 2360 reference force (Verelst and Leivseth 2004a)) and a slower relaxation rate in the wave 2361 task. This finding suggests that Pompoir practitioners are able to sustain the achieved 2362 peak pressure for longer periods, indicating an improved coordination of pressure 2363 generation and maintenance, and better control when gradually contracting and 2364 relaxing the PFM. 2365

Considering the analyzed rings and planes, we observed a more-symmetrical 2366 pressure-distribution pattern along the 5 planes and 10 rings of the vaginal canal in 2367

Pompoir practitioners. We found smaller relative contributions by the anteroposterior 2368 planes and greater participation of the latero-lateral planes during PFM contraction in 2369

Pompoir practitioners. In addition, during both tasks, the Pompoir group presented 2370 less contribution from the mid-region rings and greater participation of the cranial and 2371 caudal rings when compared to the control group. These results suggest that women 2372 trained in Pompoir technique produce different pressures over a broader surface of 2373 the vaginal canal when contracting their PFM, distinguishing the contracted regions, 2374 which resulted in an improved capacity to generate pressures through the entire canal. 2375

To our knowledge, this is the first study to characterize the spatiotemporal 2376 pressure distribution of the PFM in an asymptomatic trained population, although 2377 results should be interpreted with caution. It is not possible to confirm the influence of 2378 each muscle layer on the achieved changes in the pressure profile, or whether this 2379 type of intervention has any advantages when compared to other PFM training 2380 techniques, or even if it would result in any functional benefits for pelvic floor 2381 symptoms such as urinary incontinence or sexual dysfunctions. However, we would 2382 like to acknowledge that the description of the whole pressure profile along the 2383 vaginal length, in addition to all biomechanical parameters chosen to be analyzed, 2384 could be of great interest for clinicians and researchers. This is especially true because 2385 we could confirm that strength magnitude is definitely not the best parameter to 2386 characterize a population, and to consider only the resultant force acting within the 2387 vagina canal as treatment outcome, could mask possible spatial patterns of muscle 2388 activation that may bring important information for the field. 2389

2390

6.3. Clinical Implications 2391

2392

Pelvic floor dysfunctions are common conditions with one quarter of adult 2393 women reporting at least one disorder, resulting in a large social, medical and 2394 economic burden (Wu et al. 2011). In Brazil, out of 1500 women living in 7 different 2395 states, 29.3% presented symptoms of orgasmic dysfunction, 21.1% referred pain 2396 during sexual intercourse and 34.6% lack of sexual desire, which also increases with 2397 age (Abdo et al. 2002). Considering that, the search for medical care and treatment 2398 options, which is already high, is likely to increase as the population ages. 2399

PFM training is the first line of conservative management for women with 2400 different symptoms of pelvic floor dysfunction (Bø et al. 2000; Beji et al. 2003; Dean et 2401 al. 2008; Zahariou et al. 2008; Hagen and Stark 2011; Brækken et al. 2015; Dumoulin et 2402 al. 2015; Hagen et al. 2017; Johannessen et al. 2017), promoting pelvic organ support 2403 and control of the continence mechanism, along with better awareness of the pelvic 2404 floor structures, self- confidence and libido. Pompoir practice is not particularly 2405 focused on treating or preventing pelvic floor symptoms, but on improving 2406 coordination capacities of the PFM, being reported by practitioners to promote 2407 benefits on sexual function and self-awareness. Most importantly, it was chosen here 2408 for being a poorly studied techinique from the biomechanical perspective, although 2409 recently spread in Brazil as an option for asymptomatic women aiming to better 2410 understand their PFM function. 2411

The findings of this thesis suggest that the novel proposed device is a reliable 2412 tool, which can provide real-time visual and auditory feedbacks during pelvic floor 2413

assessments to better guide treatment outcomes, and also help clinicians and 2414 researchers to better understand the pressure profile of the vaginal canal in relation to 2415 different pathologies or treatment options. The pressure pattern assessment is already 2416 a reality for foot biomechanics, helping clinicians and researchers to map high- 2417 pressure zones and prescribe optimal footwear (Bus et al. 2011; Ulbrecht et al. 2014) 2418 and specialized treatment protocols (Sacco and Sartor 2016). We believe that adding 2419 this objective assessment either as a biofeedback or an outcome measure across 2420 symptoms or following treatments would be of great interest for this field, supporting 2421 clinicians on their practice and helping to better match women to the optimal 2422 intervention for their condition and individual characteristics. 2423

2424

6.4. General considerations and limitations 2425

2426

Voluntary PFM contraction assessments are highly recommended during routine 2427 examination for all women complaining of lower tract urinary symptoms, and it should 2428 account not only for the PFM strength assessment (static and dynamic), but also for its 2429 physical and biomechanical capabilities, expressed as the capacity to voluntarily relax 2430 the PFM (if absent, partial or complete), to sustain a maximal or sub-maximal 2431 contraction (endurance), to symmetrically contract the PFM, to homogeneously 2432 distribute loads throughout the vaginal canal, and to coordinate repeated contractions 2433

(Staskin and Kelleher 2013). 2434

We believe that with this novel device and biomechanical analysis approach, it 2435 would be possible to better characterize the pressure profile along the vaginal canal, 2436

differentiating the spatial and symmetrical (or asymmetrical) distribution of forces 2437 resulting from PFM contractions or intra-abdominal pressure rises, aiding clinicians on 2438 their practice and researchers to better understand the relationship between PFM 2439 function and symptoms and treatment techniques. However, it is important to 2440 acknowledge that this is still a work in progress, with limitations and possible 2441 amendments to be made in future studies. 2442

First, we would like to mention that variations in vaginal length were not taken 2443 into account in our analysis. Although there was no difference in body weight, height 2444 or BMI between groups, it was shown in a recent study that these anthropometric 2445 parameters are not correlated to vaginal dimension (Luo et al. 2016). Nevertheless, we 2446 made sure that the mid-portion of the vaginal canal was covered for all participants 2447

(around 3.5 cm from the vaginal introitus), which was previously described as the most 2448 relevant region for PFM contraction (Guaderrama et al. 2005). With 100 sensors, we 2449 can be confident that the high-pressure zone observed in the mid-anteroposterior 2450 portion of the vaginal canal, would not be influenced by the size of either the vagina or 2451 the device length. However, it would be important for future studies to take the 2452 vaginal length into account, specially if post menopausal women or women that went 2453 through hysterectomies, factors known to be negatively related to vaginal length, are 2454 to be included (Tan et al. 2006). 2455

The sensor is embedded in a rigid and relatively long cylinder that is more 2456 comfortably used with the subjects in supine position. Assessing the PFM in dynamic 2457 situations, such as walking, jumping or running, would be more difficult. Among the 2458 described devices, only one of them (Schell et al. 2016) presented the advantage of 2459

being designed to be retained in the vaginal canal independent of someone holding 2460 the sensor, and with communication via Bluetooth enabling data acquisition in 2461 different positions in a more ecological environment. 2462

Finally, we acknowledge that different training techniques would have to be 2463 compared in order to better understand the specific advantages of Pompoir training 2464 protocols, but here we were able to distinguish spatial and temporal differences 2465 between practitioners and non-practitioners, which can help to elucidate the PFM 2466 biomechanical characteristics, and which can be further used to compare results from 2467 different training protocols. 2468

7. CONCLUSIONS 2469

2470

2471

With this protocol and novel instrument, we obtained a high-resolution and 2472 highly reliable innovative 3D pressure distribution map of the pelvic floor, capable of 2473 distinguishing vaginal sub-regions, planes, rings, tasks and characterizing coordination 2474 patterns of the PFM following a specific training protocol. The proposed instrumented 2475 probe presented excellent reliability and repeatability and provides a dynamic and 2476 high-resolution map of the spatiotemporal pressure profile throughout the vaginal 2477 canal, discriminating the action of PFM from intra-abdominal pressure rises. We also 2478 verified that the Pompoir practice alters the vaginal pressure profile, promoting a 2479 more-symmetric pressure distribution throughout the entire vaginal length. We 2480 believe that a high spatial 3D resolution pressure profile of the vaginal canal, capable 2481 of mapping the spatiotemporal coordination patterns along the intravaginal walls can 2482 contribute to the clinical practice and help determining the optimal intervention for 2483 each patient’s condition and individual characteristics. 2484

2485

8. ANNEX – ABSTRACTS TO BE PRESENTED IN THE ICS 2017 2486

Abstract Template

Abstract Title: ASSOCIATION BETWEEN DIGITAL ASSESSMENT (FLEXIBILITY AND STRENGTH) AND ULTRASOUND MORPHOMETRIC PARAMETERS OF THE PELVIC FLOOR Abstract Text:

Hypothesis / aims of study Pelvic floor muscles (PFM) should have an adequate resting tone, symmetry and the ability to voluntarily and involuntarily contract with constriction and inward (ventro-cephalad) movement of the pelvic openings [1]. Decreases in muscle tone and strength are associated with either reduced contractile activity and/or passive stiffness, which are components of the mechanism related to pelvic organs descent and urinary incontinence (UI). PFM function is commonly assessed by digital palpation scales, with the disadvantage of being a subjective method with limited reproducibility. Transperineal ultrasound (TPUS) has been increasingly used as an objective and non-invasive method to assess both the constriction of the PFM muscle and the inward movement of the pelvic floor structure, however its relation to digital assessments of PFM function in UI women is still unclear. The aim of this study is to explore the relation between PFM digital assessment (flexibility and strength) and morphometric parameters measured by TPUS in women with UI. Study design, materials and methods This is a cohort study with 60 years or older women suffering from UI symptoms. Participants were recruited through community-based advertising. UI was defined as at least one weekly episode of involuntary urine loss during the preceding 3 months. The participants were asked to empty their bladders, and were positioned in supine. Digital and TPUS assessments of the PFM were conducted by an experienced physiotherapist. The flexibility of the vaginal opening (passive vaginal opening) was measured with the index and, if possible, the middle finger inserted into the distal vagina to the proximal interphalangeal joints and abducted in the 3 and 9 o’clock plane. It was scored from 0 (less than one finger insertion) to 4 (two finger insertion with fingers abducted horizontally ≥2cm) [2]. PFM strength was assessed intra-vaginally with one finger, using the Modified Oxford Scale (MOS) with scores ranging from 1 to 5. PFM morphometry was evaluated using TPUS imaging (Voluson E8 Expert BT10; GE Healthcare) with a 3-/4-dimensional transperineal probe (RM6C next-generation matrix). Images were recorded at rest, during maximum PFM contraction and during cough. Each maneuver was performed twice and the ultrasound volume with the most effective contraction (i.e., most reduced levator hiatus antero-posterior diameter) and cough (i.e., most caudal displacement of the bladder neck (BN)) were considered for analysis. TPUS data was analyzed offline (4D View, Version 10.2; GE Healthcare) by an observer blinded to the digital assessment. Morphometry was assessed by measuring the following parameters in the midsagittal and axial planes (at the level of minimal hiatal dimensions) planes: (1) anorectal height, distance from the apex of the anorectal angle to a horizontal reference line passing by the inferior- posterior margin of the symphysis pubis, BN (2) x-axis and (3) y-axis related to the inferior- posterior margin of the symphysis pubis, (4) levator hiatus area, (5) levator hiatal anteroposterior and (6) transverse diameters. The shift between rest condition and both tasks (cough and contraction) were calculated (rest – task), as well as the percentage of change for each variable ((rest – task)/rest %). BN cranioventral displacement was also calculated for contraction and cough as the hypotenuse of a right-angled triangle (square root: ΔBN-x2+ΔBN-y2). The relationships between digital and TPUS assessments of PFM function were investigated using Pearson correlation coefficient and hierarchical stepwise regression by assessment condition (rest, contraction/couch). This method was used to explore how well digital assessment variances are explained by morphometric parameters of the pelvic floor TPUS evaluation. Results 204 incontinent women were evaluated. Participants were aged between 60 and 84 (68 ± 5.6) years, mean BMI was 27.1 ± 4.6 Kg/m2, parity ranged from 0 to 8 (median 2, interquartile range from 1 to 3) and the mean ICIQ-UI SF score was 12.3 ± 3.3. For the digital assessment, flexibility score ranged from 0.75 to 4 (median 2, interquartile range from 2 to 2487

2.5) and MOS ranged from 0 to 5 (median 3, interquartile range from 3 to 4). Ultrasound morphometric parameters are shown in Table 1. Associations between flexibility and morphometric parameters of the PFM during rest and cough are shown in Table 2. Using hierarchical regression by assessment condition (rest, cough) levator hiatus area at rest explained 10.9% of the variance in flexibility (Beta coefficient in the final model is β= 0.327; p<0.01). When adding variables in the cough condition to the model, BN cranio-ventral shift (β = 0.028; p = 0.700) explained additionally 0.1% of the variance, for a total explained variance of 11%. Table 1 Morphometric parameters measured by transperineal ultrasound Ultrasound assessment Rest Std Dev. Contraction Std Dev. shift (%) Cough Std Dev. shift (%) Anorectal height [mm] 18.8 6.4 21.7 6.0 -2.9 (-15%) 15.6 7.2 3.2 (17%) Bladder neck x [mm] 2.0 5.4 -2.8 6.1 4.8 (246%) 8.2 6.9 -6.3 (-321%) Bladder neck y [mm] 23.6 4.2 25.2 4.8 -1.6 (-7%) 19.2 6.5 4.4 (19%) Levator hiatus area mm2] 1433.3 318.2 1184.2 262.1 249.1 (17%) 1622.5 403.8 -189.2 (-13%) Levator anteroposterior [mm] 53.5 7.5 44.9 6.7 8.6 (16%) 54.1 8.0 -0.6 (-1%) Levator transverse [mm] 38.2 4.8 37.0 4.8 1.2 (3%) 41.2 5.6 -3.0 (-8%) Bladder neck cranio-ventral shift [mm]: contraction 6.7 ± 4.6 and cough 9.2 ± 6.0. Table 2 Pearson correlation coefficients and p values (flexibility versus morphometry) Rest Cough Ultrasound assessment raw data raw data shift % of change Anorectal height r= -0.036; p=0.62 r= -0.055; p=0.44 r= 0.078; p=0.28 r= 0.107; p=0.13 Bladder neck x r= 0.127; p=0.08 r= 0.269; p<0.01 r= -0.233; p<0.01 r=-0.022; p=0.77 Bladder neck y r= 0.069; p=0.33 r= -0.131; p=0.07 r= -0.183; p<0.01 r= -0.181; p=0.01 Levator hiatus area r= 0.353; p<0.01 r= 0.349; p<0.01 r= -0.161; p=0.03 r= -0.120; p=0.11 Levator hiatus anteroposterior r= 0.275; p<0.01 r= 0.280; p<0.01 r= -0.101; p=0.16 r= -0.091; p=0.21 Levator hiatus transverse r= 0.254; p<0.01 r= 0.298; p<0.01 r= -0.151; p=0.04 r= -0.129; p=0.08 BN cranio-ventral shift (r= 267, p<0.01); Statistically significant results are highlighted, p<0.05 Associations between strength (MOS) and morphometric parameters of the PFM during rest and contraction are shown in Table 3. Using hierarchical regression by assessment condition (rest, contraction), the anorectal height at rest explained 1.6% of the variance in strength (Beta coefficient in the final model is β= 0.135; p=0.052). When adding variables in the contraction condition to the model, anorectal height percentages of change (β = -0.324; p<0.001), levator hiatus anteroposterior shift (β = -0.726; p = 0.002) and percentages of change (β = 1.198; p<0.001) explained additionally 33.8% of the variance (p<0.001) for a total explained variance of 35.4%. Table 3 Pearson correlation coefficients and p values (strenght versus morphometry) Rest Contraction Ultrasound assessment raw data raw data shift % of change Anorectal height r= -0.128; p=0.07 r= 0.070; p=0.32 r= -0.326; p<0.01 r= -0.290; p<0.01 Bladder neck x r= 0.016; p=0.82 r= -0.239; p<0.01 r= 0.363; p<0.01 r= 0.095; p=0.21 Bladder neck y r= 0.029; p=0.68 r= 0.203; p=0.01 r= 0.201; p=0.01 r= 0.174; p=0.02 Levator hiatus area r= 0.007; p=0.92 r= -0.274; p<0.01 r= 0.346; p<0.01 r= 0.421; p<0.01 Levator hiatus anteroposterior r= 0.065; p=0.36 r= -0.319; p<0.01 r= 0.461; p<0.01 r= 0.511; p<0.01 Levator hiatus transverse r= -0.044; p=0.54 r= -0.112; p=0.12 r= 0.103; p=0.15 r= 0.125; p=0.08 BN cranio-ventral shift (r= 0.357, p<0.01); Statistically significant results are highlighted, p<0.05 Interpretation of results Higher PFM flexibility (passive vaginal opening) was associated with larger levator hiatus at rest. For the cough task, higher flexibility was related to more dorsally positioned BN and larger displacements of BN and levator hiatus. Levator hiatus area at rest contributed more to predicting PFM flexibility than any other morphometric parameter assessed during rest or cough, although with poor agreement. PFM strength was associated with smaller hiatus area and anteroposterior dimension, with more cranial and ventrally positioned BN and with higher shifts and percentages of change of almost all measured variables during contraction. Anorectal height, levator hiatus dimension shift and percentages of change during contraction were the variables that better contributed to the prediction of PFM strength, with fair agreement. Concluding message In older women with UI, increased flexibility was poorly associated with PFM morphometry during rest and cough. Higher PFM strength was fairly associated with increased constriction of the PFM and inward movement of the PFM structure during contraction. 2488

Abstract Template

Abstract Title: PELVIC FLOOR MUSCLE TRAINING VERSUS NO TREATMENT OR INACTIVE CONTROL TREATMENTS FOR URINARY INCONTINENCE IN WOMEN: A COCHRANE REVIEW UPDATE Abstract Text:

Hypothesis / aims of study The objective of this study is to determine the effectiveness of pelvic floor muscle (PFM) training in the management of female urinary incontinence (UI). The following hypothesis was tested: that PFM training is better than no treatment, placebo, sham, or any other form of inactive control treatment. Because new trials are eligible for inclusion in the Cochrane systematic review (last updated 2014) (1), an update of current best evidence is needed.

Study design, materials and methods We searched (17 March 2017) the Cochrane Incontinence Group Specialised Register, which contain: trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and MEDLINE in process; hand searched journals and conference proceedings; and the reference lists of relevant articles. We included randomised or quasi-randomised trials in women with stress (SUI), urge (UUI) or mixed urinary incontinence (MUI), based on symptoms, signs, or urodynamics. One arm of the trial included PFM training. The comparator arm was no treatment, placebo, sham, or other inactive control treatment. Trials were sub- grouped by UI types. Outcomes of interest were patient reported measures, clinician reported measures, quality of life (QOL) and side effects. Two reviewers (LC and CD) independently assessed eligibility and methodological quality of trials. Any disagreement was resolved by discussion or arbitration with a third party (JHS). Two reviewers independently extracted data for the pre-defined outcomes (LC and CD). Meta-analysis was conducted when appropriate, in subgroups (by UI type), due to the heterogeneity of samples. For categorical outcomes we used risk ratio (RR) and for continuous outcomes we determined a mean difference, both with 95% confidence intervals (CI). A fixed effect model was used except if there was statistically significant heterogeneity in which case a random-effects model was considered. Risk of bias assessment was carried out as described in the Cochrane Handbook (2).

Results Nine new trials were added in the update. In total, thirty trials involving 1788 women (918 PFM training, 870 controls) were included in the review; 26 trials (1526 women) contributed data to the meta-analysis. The trials were generally of small or moderate size and many were at moderate risk of bias, based on the trial reports. Risk of bias assessment showed that across all studies approximately 55% of trials had adequate random sequence generation and 30% had adequate allocation concealment. In 40% of trials there was low risk for attrition bias, and outcome assessors were adequately blinded. 75% of trials presented adequate baseline comparability (Figure 1).

Fourteen countries contributed studies to this review (USA, Brazil, UK, Japan, Turkey, Canada, Norway, Austria, China, Iran, Korea, Portugal, The Netherland, and Sweden). There was considerable variation in: interventions used (e.g., programs lasting from 1 to 24 weeks, with 8 to 500 PFM voluntary contractions per day); study populations (e.g., pre- and postmenopausal women, women with osteoporosis and also young volleyball athletes); and outcome measures (e.g., patient reported cure or improvement of symptoms, satisfaction, quantification of symptoms, specific and non specific QOL questionnaires, adverse effects, measures of PFM function and of adherence, among others). For the first time there were trials that reported on women with mixed UI only (n=1) and urge UI only (n=1), and trials that presented an intervention provided exclusively by a smartphone app (n=1).

2489

100

2490

Figure 1. Risk of bias graph.

In women with stress UI, cure was more likely with PFM training in comparison with inactive control (4 trials, RR 8.4, 95% CI 3.7 to 19.1, p<0.00001), and cure or improvement was more likely with PFM training in comparison with inactive control (3 trials, RR 6.3, 95% CI 3.9 to 10.3, p<0.0001). For women with mixed UI, one trial reported that PFM training is associated with better quality of life (ICIQ-UI-SF) in comparison with inactive control (MD -3.97, 95% CI - 7.85 to -0.09, p<0.0001). For women with urge-predominant mixed UI one trial reported a greater reduction in the number of leakage episodes with PFM training in comparison with inactive control (MD -1.8m, 95% CI -2.7 to -1.0, p<0.0001). Finally, in trials with women with any type of UI, there was also moderate quality evidence that PFM training is associated with cure (3 trials, RR 5.5, 95% CI 2.9 to 10.5), or cure and improvement (2 trials, RR 2.4, 95% CI 1.6 to 3.5), in comparison with inactive control.

Interpretation of results We found evidence that PFM training is better than no treatment, placebo, sham, or other inactive control treatment for women with stress UI, urge UI, mixed UI or UI of any type. The addition of nine new trials did not change the essential findings of the prior review. The wider range of populations, countries and secondary outcomes within these new trials emphasized the strength of recommendation for women with UI. Of note, in almost all new included trials, the PFM training protocols were described in more detail, with progressive training based on exercise physiology. Moreover, there were more use of patient reported symptoms and QOL outcomes, in line with recent recommendations (3).

Concluding message Notwithstanding that long-term effectiveness of PFM training needs to be further researched, the updated review provides support for the widespread recommendation that PFM training be included as first-line conservative management programs for women with stress UI, mixed UI, urge UI and UI of any type.

References 1. Cochrane Database of Systematic Reviews 2014, Issue 5. Art. No.: CD005654 2. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0, March, 2011. 3. Incontinence. 5th edition. Paris: Health Publication Ltd, 2013:389-428.

2491

2492

101

9. REFERENCES 2493

2494

2495

Abdo CHN, Oliveira WM, Moreira ED, Fittipaldi JAS. Perfil sexual da população Brasileira: 2496 Resultados do Estudo do Comportamento Sexual (ECOS) do Brasileiro. Rev Bras Med. 2497 2002;59:250–7. 2498 Abrams P, Andersson KE, Birder L, Brubaker L, Cardozo L, Chapple C, et al. Fourth International 2499 Consultation on Incontinence Recommendations of the International Scientific 2500 Committee: Evaluation and treatment of urinary incontinence, pelvic organ prolapse, and 2501 fecal incontinence. Neurourol Urodyn. 2010;29(1):213–40. 2502 Aksac B, Aki S, Karan A, Yalcin O, Isikoglu M, Eskiyurt N. Biofeedback and pelvic floor exercises 2503 for the rehabilitation of urinary stress incontinence. Gynecol Obstet Invest. 2003;56:23– 2504 7. 2505 Albrich S, Steetskamp J, Knoechel S-L, Porta S, Hoffmann G, Skala C. Assessment of pelvic floor 2506 muscle contractility: digital palpation versus 2D and 3D perineal ultrasound. Arch Gynecol 2507 Obstet. 2016 Apr;293(4):839–43. 2508 Alperin M, Cook M, Tuttle LJ, Esparza MC, Lieber RL. Impact of vaginal parity and aging on the 2509 architectural design of pelvic floor muscles. Am J Obstet Gynecol. 2016 2510 Sep;215(3):312.e1-9. 2511 Alves S. Pompoar. 8th ed. Brasil: Madras; 2013. 2512 Amaro JL, Moreira ECH, Gameiro MO, Padovani CR. Pelvic floor muscle evaluation in 2513 incontinent patients. Int Urogynecol J. 2005 Oct 12;16(5):352–4. 2514 Arora AS, Kruger JA, Budgett DM, Hayward LM, Smalldridge J, Nielsen PF, et al. Clinical 2515 evaluation of a high-fidelity wireless intravaginal pressure sensor. Int Urogynecol J. 2015 2516 Feb 16;26(2):243–9. 2517 Ashton-Miller J a, Delancey JOL. On the biomechanics of vaginal birth and common sequelae. 2518 Annu Rev Biomed Eng. 2009;11:163–76. 2519 Ashton-Miller JA, DeLancey JOL. Functional anatomy of the female pelvic floor. Ann N Y Acad 2520 Sci. 2007;1101:266–96. 2521 Ashton-Miller JA, DeLancey JOL, Warwick DN. Method and Apparatus for Measuring Properties 2522 of the Pelvic Floor Muscles. US Patent # 6,468,232 B1. 2002. 2523 Ashton-Miller JA, Zielinski R, Miller JM, DeLancey JOL. Validity and reliability of an 2524 instrumented speculum designed to minimize the effect of intra-abdominal pressure on 2525

102

the measurement of pelvic floor muscle strength. Clin Biomech. 2014;29(10):1146–50. 2526 Auchincloss CC, McLean L. The reliability of surface EMG recorded from the pelvic floor 2527 muscles. J Neurosci Methods. 2009;182:85–96. 2528 Aukee P, Immonen P, Laaksonen DE, Laippala P, Penttinen J, Airaksinen O. The effect of home 2529 biofeedback training on stress incontinence. Acta Obstet Gynecol Scand. 2004;83:973–7. 2530 Baracho SM, Barbosa da Silva L, Baracho E, Lopes da Silva Filho A, Sampaio RF, Mello de 2531 Figueiredo E. Pelvic floor muscle strength predicts stress urinary incontinence in 2532 primiparous women after vaginal delivery. Int Urogynecol J. 2012;23:899–906. 2533 Barbosa PB, Franco MM, de Oliveira Souza F, Antônio FI, Montezuma T, Ferreira CHJ. 2534 Comparison between Measurements Obtained with three Different Perineometers. 2535 Clinics. 2009;64(6):527–33. 2536 Beji NK, Yalcin O, Erkan HA. The effect of pelvic floor training on sexual function of treated 2537 patients. Int Urogynecol J Pelvic Floor Dysfunct. 2003 Oct 1;14(4):234–8. 2538 Betschart C, Kim J, Miller JM, Ashton-Miller JA, DeLancey JOL. Comparison of muscle fiber 2539 directions between different levator ani muscle subdivisions: in vivo MRI measurements 2540 in women. Int Urogynecol J. 2014;25(9):1263–8. 2541 Bø K. Pelvic floor muscle strength and response to pelvic floor muscle training for stress 2542 urinary incontinence. Neurourol Urodyn. 2003;22(January):654–8. 2543 Bø K. Pelvic floor muscle training is effective in treatment of female stress urinary 2544 incontinence, but how does it work? Int Urogynecol J. 2004;15:76–84. 2545 Bø K. Pelvic floor muscle training in treatment of female stress urinary incontinence, pelvic 2546 organ prolapse and sexual dysfunction. World J Urol. 2012;30(4):437–43. 2547 Bø K, Finckenhagen HB. Vaginal palpation of pelvic floor muscle strength: inter-test 2548 reproducibility and comparison between palpation and vaginal squeeze pressure. Acta 2549 Obstet Gynecol Scand. 2001;80(6):883–7. 2550 Bø K, Frawley HC, Haylen BT, Abramov Y, Almeida FG, Berghmans B, et al. An International 2551 Urogynecological Association (IUGA)/International Continence Society (ICS) joint report 2552 on the terminology for the conservative and nonpharmacological management of female 2553 pelvic floor dysfunction. Int Urogynecol J. 2017a Feb 5;28(2):191–213. 2554 Bø K, Hilde G, Tennfjord MK, Engh ME. Does episiotomy influence vaginal resting pressure, 2555 pelvic floor muscle strength and endurance, and prevalence of urinary incontinence 6 2556 weeks postpartum? Neurourol Urodyn. 2017b Mar;36(3):683–6. 2557 Bø K, Kvarstein B, Hagen R, Larsen S. Pelvic floor muscle exercise for the treatment of female 2558 stress urinary incontinence: I. Reliability of vaginal pressure measurements of pelvic floor 2559

103

muscle strength. Neurourol Urodyn. 1990a;9(5):471–7. 2560 Bø K, Kvarstein B, Hagen R, Larsen S. Pelvic floor muscle exercise for the treatment of female 2561 stress urinary incontinence: II. Validity of vaginal pressure measurements of pelvic floor 2562 muscle strength and the necessity of supplementary methods for control of correct 2563 contraction. Neurourol Urodyn. 1990b;9(5):479–87. 2564 Bø K, Mørkved S, Frawley HC, Sherburn M. Evidence for benefit of transversus abdominis 2565 training alone or in combination with pelvic floor muscle training to treat female urinary 2566 incontinence: A systematic review. Neurourol Urodyn. 2009;28(November 2008):368–73. 2567 Bø K, Raastad R, Finckenhagen HB. Does the size of the vaginal probe affect measurement of 2568 pelvic floor muscle strength? Acta Obstet Gynecol Scand. 2005;84(2):129–33. 2569 Bø K, Sherburn M. Evaluation of female pelvic-floor muscle function and strength. Phys Ther. 2570 2005;85(3):269–82. 2571 Bø K, Talseth T, Vinsnes A. Randomized controlled trial on the effect of pelvic floor muscle 2572 training on quality of life and sexual problems in genuine stress incontinent women. Acta 2573 Obstet Gynecol Scand. 2000;79(2):598–603. 2574 Brækken IH, Majida M, Ellstrøm-Engh M, Bø K. Morphological Changes After Pelvic Floor 2575 Muscle Training Measured by 3-Dimensional Ultrasonography. Obstet Gynecol. 2576 2010;115(2):317–24. 2577 Brækken IH, Majida M, Ellstrøm-Engh M, Bø K. Are pelvic floor muscle thickness and size of 2578 levator hiatus associated with pelvic floor muscle strength, endurance and vaginal resting 2579 pressure in women with pelvic organ prolapse stages I-III? A cross sectional 3D 2580 ultrasound study. Neurourol Urodyn. 2014;33(February 2013):115–20. 2581 Brækken IH, Majida M, Ellstrøm-Engh M, BØ K. Test-retest reliability of pelvic floor muscle 2582 contraction measured by 4D ultrasound. Neurourol Urodyn. 2009 Jan;28(1):68–73. 2583 Brækken IH, Majida M, Ellstrøm-Engh M, Dietz HP, Umek W, Bø K. Test-Retest and intra- 2584 observer repeatability of two-, three- and four-dimensional perineal ultrasound of pelvic 2585 floor muscle anatomy and function. Int Urogynecol J. 2008;19:227–35. 2586 Brækken IH, Majida M, Ellström Engh M, Bø K. Can Pelvic Floor Muscle Training Improve Sexual 2587 Function in Women with Pelvic Organ Prolapse? A Randomized Controlled Trial. J Sex 2588 Med. 2015;12(2):470–80. 2589 Bus SA, Haspels R, Busch-Westbroek TE. Evaluation and Optimization of Therapeutic Footwear 2590 for Neuropathic Diabetic Foot Patients Using In-Shoe Plantar Pressure Analysis. Diabetes 2591 Care. 2011 Jul 1;34(7):1595–600. 2592 Cacciari LP, Pássaro AC, Amorim AC, Geuder M, Sacco IC. Novel instrumented probe for 2593

104

measuring 3D pressure distribution along the vaginal canal. J Biomech. 2017 May; 2594 Caldwell LS, Chaffin DB, Dukes-Dobos FN, Kroemer KH, Laubach LL, Snook SH, et al. A proposed 2595 standard procedure for static muscle strength testing. Am Ind Hyg Assoc J. 2596 1974;35(4):201–6. 2597 Cescon C, Riva D, Začesta V, Drusany-Starič K, Martsidis K, Protsepko O, et al. Effect of vaginal 2598 delivery on the external anal sphincter muscle innervation pattern evaluated by 2599 multichannel surface EMG: results of the multicentre study TASI-2. Int Urogynecol J. 2014 2600 Nov;25(11):1491–9. 2601 Chamochumbi CCM, Nunes FR, Guirro RRJ, Guirro ECO. Comparison of active and passive 2602 forces of the pelvic floor muscles in women with and without stress urinary incontinence. 2603 Rev Bras Fisioter. 2012;16(4):314–9. 2604 Chang ST. The Complete System of Self-healing: Internal Exercises. 1st ed. Pub T, editor. Tao 2605 Pub.; 1986. 2606 Chen R, Song Y, Jiang L, Hong X, Ye P. The assessment of voluntary pelvic floor muscle 2607 contraction by three-dimensional transperineal ultrasonography. Arch Gynecol Obstet. 2608 2011 Oct;284(4):931–6. 2609 Constantinou CE, Omata S. Direction sensitive sensor probe for the evaluation of voluntary and 2610 reflex pelvic floor contractions. Neurourol Urodyn. 2007;26(February):386–91. 2611 Cyr M-P, Kruger JA, Wong V, Dumoulin C, Girard I, Morin M. Pelvic floor morphometry and 2612 function in women with and without puborectalis avulsion in the early postpartum 2613 period. Am J Obstet Gynecol. 2017 Mar;216(3):274.e1-274.e8. 2614 Dean N, Wilson D, Herbison P, Glazener C, Aung T, Macarthur C. Sexual function, delivery 2615 mode history, pelvic floor muscle exercises and incontinence: a cross-sectional study six 2616 years post-partum. Aust N Z J Obstet Gynaecol. 2008 Jun;48(3):302–11. 2617 Deindl FM, Vodušek DB, Hesse U, Schüssler B. Pelvic floor activity patterns: comparison of 2618 nulliparous continent and parous urinary stress incontinent women. A kinesiological EMG 2619 study. Br J Urol. 1994 Apr;73(4):413–7. 2620 DeLancey JOL, Morgan DM, Fenner DE, Kearney R, Guire KE, Miller JM, et al. Comparison of 2621 levator ani muscle defects and function in women with and without pelvic organ 2622 prolapse. Obstet Gynecol. 2007;109(2):295–302. 2623 Van Delft K, Schwertner-Tiepelmann N, Thakar R, Sultan AH. Inter-rater reliability of 2624 assessment of levator ani muscle strength and attachment to the pubic bone in 2625 nulliparous women. Ultrasound Obstet Gynecol. 2013;42:341–6. 2626 van Delft K, Thakar R, Sultan AH. Pelvic floor muscle contractility: digital assessment vs 2627

105

transperineal ultrasound. Ultrasound Obstet Gynecol. 2015 Feb;45(2):217–22. 2628 Devreese A, Staes F, Janssens L, Penninckx F, Vereecken R, de Weerdt W. Incontinent Women 2629 Have Altered Pelvic Floor Muscle Contraction Patterns. J Urol. 2007;178(August):558–62. 2630 Devreese A, Staes F, de Weerdt W, Feys H, Van Assche A, Penninckx F, et al. Clinical evaluation 2631 of pelvic floor muscle function in continent and incontinent women. Neurourol Urodyn. 2632 2004;23(3):190–7. 2633 Dietz HP. Pelvic floor ultrasound: a review. Am J Obstet Gynecol. 2010;202(4):321–34. 2634 Dietz HP, Jarvis SK, Vancaillie TG. The assessment of levator muscle strength: A validation of 2635 three ultrasound techniques. Int Urogynecol J Pelvic Floor Dysfunct. 2002;13(3):156–9. 2636 Dietz HP, Wilson PD, Clarke B. The use of perineal ultrasound to quantify levator activity and 2637 teach pelvic floor muscle exercises. Int Urogynecol J Pelvic Floor Dysfunct. 2001;12:166– 2638 9. 2639 Dorey G, Speakman M, Feneley R, Swinkels A, Dunn C, Ewings P. Randomised controlled trial of 2640 pelvic floor muscle exercises and manometric biofeedback for erectile dysfunction. Br J 2641 Gen Pract. 2004;54(November):819–25. 2642 Dumoulin C, Bourbonnais D, Lemieux M-C. Development of a Dynamometer for Measuring the 2643 Isometric Force of the Pelvic Floor Musculature. Neurourol Urodyn. 2003;22(July 2644 2002):648–53. 2645 Dumoulin C, Gravel D, Bourbonnais D, Lemieux MC, Morin M. Reliability of Dynamometric 2646 Measurements of the Pelvic Floor Musculature. Neurourol Urodyn. 2004a;23(July 2647 2003):134–42. 2648 Dumoulin C, Hay-Smith EJC, Mac Habée-Séguin G. Pelvic floor muscle training versus no 2649 treatment, or inactive control treatments, for urinary incontinence in women. Cochrane 2650 Database Syst Rev. 2014;5(5):CD005654. 2651 Dumoulin C, Hay-Smith EJC, Habée-Séguin G Mac, Mercier J. Pelvic floor muscle training versus 2652 no treatment, or inactive control treatments, for urinary incontinence in women: a short 2653 version Cochrane systematic review with meta-analysis. Neurourol Urodyn. 2015 2654 Apr;34(4):300–8. 2655 Dumoulin C, Lemieux M-C, Bourbonnais D, Gravel D, Bravo G, Morin M. Physiotherapy for 2656 persistent postnatal stress urinary incontinence: a randomized controlled trial. Obstet 2657 Gynecol. 2004b;104:504–10. 2658 Dumoulin C, Peng Q, Stodkilde-Jorgensen H, Shishido K, Constantinou CE. Changes in Levator 2659 Ani Anatomical Configuration Following Physiotherapy in Women With Stress Urinary 2660 Incontinence. J Urol. 2007;178(September):970–7. 2661

106

Egorov V, van Raalte H, Sarvazyan AP. Vaginal Tactile Imaging. IEEE Trans Biomed Eng. 2010 2662 Jul;57(7):1736–44. 2663 Enck P, Hinninghofen H, Wietek B, Becker HD. Functional asymmetry of pelvic floor innervation 2664 and its role in the pathogenesis of fecal incontinence. Digestion. 2004;69:102–11. 2665 Ferreira CHJ, Barbosa PB, Souza FDO, Antônio FI, Franco MM, Bø K. Inter-rater reliability study 2666 of the modified Oxford Grading Scale and the Peritron manometer. Physiotherapy. 2667 2011;97(2):132–8. 2668 Ferreira CHJ, Dwyer PL, Davidson M, De Souza A, Ugarte JA, Frawley HC. Does pelvic floor 2669 muscle training improve female sexual function? A systematic review. Int Urogynecol J. 2670 2015 Dec 14;26(12):1735–50. 2671 Frawley HC, Galea MP, Phillips BA, Sherburn M, Bø K. Reliability of pelvic floor muscle strength 2672 assessment using different test positions and tools. Neurourol Urodyn. 2006;25(August 2673 2005):236–42. 2674 Freeman RM. Can we prevent childbirth-related pelvic floor dysfunction? BJOG An Int J Obstet 2675 Gynaecol. 2013;120:137–40. 2676 Friedman S, Blomquist JL, Nugent JM, McDermott KC, Muñoz A, Handa VL. Pelvic Muscle 2677 Strength After Childbirth. Obstet Gynecol. 2012;120(5):1. 2678 Guaderrama NM, Nager CW, Liu J, Pretorius DH, Mittal RK. The vaginal pressure profile. 2679 Neurourol Urodyn. 2005;24:243–7. 2680 Guzmán-Rojas R, Wong V, Shek KL, Dietz HP. Impact of levator trauma on pelvic floor muscle 2681 function. Int Urogynecol J. 2014;25:375–80. 2682 Hagen S, Glazener C, McClurg D, Macarthur C, Elders A, Herbison P, et al. Pelvic floor muscle 2683 training for secondary prevention of pelvic organ prolapse (PREVPROL): a multicentre 2684 randomised controlled trial. Lancet. 2017 Jan 28;389(10067):393–402. 2685 Hagen S, Stark D. Conservative prevention and management of pelvic organ prolapse in 2686 women. Cochrane Database Syst Rev. 2011;CD003882. 2687 Hallgren KA. Computing Inter-Rater Reliability for Observational Data: An Overview and 2688 Tutorial. Tutor Quant Methods Psychol. 2012;8(1):23–34. 2689 Halski T, Ptaszkowski K, Słupska L, Dymarek R. The evaluation of bioelectrical activity of pelvic 2690 floor muscles depending on probe location: a pilot study. Biomed Res Int. 2691 2013;2013:238312. 2692 Haylen BT, Maher CF, Barber MD, Camargo S, Dandolu V, Digesu A, et al. An International 2693 Urogynecological Association (IUGA) / International Continence Society (ICS) Joint Report 2694 on the Terminology for Female Pelvic Organ Prolapse (POP). Neurourol Urodyn. 2016 2695

107

Feb;35(2):137–68. 2696 Haylen BT, de Ridder D, Freeman RM, Swift SE, Berghmans B, Lee J, et al. An International 2697 Urogynecological Association (IUGA)/International Continence Society (ICS) joint report 2698 on the terminology for female pelvic floor dysfunction. Int Urogynecol J. 2010 2699 Jan;21(1):5–26. 2700 Heilbrun ME, Nygaard IE, Lockhart ME, Richter HE, Brown MB, Kenton KS, et al. Correlation 2701 between levator ani muscle injuries on magnetic resonance imaging and fecal 2702 incontinence, pelvic organ prolapse, and urinary incontinence in primiparous women. Am 2703 J Obstet Gynecol. 2010;202(5):488.e1-488.e6. 2704 Hilde G, Stær-Jensen J, Siafarikas F, Ellstrøm-Engh M, Brækken IH, Bø K. Impact of childbirth 2705 and mode of delivery on vaginal resting pressure and on pelvic floor muscle strength and 2706 endurance. Am J Obstet Gynecol. 2013;208(January). 2707 Hundley AF, Wu JM, Visco AG. A comparison of perineometer to brink score for assessment of 2708 pelvic floor muscle strength. Am J Obstet Gynecol. 2005;192:1583–91. 2709 Isherwood PJ, Rane A. Comparative assessment of pelvic floor strength using a perineometer 2710 and digital examination. BJOG An Int J Obstet Gynaecol. 2000;107(August):1007–11. 2711 Janura M, Peham C, Dvorakova T, Elfmark M. An assessment of the pressure distribution 2712 exerted by a rider on the back of a horse during hippotherapy. Hum Mov Sci. 2713 2009;28(3):387–93. 2714 Jean-Michel M, Biller DH, Bena JF, Davila GW. Measurement of pelvic floor muscular strength 2715 with the Colpexin pull test: A comparative study. Int Urogynecol J. 2010;21(8):1011–7. 2716 Johannessen HH, Wibe A, Stordahl A, Sandvik L, Mørkved S. Do pelvic floor muscle exercises 2717 reduce postpartum anal incontinence? A randomised controlled trial. BJOG An Int J 2718 Obstet Gynaecol. 2017 Mar;124(4):686–94. 2719 Jones RCL, Peng Q, Stokes M, Humphrey VF, Payne C, Constantinou CE. Mechanisms of Pelvic 2720 Floor Muscle Function and the Effect on the Urethra during a Cough. Eur Urol. 2721 2010;57(6):1101–10. 2722 Jung S-A, Pretorius DH, Padda BS, Weinstein MM, Nager CW, den Boer DJ, et al. Vaginal high- 2723 pressure zone assessed by dynamic 3-dimensional ultrasound images of the pelvic floor. 2724 Am J Obstet Gynecol. 2007;197(July):1–7. 2725 Kearney R, Sawhney R, DeLancey JOL. Levator ani muscle anatomy evaluated by origin- 2726 insertion pairs. Obstet Gynecol. 2004;104(1):168–73. 2727 Kegel AH. Progressive resistance exercise in the functional restoration of the perineal muscles. 2728 Am J Obstet Gynecol. 1948 Aug;56(2):238–48. 2729

108

Kepenekci I, Keskinkilic B, Akinsu F, Cakir P, Elhan AH, Erkek AB, et al. Prevalence of pelvic floor 2730 disorders in the female population and the impact of age, mode of delivery, and parity. 2731 Dis Colon Rectum. 2011 Jan;54(1):85–94. 2732 Kernozek TW, Wilder PA, Amundson A, Hummer J. The effects of body mass index on peak 2733 seat-interface pressure of institutionalized elderly. Arch Phys Med Rehabil. 2734 2002;83(6):868–71. 2735 Kruger JA, Nielsen PMF, Budgett SC, Taberner AJ. An automated hand-held elastometer for 2736 quantifying the passive stiffness of the levator ani muscle in women. Neurourol Urodyn. 2737 2015 Feb;34(2):133–8. 2738 Lavoisier P, Aloui R, Schmidt MH, Watrelot A. Clitoral blood flow increases following vaginal 2739 pressure stimulation. Arch Sex Behav. 1995 Feb;24(1):37–45. 2740 Laycock J, Jerwood D. Pelvic Floor Muscle Assessment: The PERFECT Scheme. Physiotherapy. 2741 2001;87(12):631–42. 2742 Lewicky-Gaupp C, Brincat CA, Yousuf A, Patel DA, DeLancey JOL, Fenner DE. Fecal incontinence 2743 in older women: are levator ani defects a factor? Am J Obstet Gynecol. 2744 2010;202(5):491.e1-491.e6. 2745 Lewis RW, Fugl-Meyer KS, Corona G, Hayes RD, Laumann EO, Moreira ED, et al. 2746 Definitions/Epidemiology/Risk Factors for Sexual Dysfunction. J Sex Med. 2010 2747 Apr;7(4):1598–607. 2748 Løwenstein E, Ottesen B, Gimbel H. Incidence and lifetime risk of pelvic organ prolapse surgery 2749 in Denmark from 1977 to 2009. Int Urogynecol J. 2015 Jan 20;26(1):49–55. 2750 Lowenstein L, Gruenwald I, Gartman I, Vardi Y. Can stronger pelvic muscle floor improve sexual 2751 function? Int Urogynecol J. 2010 May 20;21(5):553–6. 2752 Luginbuehl H, Baeyens J-P, Taeymans J, Maeder I-M, Kuhn A, Radlinger L. Pelvic floor muscle 2753 activation and strength components influencing female urinary continence and stress 2754 incontinence: a systematic review. Neurourol Urodyn. 2015 Aug;34(6):498–506. 2755 Luo J, Betschart C, Ashton-Miller JA, DeLancey JOL. Quantitative analyses of variability in 2756 normal vaginal shape and dimension on MR images. Int Urogynecol J. 2016 2757 Jul;27(7):1087–95. 2758 MacLennan AH, Taylor AW, Wilson DH, Wilson PD. The prevalence of pelvic floor disorders and 2759 their relationship to gender, age, parity and mode of delivery. BJOG An Int J Obstet 2760 Gynaecol. 2000;107(12):1460–70. 2761 Madill SJ, Pontbriand-Drolet S, Tang A, Dumoulin C. Effects of PFM rehabilitation on PFM 2762 function and morphology in older women. Neurourol Urodyn. 2013;32(8):1086–95. 2763

109

Madill SJ, Pontbriand-Drolet S, Tang A, Dumoulin C. Changes in urethral sphincter size 2764 following rehabilitation in older women with stress urinary incontinence. Int Urogynecol 2765 J. 2015;26(2):277–83. 2766 Martinez CS, Ferreira F V, Castro AAM, Gomide LB. Women with greater pelvic floor muscle 2767 strength have better sexual function. Acta Obstet Gynecol Scand. 2014;93:497–502. 2768 Martinho NM, Marques J, Silva VR, Silva SLA, Carvalho LC, Botelho S. Intra and inter-rater 2769 reliability study of pelvic floor muscle dynamometric measurements. Brazilian J Phys 2770 Ther. 2015 Apr;19(2):97–104. 2771 de Menezes Franco M, Driusso P, Bø K, Carvalho de Abreu DC, da Silva Lara LA, de Sá Rosa E 2772 Silva ACJ, et al. Relationship between pelvic floor muscle strength and sexual dysfunction 2773 in postmenopausal women: a cross-sectional study. Int Urogynecol J. 2016 Dec 6; 2774 Merletti R, Botter A, Troiano A, Merlo E, Minetto MA. Technology and instrumentation for 2775 detection and conditioning of the surface electromyographic signal: State of the art. Clin 2776 Biomech. 2009;24(2):122–34. 2777 Messelink B, Benson T, Berghmans B, Bø K, Corcos J, Fowler C, et al. Standardization of 2778 terminology of pelvic floor muscle function and dysfunction: Report from the pelvic floor 2779 clinical assessment group of the International Continence Society. Neurourol Urodyn. 2780 2005;24(June):374–80. 2781 Middlekauff ML, Egger MJ, Nygaard IE, Shaw JM. The impact of acute and chronic strenuous 2782 exercise on pelvic floor muscle strength and support in nulliparous healthy women. Am J 2783 Obstet Gynecol. 2016;215(3):1–7. 2784 Miller JM, Low LK, Zielinski R, Smith AR, DeLancey JOL, Brandon C. Evaluating maternal 2785 recovery from labor and delivery: bone and levator ani injuries. Am J Obstet Gynecol. 2786 2015 Aug;213(2):188.e1-188.e11. 2787 Morin M, Bourbonnais D, Gravel D, Dumoulin C, Lemieux MC. Pelvic floor muscle function in 2788 continent and stress urinary incontinent women using dynamometric measurements. 2789 Neurourol Urodyn. 2004a;23(December 2003):668–74. 2790 Morin M, Dumoulin C, Bourbonnais D, Gravel D, Lemieux M-C. Pelvic floor maximal strength 2791 using vaginal digital assessment compared to dynamometric measurements. Neurourol 2792 Urodyn. 2004b;23(4):336–41. 2793 Mørkved S, Salvesen KÅ, Bø K, Eik-Nes S. Pelvic floor muscle strength and thickness in 2794 continent and incontinent nulliparous pregnant women. Int Urogynecol J. 2004 Dec 2795 3;15(6):384–90. 2796 Nunes FR, Martins CC, Guirro ECO, Guirro RRJ. Reliability of Bidirectional and Variable-Opening 2797

110

Equipment for the Measurement of Pelvic Floor Muscle Strength. PM&R. 2798 2011;3(January):21–6. 2799 Nygaard IE, Barber MD, Burgio KL, Kenton K, Meikle S, Schaffer J, et al. Prevalence of 2800 symptomatic pelvic floor disorders in US women. JAMA. 2008;300(11):1311–6. 2801 Olsen AL, Smith VJ, Bergstromm JO, Colling JC, Clark AL. Epidemiology of surgically managed 2802 pelvic organ prolapse and urinary incontinence. Obstet Gynecol. 1997 Apr;89(4):501–6. 2803 Orejuela FJ, Shek KL, Dietz HP. The time factor in the assessment of prolapse and levator 2804 ballooning. Int Urogynecol J. 2012 Feb;23(2):175–8. 2805 Ornö AK, Dietz HP. Levator co-activation is a significant confounder of pelvic organ descent on 2806 Valsalva maneuver. Ultrasound Obstet Gynecol. 2007 Sep;30(3):346–50. 2807 Oversand SH, Kamisan Atan I, Shek KL, Dietz HP. The association between different measures 2808 of pelvic floor muscle function and female pelvic organ prolapse. Int Urogynecol J. 2015 2809 Dec 7;26(12):1777–81. 2810 Parkinson LA, Gargett CE, Young N, Rosamilia A, Vashi A V, Werkmeister JA, et al. Real-time 2811 measurement of the vaginal pressure profile using an optical-fiber-based instrumented 2812 speculum. J Biomed Opt. 2016;21(12):127008. 2813 Peng Q, Jones RCL, Shishido K, Omata S, Constantinou CE. Spatial distribution of vaginal closure 2814 pressures of continent and stress urinary incontinent women. Physiol Meas. 2815 2007;28(11):1429–50. 2816 Peng Y, He J, Khavari R, Boone TB, Zhang Y. Functional mapping of the pelvic floor and 2817 sphincter muscles from high-density surface EMG recordings. Int Urogynecol J. 2016 2818 Nov;27(11):1689–96. 2819 Perez N, Garcier JM, Pin-Leveugle J, Lhoste-Trouilloud A, Ravel A, McLaughlin P, et al. Dynamic 2820 magnetic resonance imaging of the female pelvis: radio-anatomy and pathologic 2821 applications. Preliminary results. Surg Radiol Anat. 1999 May;21(2):133–8. 2822 Peschers UM, Fanger G, Schaer GN, Vodušek DB, DeLancey JOL, Schuessler B. Bladder neck 2823 mobility in continent nulliparous women. Br J Obstet Gynaecol. 2001a;108(3):320–4. 2824 Peschers UM, Gingelmaier A, Jundt K, Leib B, Dimpfl T. Evaluation of pelvic floor muscle 2825 strength using four different techniques. Int Urogynecol J Pelvic Floor Dysfunct. 2826 2001b;12(1):27–30. 2827 Pontbriand-Drolet S, Tang A, Madill SJ, Tannenbaum C, Lemieux M-C, Corcos J, et al. 2828 Differences in pelvic floor morphology between continent, stress urinary incontinent, and 2829 mixed urinary incontinent elderly women: An MRI study. Neurourol Urodyn. 2015 2830 Apr;35(4):515–21. 2831

111

Ptaszkowski K, Paprocka-Borowicz M, Słupska L, Bartnicki J, Dymarek R, Rosińczuk J, et al. 2832 Assessment of bioelectrical activity of synergistic muscles during pelvic floor muscles 2833 activation in postmenopausal women with and without stress urinary incontinence: a 2834 preliminary observational study. Clin Interv Aging. 2015 Jan 23;10:1521–8. 2835 Quartly E, Hallam T, Kilbreath S, Refshauge K. Strength and endurance of the pelvic floor 2836 muscles in continent women: An observational study. Physiotherapy. 2010;96(4):311–6. 2837 van Raalte H, Egorov V. Tactile Imaging Markers to Characterize Female Pelvic Floor 2838 Conditions. Open J Obstet Gynecol. 2015 Aug;5(9):505–15. 2839 Rahmani N, Mohseni-Bandpei MA. Application of perineometer in the assessment of pelvic 2840 floor muscle strength and endurance: A reliability study. J Bodyw Mov Ther. 2841 2011;15(2):209–14. 2842 Raizada V, Bhargava V, Jung S-A, Karstens A, Pretorius D, Krysl P, et al. Dynamic assessment of 2843 the vaginal high-pressure zone using high-definition manometery, 3-dimensional 2844 ultrasound, and magnetic resonance imaging of the pelvic floor muscles. Am J Obstet 2845 Gynecol. 2010;203(2):172.e1-172.e8. 2846 Ribeiro J dos S, Guirro ECO, Franco M de M, Duarte TB, Pomini JM, Ferreira CHJ. Inter-rater 2847 reliability study of the PeritronTM perineometer in pregnant women. Physiother Theory 2848 Pract. 2016;32(3):209–17. 2849 Riesco MLG, Caroci ADS, de Oliveira SMJV, Lopes MHB de M. Perineal muscle strength during 2850 pregnancy and postpartum: the correlation between perineometry and digital vaginal 2851 palpation. Rev Lat Am Enfermagem. 2010;18(6):1138–44. 2852 Romero-Cullerés G, Peña-Pitarch E, Jané-Feixas C, Arnau A, Montesinos J, Abenoza-Guardiola 2853 M. Intra-rater reliability and diagnostic accuracy of a new vaginal dynamometer to 2854 measure pelvic floor muscle strength in women with urinary incontinence. Neurourol 2855 Urodyn. 2017 Feb;36(2):333–7. 2856 Rosenbaum TY. Pelvic floor involvement in male and female sexual dysfunction and the role of 2857 pelvic floor rehabilitation in treatment: A literature review. J Sex Med. 2007;4:4–13. 2858 da Roza T, Mascarenhas T, Araujo M, Trindade V, Jorge RN. Oxford Grading Scale vs 2859 manometer for assessment of pelvic floor strength in nulliparous sports students. 2860 Physiotherapy. 2013;99:207–11. 2861 Sacco ICN, Sartor CD. From treatment to preventive actions: improving function in patients 2862 with diabetic polyneuropathy. Diabetes Metab Res Rev. 2016 Jan;32(1):206–12. 2863 Saleme CS, Rocha DN, Del Vecchio S, Silva Filho AL, Pinotti M. Multidirectional Pelvic Floor 2864 Muscle Strength Measurement. Ann Biomed Eng. 2009;37(8):1594–600. 2865

112

Sampselle CM, Miller JM, Mims BL, DeLancey JOL, Ashton-Miller JA, Antonakos CL. Effect of 2866 pelvic muscle exercise on transient incontinence during pregnancy and after birth. Obstet 2867 Gynecol. 1998 Mar;91(3):406–12. 2868 Sartori DVB, Gameiro MO, Yamamoto HA, Kawano PR, Guerra R, Padovani CR, et al. Reliability 2869 of pelvic floor muscle strength assessment in healthy continent women. BMC Urol. 2015 2870 Dec;15(1):29. 2871 Schaer GN, Koechli OR, Schuessler B, Haller U. Perineal ultrasound for evaluating the bladder 2872 neck in urinary stress incontinence. Obstet Gynecol. 1995 Feb;85(2):220–4. 2873 Schell A, Bugett D, Nielsen P, Samalldridge J, Hayward LM, Dumoulin C, et al. Design and 2874 development of a novel intra-vaginal pressure sensor array. Neurourol Urodyn. 2875 2016;35(S4):S355-356. 2876 Shafik A. A new concept of the anatomy of the anal sphincter mechanism and the physiology 2877 of defecation: Mass contraction of the pelvic floor muscles. Int Urogynecol J Pelvic Floor 2878 Dysfunct. 1998;9(1):28–32. 2879 Shafik A. The role of the levator ani muscle in evacuation, sexual performance and pelvic floor 2880 disorders. Int Urogynecol J Pelvic Floor Dysfunct. 2000;11(6):361–76. 2881 Shafik A, El Sibai O, Shafik AA, Ahmed I, Mostafa RM. The electrovaginogram: study of the 2882 vaginal electric activity and its role in the sexual act and disorders. Arch Gynecol Obstet. 2883 2004 May;269(4):282–6. 2884 Shishido K, Peng Q, Jones RCL, Omata S, Constantinou CE. Influence of Pelvic Floor Muscle 2885 Contraction on the Profile of Vaginal Closure Pressure in Continent and Stress Urinary 2886 Incontinent Women. J Urol. 2008;179(5):1917–22. 2887 Silveira SB, Margarido P, Cacciari LP, Baracat EC. TVL, GH and PB points after a year of surgical 2888 treatment for severe genital prolapse. Neurourol Urodyn. 2015 Aug;33(6):194. 2889 Slieker-ten Hove MCP, Pool-Goudzwaard AL, Eijkemans MJC, Steegers-Theunissen RPM, Burger 2890 CW, Vierhout ME. Face validity and reliability of the first digital assessment scheme of 2891 pelvic floor muscle function conform the new standardized terminology of the 2892 International Continence Society. Neurourol Urodyn. 2009 Apr;28(4):295–300. 2893 Smith FJ, Holman CDJ, Moorin RE, Tsokos N. Lifetime Risk of Undergoing Surgery for Pelvic 2894 Organ Prolapse. Obstet Gynecol. 2010 Nov;116(5):1096–100. 2895 Staskin DR, Kelleher CJ. Initial Assessment of Urinary Incontinence in Adult Male and Female 2896 Patients. In: Abrams P, Cardozo L, Khoury S, Wein A, editors. Incontinence. 5th ed. Paris: 2897 5th International Consultation on Incontinence. EAU; 2013. p. 363–88. 2898 Streiner DL, Norman GR. “Precision” and “accuracy”: Two terms that are neither. J Clin 2899

113

Epidemiol. 2006;59(4):327–30. 2900 Swift SE, Woodman PJ, O’Boyle A, Kahn M, Valley M, Bland DR, et al. Pelvic Organ Support 2901 Study (POSST): The distribution, clinical definition, and epidemiologic condition of pelvic 2902 organ support defects. Am J Obstet Gynecol. 2005 Mar;192(3):795–806. 2903 Tan JS, Lukacz ES, Menefee SA, Luber KM, Albo ME, Nager CW. Determinants of vaginal length. 2904 Am J Obstet Gynecol. 2006 Dec;195(6):1846–50. 2905 Thalheimer W, Cook S. How to calculate effect sizes from published research: A simplified 2906 methodology. Work Res. 2002;(August):1–9. 2907 Theofrastous JP, Wyman JF, Bump RC, McClish DK, Elser DM, Bland DR, et al. Effects of pelvic 2908 floor muscle training on strength and predictors of response in the treatment of urinary 2909 incontinence. Neurourol Urodyn. 2002;21(5):486–90. 2910 Thompson JA, O’Sullivan PB, Briffa NK, Neumann P. Altered muscle activation patterns in 2911 symptomatic women during pelvic floor muscle contraction and valsalva manouevre. 2912 Neurourol Urodyn. 2006a;25(April 2005):268–76. 2913 Thompson JA, O’Sullivan PB, Briffa NK, Neumann P. Assessment of voluntary pelvic floor 2914 muscle contraction in continent and incontinent women using transperineal ultrasound, 2915 manual muscle testing and vaginal squeeze pressure measurements. Int Urogynecol J. 2916 2006b Nov 12;17(6):624–30. 2917 Thompson JA, O’Sullivan PB, Briffa NK, Neumann P, Court S. Assessment of pelvic floor 2918 movement using transabdominal and transperineal ultrasound. Int Urogynecol J. 2919 2005;16(4):285–92. 2920 Tibaek S, Dehlendorff C. Pelvic floor muscle function in women with pelvic floor dysfunction : A 2921 retrospective chart review, 1992-2008. Int Urogynecol J. 2014;25:663–9. 2922 Torelli L, de Jarmy Di Bella ZIK, Rodrigues CA, Stüpp L, Girão MJBC, Sartori MGF. Effectiveness 2923 of adding voluntary pelvic floor muscle contraction to a Pilates exercise program: an 2924 assessor-masked randomized controlled trial. Int Urogynecol J. 2016;1–10. 2925 Ulbrecht JS, Hurley T, Mauger DT, Cavanagh PR. Prevention of Recurrent Foot Ulcers With 2926 Plantar Pressure–Based In-Shoe Orthoses: The CareFUL Prevention Multicenter 2927 Randomized Controlled Trial. Diabetes Care. 2014 Jul;37(7):1982–9. 2928 Verelst M, Leivseth G. Are Fatigue and Disturbances in Pre-Programmed Activity of Pelvic Floor 2929 Muscles Associated with Female Stress Urinary Incontinence? Neurourol Urodyn. 2930 2004a;23(2):143–7. 2931 Verelst M, Leivseth G. Force-length relationship in the pelvic floor muscles under transverse 2932 vaginal distension: a method study in healthy women. Neurourol Urodyn. 2933

114

2004b;23(7):662–7. 2934 Verelst M, Leivseth G. Force and stiffness of the pelvic floor as function of muscle length: A 2935 comparison between women with and without stress urinary incontinence. Neurourol 2936 Urodyn. 2007 Oct;26(6):852–7. 2937 Volløyhaug I, Mørkved S, Salvesen Ø, Salvesen KÅ. Assessment of pelvic floor muscle 2938 contraction with palpation, perineometry and transperineal ultrasound: a cross-sectional 2939 study. Ultrasound Obstet Gynecol. 2016 Jun;47(6):768–73. 2940 Voorham-van der Zalm PJ, Voorham JC, Van den Bos TWL, Ouwerkerk TJ, Putter H, Wasser 2941 MNJM, et al. Reliability and differentiation of pelvic floor muscle electromyography 2942 measurements in healthy volunteers using a new device: The Multiple Array Probe Leiden 2943 (MAPLe). Neurourol Urodyn. 2013;32(4):341–8. 2944 Weinstein MM, Jung S-A, Pretorius DH, Nager CW, den Boer DJ, Mittal RK. The reliability of 2945 puborectalis muscle measurements with 3-dimensional ultrasound imaging. Am J Obstet 2946 Gynecol. 2007 Jul;197(1):68.e1-6. 2947 Wood LN, Anger JT. Urinary incontinence in women. BMJ Br Med J. 2014;349:1–11. 2948 World Health Organization. Sexual Health, human rights and the law. WHO. 2015;1–48. 2949 Wu JM, Kawasaki A, Hundley AF, Dieter AA, Myers ER, Sung VW. Predicting the number of 2950 women who will undergo incontinence and prolapse surgery, 2010 to 2050. Am J Obstet 2951 Gynecol. 2011;205(3):1–5. 2952 Wu JM, Vaughan CP, Goode PS, Redden DT, Burgio KL, Richter HE, et al. Prevalence and Trends 2953 of Symptomatic Pelvic Floor Disorders in U.S. Women. Obstet Gynecol. 2014 2954 Jan;123(1):141–8. 2955 Zahariou AG, Karamouti M V, Papaioannou PD. Pelvic floor muscle training improves sexual 2956 function of women with stress urinary incontinence. Int Urogynecol J. 2008 2957 Mar;19(3):401–6. 2958 2959 2960

APPENDICES 2961

2962

APPENDIX A – Project approved by São Paulo Research Foundation (FAPESP) 2963

INFLUÊNCIA DO TREINAMENTO PERINEAL E DA FUNÇÃO SEXUAL NA DISTRIBUIÇÃO MULTIVETORIAL 2964 DE CARGAS DO ASSOALHO PÉLVICO FEMININO 2965 2966 The influence of perineal training and sexual function on multidirectional load 2967 distribution of the female pelvic floor 2968 2969

Profa. Dra. Isabel de Camargo Neves Sacco – Orientadora 2970 Licia Pazzoto Cacciari- Doutorado fluxo contínuo 2971 2972 Laboratório de Biomecânica do Movimento e da Postura Humana - LABIMPH 2973 Depto. Fisioterapia, Fonoaudiologia e Terapia Ocupacional, Faculdade de Medicina, 2974 Universidade de São Paulo 2975 2976 RESUMO 2977 O assoalho pélvico é um conjunto de músculos, ligamentos e fáscias, localizado na região da pelve ainda 2978 pouco estudado do ponto de vista da biomecânica. Sua função é sustentar os órgãos pélvicos e garantir 2979 a continência urinária e fecal. Embora 45% das mulheres não sejam capazes de contrair o assoalho 2980 pélvico voluntariamente, a força e a capacidade de sustentação da contração dessa musculatura estão 2981 relacionadas à severidade da incontinência urinária e à satisfação sexual. O fator de risco mais bem 2982 estabelecido para disfunção e enfraquecimento da musculatura do assoalho pélvico é o parto vaginal. 2983 Os objetivos deste estudo são: (1) Investigar a relação entre a distribuição espaço-temporal das cargas 2984 do assoalho pélvico feminino e a técnica de pompoarismo, e (2) Investigar a relação entre a distribuição 2985 espaço-temporal das cargas no assoalho pélvico e a satisfação sexual. A distribuição espaço-temporal e 2986 multivetorial de cargas do assoalho pélvico será obtida por meio de um probe instrumentado por 2987 sensores capacitivos (Pliance System- Novel, Monique, Alemanha) e de um dinamômetro instrumentado 2988 por célula de carga; (EMG-system do Brasil 020653/ 2013 – São José dos Campos, SP/Brasil). Para 2989 responder ao primeiro objetivo, 20 mulheres primíparas que passaram pelo parto vaginal com e sem a 2990 preparação perineal serão avaliadas quanto à distribuição multivetorial de cargas. Para responder ao 2991 segundo objetivo, 20 mulheres nulíparas praticantes e não praticantes de pomporismo serão avaliadas 2992 pelo mesmo protocolo do primeiro objetivo. Após a palpação vaginal, a distribuição espaço-temporal da 2993 força da musculatura do assoalho pélvico será avaliada durante 3 contrações voluntárias máximas e uma 2994 contração sustentada. As medidas obtidas entre os diferentes grupos independentes de mulheres em 2995 cada objetivo serão comparadas por meio de análises de variância (ANOVA), seguidas de testes post hoc 2996 de Newman-Keuls. Será adotado p= 0,05 para diferenças significativas. 2997 2998 Descritores: assoalho pélvico; treinamento; força; mulheres; pressão; distribuição de cargas 2999 3000

ABSTRACT 3001 The pelvic floor is a group of muscles, joints and fascia, forming the base of the abdomino-pelvic cavity, 3002 considered an understudied region of the body from a biomechanical perspective. Together these 3003 structures contribute to support the pelvic organs and to maintain urinary and faecal continence. 3004 Although 45% of the women are not capable to contract the pelvic floor voluntarily, the strength and 3005 the capacity to maintain the pelvic floor muscle contraction are related to the severity of incontinence 3006 and sexual satisfaction. The aims of the present study are to: (1) investigate the effect of a pompoir 3007 training practice on strength, endurance and coordination of these muscles; and to (2) investigate the 3008 effect of sexual dysfunction symptoms on strength, endurance and coordination of these muscles. A 3009 multidirectional spatiotemporal load distribution of the pelvic floor will be assessed by a probe fully 3010 instrumented with capacitive sensors (Pliancy System- Novel, Munich, Germany). To answer the first 3011 question, 20 women with and without symptoms of pelvic floor dysfunction; and to answer the second 3012 question 20 nulliparous that practiced or not the pompoir training will be assessed by the same 3013 protocol. After vaginal palpation, pelvic floor muscle strength will be evaluated during three consecutive 3014 maximal voluntary contractions and one sustained contraction. The variables will be compared between 3015 groups by analysis of variance (ANOVA) followed by Newman-Keuls post-hoc test. Alpha will be set at 3016 0.05 for all analysis. 3017 3018 Descriptors: pelvic floor; training; strength; women; pressure; load distribution 3019 3020 1. CARACTERIZAÇÃO DO PROBLEMA 3021 O assoalho pélvico feminino é uma região do corpo ainda pouco estudada do ponto de vista 3022 biomecânico. Esse conjunto de estruturas tem como função comum a sustentação dos órgãos pélvicos e 3023 a manutenção da continência urinária, mas também deve permitir a eliminação de resíduos, 3024 proporcionar prazer sexual, garantir a estabilidade lombo-pélvica e possibilitar o parto vaginal (1, 2). 3025 Disfunções do assoalho pélvico podem levar a quadros de prolapso, incontinência ou urgência urinária 3026 que afetam a qualidade de vida e resultam na necessidade de operação cirúrgica complexa e com alta 3027 taxa de reincidência (2). 3028 Para que a contenção urinária seja mantida, a pressão de fechamento uretral deve ser maior que 3029 a pressão da bexiga, tanto durante o repouso quanto durante aumentos da pressão intra-abdominal (3). 3030 Essa pressão de fechamento uretral é mantida pela musculatura estriada do esfíncter uretral, pela 3031 musculatura lisa uretral e por elementos vasculares da submucosa (4, 5). 3032 Outras estruturas ativas também são essenciais para o bom funcionamento do mecanismo de 3033 contenção, como o esfíncter uretral externo e o músculo elevador do ânus (pubococcígeo, puborretal, 3034 pubovaginal, e iliococcígeo). Esses último tem origem no púbis e ílio e inserção na vagina (porções 3035 laterais posteriores), no canal anal (porções laterais posteriores), no cóccix e na fáscia do músculo 3036 obturador interno (2). 3037 O esfíncter uretral externo está ancorado ao músculo elevador do ânus e funciona como um 3038 ponto fixo para a sua contração. Desse modo, a funcionalidade de um é intimamente dependente da 3039 integridade do outro (7). A atividade basal do músculo elevador do ânus mantém o hiato urogenital 3040 fechado, impedindo o prolapso dos órgãos pélvicos pela compressão da vagina, uretra e reto contra o 3041 púbis, o assoalho e os órgãos pélvicos. Durante aumentos da pressão intra-abdominal, como na tosse, a 3042 contração do músculo elevador do ânus, juntamente com a contração do diafragma e do abdômen, 3043 movimenta a vagina e o reto ventral e cranialmente (8) gerando um aumento de tensão da fáscia 3044

endopélvica, necessária para o fechamento do lúmen uretral (2). 3045 O músculo elevador do ânus é composto predominantemente por fibras do tipo I, com alta 3046 resistência à fadiga responsáveis pela manutenção do tônus basal do assoalho pélvico, mas também 3047 contém fibras do tipo II, responsáveis pela contração voluntária rápida que permite o fechamento 3048 adicional do canal em casos de maior demanda (9). 3049 Considera-se que força de contração do elevador do ânus, assim como a habilidade de sustentar 3050 a contração máxima desse músculo, estão relacionadas à severidade da incontinência urinária (10) assim 3051 como a queixas gástricas e sexuais (11). No entanto, aproximadamente 45% das mulheres não é capaz 3052 de contrair o assoalho pélvico voluntariamente e apenas 27%, apresentam uma contração involuntária 3053 antes do aumento da pressão intra-abdominal (12). 3054

1.1. DISFUNÇÕES DO ASSOALHO PÉLVICO 3055

A Sociedade Internacional de Continência (13) define como incontinência a condição em que a 3056 perda involuntária de urina é um problema social ou higiênico, e considera como sintomas urogenitais 3057 mais comuns as incontinências urinárias de esforço e de urgência. A primeira é geralmente associada à 3058 fraqueza da musculatura do assoalho pélvico, e definida como a perda involuntária de qualquer 3059 quantidade de urina durante a execução de tarefas que provoquem aumento da pressão intra- 3060 abdominal, como a tosse ou o espirro. A segunda, também chamada de urge-incontinência, é definida 3061 como a perda de urina acompanhada ou precedida por uma forte urgência de urinar, geralmente 3062 explicada pela hiperatividade do músculo detrusor da bexiga. A combinação entre as incontinências de 3063 esforço e de urgência é classificada como incontinência mista. A bexiga hiperativa é uma disfunção 3064 uroginecológica caracterizada pela contração involuntária do músculo detrusor durante a fase de 3065 enchimento vesical, culminando em sintomas de urgência, com ou sem incontinência, geralmente 3066 acompanhados por aumento da frequência urinária. Apesar da diferença entre as causas e sintomas 3067 descritos, considera-se o treinamento supervisionado da contração adequada do assoalho pélvico como 3068 o tratamento conservador de primeira linha para estas disfunções, colaborando com os três tipos de 3069 incontinência (14, 15). 3070 A incontinência urinária é uma disfunção comum, que acomete de 9 a 72% das mulheres de 17 a 3071 79 anos (16), que varia de acordo com a idade (17-19), o número de partos (18, 20) o índice de massa 3072 corpórea (21, 22). 3073 O parto vaginal é considerado o mais bem estabelecido fator de risco para disfunções do 3074 assoalho pélvico, principalmente quando associado ao uso de fórceps, ruptura do esfíncter anal, 3075 episiotomia, maior duração do 2o estágio do parto (23), excesso de peso do bebê, fraqueza do assoalho 3076 pélvico (24), presença de diabetes mellitus, alto índice de massa corpórea, idade, paridade, anestesia 3077 epidural (25), histórico de incontinência antes ou durante a primeira gravidez (26) ou ao excesso de 3078 mobilidade do colo vesical (27). 3079 Estudos neurofisiológicos mostram que o parto vaginal pode causar denervação parcial dos 3080

músculos estriados do assoalho pélvico (28, 29), enquanto estudos de imagem mostram que o principal 3081 trauma ocorre no músculo pubococcígeo, acometendo de 20 a 40% de mulheres primíparas (30-32). 3082 Esta denervação parcial dos músculos do assoalho pélvico tem sido associada a alterações da ativação 3083 do elevador do ânus (33) e ao desenvolvimento de incontinências urinárias, fecais ou prolapsos (34). 3084

1.2. AVALIAÇÃO DO ASSOALHO PÉLVICO 3085

Nos cinco últimos anos, o número de trabalhos dentro da área da Fisioterapia relacionados à 3086 função e disfunção do assoalho pélvico aumentou razoavelmente (40% em relação aos 10 anos 3087 anteriores), tendo atualmente 160 trabalhos na base de dados da biblioteca nacional americana 3088 (Medline). Ainda assim, a produção científica da qualidade do assoalho pélvico sob o ponto de vista 3089 biomecânico ainda ocupa um posição pequena dentro do universo acadêmico, com apenas 29 trabalhos 3090 na mesma base de dados. Devido a grande complexidade dos músculos do assoalho pélvico e a íntima 3091 relação destes com disfunções uroginecológicas recorrentes em mulheres, a demanda por avaliações 3092 objetivas em biomecânica deve ser crescente. 3093 A avaliação objetiva da ação muscular do assoalho pélvico é altamente recomendada pela 3094 Sociedade Internacional de Continência (13) como parte da avaliação de rotina de mulheres com 3095 queixas uroginecológicas, mas torna-se complicada por seu formato côncavo, com ação concêntrica (35) 3096 e inserções na fáscia endopélvica e órgãos, além da variabilidade nas suas não únicas zonas de 3097 inervação. O assoalho pélvico normalmente contrai simultaneamente como um sincício, mas a 3098 qualidade da contração e a contribuição de cada camada muscular podem diferir (36) e influenciar 3099 diretamente nos mecanismos de continência e outros tantos relacionados a esta região do corpo. 3100 Subjetivamente a avaliação do assoalho pélvico pode ser feita por meio de observações clínicas 3101 (anatômica ou funcional), da quantificação dos sintomas (perda urinária), ou avaliação da qualidade de 3102 vida e socioeconômica (37) relacionadas à função do assoalho pélvico. Já avaliações objetivas podem ser 3103 obtidas por meio da palpação digital, da eletromiografia, da perineometria ou da dinamometria (36). 3104 A palpação digital é uma avaliação rotineiramente utilizada na clínica, geralmente empregada em 3105 combinação com escalas de força muscular (38), mas que, embora prática, pode ser pouco sensível e 3106 específica, mesmo para examinadores experientes, devendo idealmente ser acompanhada de outras 3107 análises mais quantitativas da função muscular (39, 40). 3108 A perineometria e a dinamometria são consideradas avaliações mais diretas e objetivas da 3109 função do assoalho pélvico (41, 42). Estas são geralmente empregadas como (a) biofeedback da pressão 3110 da cavidade vaginal durante o tratamento (43), (b) ferramenta diagnóstica da pressão para diferenciar 3111 grupos de pacientes (continentes e incontinentes) (18, 44), (c) resposta do sucesso ou não da terapia 3112 utilizada (45). Apesar de aparentemente correspondentes e serem ainda usadas na literatura sem 3113 distinção apropriada, a dinamometria é uma ferramenta mais sensível, precisa, direta e específica que a 3114 perineometria. A dinamometria é capaz de fornecer precisamente a força máxima, a taxa de 3115 desenvolvimento da força, a resistência de sustentação e de repetição das contrações (46-49), 3116

diferentemente da perineometria, já que o comprimento dos músculos do assoalho pélvico são 3117 influenciados diretamente pela alta complacência dos transdutores de pressão (perineometria) durante 3118 a avaliação (50) e consequentemente, a mensuração da força, resistência e taxas serão diretamente 3119 modificadas pela mudança de comprimento muscular. 3120 No entanto, aumentos de pressão da cavidade abdominal refletem em aumentos da pressão 3121 uretral e vaginal, tornando complexa a diferenciação entre o que seria uma contração do assoalho 3122 pélvico ou da parede do abdômen (51). Além disso, a medida univetorial da pressão obtida por meio da 3123 perineometria ou da força no caso da dinamometria nos diz relativamente pouco sobre a qualidade, a 3124 simetria ou inclusive sobre o movimento cranial da contração muscular, mesmo este sendo considerado 3125 essencial para o mecanismo de contenção urinária (8, 51). 3126 De acordo com a International Urogynecological Association (52) a avaliação da musculatura do 3127 assoalho pélvico deve incluir, além da avaliação da força máxima estática e dinâmica, a avaliação do 3128 relaxamento voluntário, da resistência ou endurance (capacidade de sustentar a força máxima ou quase 3129 máxima), da repetibilidade (número de contrações máximas realizadas em determinado tempo), da 3130 coordenação, do deslocamento cranial e da simetria da contração muscular. É portanto fundamental 3131 um diagnóstico feito a partir de uma ferramenta objetiva, fidedigna e multivetorial, capaz de identificar 3132 a magnitude, a distribuição espacial, temporal e a direção relativa da contração do assoalho pélvico. 3133 Esta forma de avaliação pode ser facilitada por um cilindro não deformável totalmente instrumentado 3134 por sensores capacitivos que tem alta linearidade com a medida de força/pressão exercida, que pode 3135 dar um mapa da distribuição destas forças e pressões numa série temporal. Este equipamento seria uma 3136 inovação de alta qualificação na avaliação da força e função do assoalho pélvico. 3137

1.3. TERAPÊUTICA DE DISFUNÇOES DO ASSOALHO PÉLVICO 3138

O treinamento específico dos músculos do assoalho pélvico tem sido preconizado como padrão 3139 ouro no tratamento e na prevenção das disfunções uroginecológicas (53), sendo altamente 3140 recomendado para prevenção e tratamento de incontinências (54, 55) e de disfunções sexuais (56, 57). 3141 Embora o treinamento do assoalho pélvico tenha sido popularizado por Arnold Kegel em 1948, há 3142 relatos bem mais antigos de sua utilização que chegam a datar de 6.000 anos atrás (58). 3143 Em mulheres com prolapso dos órgãos pélvicos, o treinamento supervisionado induziu alterações 3144 morfológicas do períneo, tais como: o aumento do volume muscular, redução da área do hiato 3145 urogenital e do comprimento muscular, elevação da posição da bexiga e do reto, além da redução da 3146 área do hiato e do comprimento muscular mesmo durante manobras que aumentavam a pressão intra- 3147 abdominal (59). 3148 Para a incontinência urinária de esforço, o treinamento por exercícios é empregado para otimizar 3149 a sustentação dos órgãos pélvicos, principalmente a bexiga e a uretra, garantindo a continência por 3150 aumento da pressão intra-uretral (60) e prevenindo o prolapso durante o esforço (61). Foi demonstrado 3151 que com treinamento é possível contrair conscientemente a musculatura do assoalho pélvico antes e 3152

durante situações de aumento de pressão abdominal (como a tosse) (62), ao mesmo tempo que a 3153 hipertrofia adquirida do músculo elevador do ânus facilitaria uma resposta mais automática do assoalho 3154 pélvico frente a alterações da pressão intra-abdominal (58). 3155 Para a incontinência urinária de urgência, acredita-se que o aumento da pressão intra-uretral, 3156 decorrente da contração voluntária do assoalho pélvico, seja responsável pela inibição da contração 3157 involuntária do músculo detrusor da bexiga (63), tornando possível o controle da frequência ou a 3158 redução dos episódios de perda urinária. 3159 O treinamento do assoalho pélvico é também recomendado na prevenção de incontinências 3160 decorrentes da gravidez e do parto vaginal. Este treinamento tem o objetivo de preparar o assoalho 3161 pélvico para o parto vaginal podendo ser direcionado para um fortalecimento (54, 64, 65) e/ou para um 3162 alongamento da musculatura (66-68). Durante o parto vaginal, o assoalho pélvico se alonga de 3 a 4 3163 vezes o seu tamanho original, o que pode levar ao rompimento de sarcômeros (microtrauma) ou 3164 mesmo à avulsão do elevador do ânus (macrotrauma) (69), o que justificaria a diminuição da pressão 3165 vaginal de repouso, de sua força e funcionalidade (70), além do aumento da prevalência de 3166 incontinência, que é três vezes maior em mulheres submetidas a parto vaginal (71). 3167 Exercícios simples de fortalecimento e coordenação muscular do assoalho pélvico são 3168 preconizados também como prevenção e tratamento de disfunções sexuais, pressupondo-se que essas 3169 disfunções estejam relacionadas a alterações da força, resistência e coordenação da musculatura dessa 3170 região. Em alguns casos, as disfunções sexuais podem estar relacionadas à hipertonia associada ou não à 3171 fraqueza da musculatura do assoalho pélvico (72), disfunções estas que poderiam ser corrigidas com 3172 técnicas de relaxamento, alongamento, fortalecimento e coordenação muscular (73). Estas técnicas tem 3173 potencial para beneficiar a função sexual, incluindo excitação e orgasmo (74), assim como para reduzir a 3174 perda urinária durante a relação, trazendo benefícios para a qualidade de vida dessas pacientes (56). 3175 O pompoarismo é uma antiga técnica oriental, derivada do tantra, que consiste na contração e 3176 relaxamento dos músculos vaginais, buscando como resultado autoconhecimento e o prazer sexual, 3177 sendo inclusive indicado como tratamento de incontinências urinária e fecal e lesões perineais 3178 relacionadas ao parto vaginal (75). No entanto até o momento, não encontramos na literatura nenhuma 3179 avaliação dos possíveis efeitos deste treinamento na força, coordenação e simetria da contração 3180 muscular perineal. 3181 Considerando que o fortalecimento do assoalho pélvico é preconizado como prevenção e 3182 tratamento da maioria das suas disfunções uroginecológicas, supõe-se que mulheres continentes 3183 apresentem força, resistência e coordenação dessa musculatura maior e melhor em relação a mulheres 3184 de mesma idade, características antropométricas e condição gestacional, porém incontinentes, cuja pior 3185 qualidade de funcionamento do assoalho contribuiria para sua condição clínica. 3186 3187 3188 3189

2. RELEVANCIA DA PROPOSTA 3190

Embora a função do assoalho pélvico seja fundamental para manutenção da qualidade de vida 3191 das mulheres, aproximadamente 45% delas não são capazes de contrair o assoalho pélvico 3192 voluntariamente e apenas 27%, apresentam uma contração involuntária antes do aumento da pressão 3193 intra-abdominal. Em muitos casos, a percepção da musculatura do assoalho pélvico é reduzida, o que, se 3194 não impossibilita, pelo menos dificulta a realização de tarefas aparentemente simples como a contração 3195 e o relaxamento dessa musculatura. A incontinência urinária é comum acometendo de 9 a 72% das 3196 mulheres de 17 a 79 anos, que varia de acordo com tipo de parto e o índice de massa corpórea. Ela tem 3197 sido frequentemente relacionada à fraqueza e a falta de coordenação da musculatura do assoalho 3198 pélvico. Da mesma forma que para as disfunções urinárias, a fraqueza dos músculos do assoalho pélvico 3199 pode causar disfunção sexual. Segundo a Organização Mundial de Saúde, a sexualidade humana forma 3200 parte integral da personalidade de cada um, é uma necessidade básica e um aspecto do ser que não 3201 pode ser separado dos outros aspectos da vida. 3202 O treinamento desses músculos pode melhorar a função sexual e tem sido preconizado como 3203 padrão ouro no tratamento e na prevenção das disfunções uroginecológicas e sexuais. Porém, em 3204 alguns casos, mesmo mulheres capazes de realizar as contrações e o treinamento proposto, ainda 3205 permanecem com algum grau de disfunção. Devido a grande complexidade do assoalho pélvico e a 3206 íntima relação deste com as disfunções uroginecológicas, a demanda por avaliações objetivas em 3207 biomecânica deve ser crescente. Aperfeiçoar o conhecimento científico nesta área de pesquisa poderá 3208 beneficiar mulheres em diversas fases de sua vida, agindo principalmente na prevenção e promoção da 3209 saúde, princípios norteadores do nosso sistema de saúde, o qual devemos almejar. 3210 Além disso, ao melhorar o conhecimento sobre o assoalho pélvico, inevitavelmente aborda-se a 3211 sexualidade, outro conceito deixado de lado pela maioria dos profissionais de saúde e que segundo a 3212 OMS, deveria ser considerada como direito humano básico. Desta forma, a atual equipe formada para 3213 desenvolver este projeto pretende unir o conhecimento e experiência clínica já estabelecidos há pelo 3214 menos 10 anos de investimento na área do projeto, com conhecimento biomecânico robusto de parte 3215 da equipe para o potencial êxito da proposta. 3216 3217

3. OBJETIVOS E HIPÓTESES DO PROJETO 3218

3.1. OBJETIVOS 3219 • Investigar a relação entre a distribuição espaço-temporal das cargas do assoalho pélvico 3220 feminino e a técnica de pompoarismo. 3221 • Investigar a relação entre a distribuição espaço-temporal das cargas no assoalho pélvico e a 3222 satisfação sexual. 3223

3.2. HIPÓTESES 3224 • As mulheres praticantes de pompoarismo apresentarão maior magnitude de pressão, 3225

resistência e melhor distribuição de cargas, em relação às não treinadas. 3226 • Mulheres com disfunção sexual apresentaram menor magnitude de pressão, resistência e 3227 alteração do padrão espacial de distribuição da pressão ao longo do canal vaginal 3228 3229

4. METODOLOGIA 3230

4.1. DESENHO EXPERIMENTAL 3231

Serão dois estudos laboratoriais transversais elaborados para responder os objetivos 1 e 2: 3232 (1) Dois grupos independentes onde o fator treinamento de pompoarismo (fator 3233 independente) será apresentado em dois níveis em: (i) mulheres com treinamento de 3234 pompoarismo, (ii) mulheres sem treinamento de pompoarismo 3235 (2) Dois grupos independentes onde o fator satisfação sexual (fator independente) será 3236 apresentado em dois níveis em: (i) mulheres sem insatisfação sexual relatada, (ii) 3237 mulheres com insatisfação sexual relatada. 3238 Os grupos independentes e fator medida repetida serão relacionados com o grupo de variáveis 3239 dependentes provindas da avaliação da força e pressão. As hipóteses a serem testadas para os grupos 3240 (dependentes ou independentes) estudados nos objetivos 1 e 2 serão: 3241 H0: λ1 = λ2 = 0 e 3242 HA: no mínimo um λi ≠ 0, 3243 onde λi, i = 1 e2 representando os efeitos do pompoarismo e da satisfação sexual. 3244

4.2. CASUÍSTICA 3245

Para responder ao objetivo 1 da proposta, serão avaliadas 20 mulheres nulíparas, igualmente 3246 divididas em 2 grupos: mulheres não praticantes e praticantes da técnica de pompoarismo há pelo 3247 menos 3 meses. Para responder ao objetivo 2 da proposta, serão recrutadas 30 mulheres igualmente 3248 divididas em 2 grupos: mulheres com disfunção sexual e mulheres sem disfunção sexual avaliadas e 3249 classificadas segundo o questionário Female Sexual Function Index (Anexo E). As voluntárias deste 3250 estudo serão recrutadas dentro do quadro de estudantes e funcionárias do departamento de 3251 Fisioterapia, Fonoaudiologia e Terapia Ocupacional da Faculdade de Medicina da USP, assim como do 3252 ambulatório de Fisioterapia do Hospital Universitário, e do serviço de ginecologia do mesmo Hospital. 3253 Todas as voluntárias serão informadas dos procedimentos desta pesquisa por meio de um termo de 3254 consentimento livre e esclarecido, elaborado conforme resolução 196/96 do Conselho Nacional de 3255 Saúde ficando uma cópia com o voluntário e outra com o pesquisador. Este termo obedece às 3256 características metodológicas e éticas orientadoras deste projeto. 3257 Para ambos objetivos, serão consideradas elegíveis mulheres: com idade entre 18 e 55 anos, que 3258 não estejam no climatério ou menopausa, não virgens, com índice de massa corporal abaixo de 29 3259 kg/m2, sem comorbidades neurológicas ou psicológicas que possam interferir na função do assoalho 3260

pélvico, prolapso genital acima de II de acordo com a classificação Pelvic Organ Prolapse Quantification 3261 (POP-Q), diagnóstico de vaginismo que impossibilite a avaliação intra-vaginal, infecção urinária, doenças 3262 venéreas, histórico de cirurgia vaginal ou abdominal e treinamento perineal. 3263

4.3. PROTOCOLO DE AVALIAÇÃO 3264

O protocolo será desenvolvido no Laboratório de Biomecânica do Movimento e Postura Humana 3265 do Departamento de Fisioterapia, Fonoaudiologia e Terapia Ocupacional da Faculdade de Medicina da 3266 Universidade de São Paulo, sendo constituído das seguintes etapas: (1) avaliação inicial, em que 3267 explicaremos os objetivos do estudo e, após a assinatura do termo de consentimento, realizaremos uma 3268 entrevista para checagem dos critérios de elegibilidade, tanto por questionários específicos de sintomas 3269 urogenitais, quanto por meio de avaliação física, e (2) avaliação da distribuição de cargas do assoalho 3270 pélvico por meio de um sistema de sensores capacitivos Pliance System (Novel, Munique, Alemanha). 3271

4.4. AVALIAÇÃO INICIAL 3272

As voluntárias elegíveis serão convocadas para uma visita onde serão informadas do escopo do 3273 estudo. Caso concordem em participar do mesmo, assinarão o termo de consentimento livre e 3274 esclarecido aprovado pela Comissão de Ética. Em seguida responderão a três breves questionários 3275 digitalizados e auto-administráveis, com caráter investigativo sobre possíveis sintomas uroginecológicos 3276 ou sexuais para checagem dos critérios de elegibilidade (Anexo E). 3277 O primeiro, King’s Health Questionnarie, é de fácil compreensão, vastamente utilizado e validado 3278 para a língua portuguesa (16, 17), desenvolvido pelo King's College Hospital em Londres, 3279 especificamente para avaliar e diagnosticar sintomas uroginecológicos. O segundo, Female Sexual 3280 Function Index (FSFI), já validado no Brasil (18), proposto por Rosen et al., em 2000 (19), nos Estados 3281 Unidos, para ser um instrumento de avaliação epidemiológica que respeita a natureza multidimensional 3282 da função sexual feminina. O FSFI é um questionário breve, que pode ser auto-aplicado, e que se propõe 3283 a avaliar a resposta sexual feminina em seis domínios: desejo sexual, excitação sexual, lubrificação 3284 vaginal, orgasmo, satisfação sexual e dor. Sua escala varia de 2 a 36, sendo que quanto menor a 3285 pontuação, maior a disfunção relatada. Vamos considerar aqui como disfunção sexual scores menores 3286 que 26 (20). Por fim, as voluntárias preencherão também uma fixa de avaliação, que consiste em 3287 questões de caracterização da amostra (como massa, idade e estatura) e de checagem dos critérios de 3288 elegibilidade (como a paridade, e o histórico de comorbidades ou cirurgias que comprometam a função 3289 perineal). 3290 Para a avaliação física as voluntárias receberão um avental e se posicionarão em decúbito dorsal 3291 com os joelhos fletidos, sobre uma maca. Em primeiro lugar, uma fisioterapeuta experiente dará 3292 instruções detalhadas sobre a contração dos músculos do assoalho pélvico e realizará, em seguida, o 3293 exame físico, constituído da inspeção do trofismo vaginal, distopias pélvicas, reflexos bulboesponjoso e 3294 anal, e da classificação funcional da musculatura do assoalho pélvico por meio da escala de Oxford (21) 3295

Tabela 1- Avaliação subjetiva da contração muscular perineal- Escala Oxford 3296 Avaliação subjetiva da contração muscular perineal – Esquema PERFECT Grau 0 - sem contração perineal visível, nem à palpação (ausência de contração). Grau 1 - esboço de contração muscular não sustentada, Grau 2 - contração de pequena intensidade, mas que se sustenta. Grau 3 - contração moderada, com aumento de pressão intravaginal, comprimindo P POWER os dedos, e apresentando pequena elevação da parede vaginal. Grau 4 - contração satisfatória, que aperta os dedos do examinador, com elevação da parede vaginal em direção à sínfise púbica. Grau 5 - contração forte, compressão firme dos dedos do examinador com movimento positivo em direção à sínfise púbica. a quantidade de tempo que a contração é mantida e sustentada, preferencialmente E ENDURANCE acima de 10 segundos. número de contrações mantidas repetidas 6 vezes, com 4 segundos de descanso R REPETITIONS entre elas. número das contrações rápidas (contração e relaxamento o mais rápido e o mais F FAST forte possível), medido após pelo menos um minuto de descanso, e acima de 10 contrações. 3297

4.5. ANÁLISE DA DISTRIBUIÇÃO DE CARGAS 3298

Caso enquadradas nos critérios de elegibilidade, as voluntárias passarão por uma avaliação 3299 objetiva da distribuição de cargas do assoalho pélvico por meio de um equipamento cilíndrico 3300 instrumentado com uma matriz de 10x10 sensores capacitivos (Pliance System - Novel, Munique, 3301 Alemanha). Esse equipamento tem resolução espacial de 1 cm2 (Figura 1), e fornece sinal 3302 correspondente a força de preensão dos músculos do assoalho pélvico (leitura de 0 a 200 KPa), 3303 permitindo um diagnóstico objetivo, fidedigno e multivetorial, capaz de identificar a magnitude, a 3304 distribuição espacial, temporal e a direção relativa da deformação da parede vaginal. O comprimento do 3305 probe foi definido com base em um levantamento prévio do comprimento vaginal de 63 mulheres. 3306 3307

3308 Figura 1- (A) probe vaginal cilíndrico com acabamento em cúpula e “trava” posicionada a 7cm do fim 3309 do sensor, coberto por matriz de 11x10 sensores capacitivos (Pliance System - Novel, 3310 Munique, Alemanha). (B) sistema Piance, com condicionador de sinais Bluetooth e bateria. 3311 3312 A avaliadora irá cobrir o probe com um preservativo não lubrificado, e utilizando-se de um 3313 lubrificante hipo-alergênico, irá inseri-lo 7cm ântero-posteriormente, para dentro do canal vaginal. Num 3314 primeiro momento, realizaremos a coleta de dados da força passiva do assoalho pélvico um minuto 3315 após a inserção do probe vaginal. Para isso, as voluntárias serão orientadas a respirar tranquilamente e 3316

relaxar o máximo possível seu assoalho pélvico. Como fizemos nos estudos piloto, utilizaremos esse 3317 parâmetro para checagem do tônus basal e futura calibração da força muscular. Em seguida 3318 realizaremos um treinamento da adequada contração perineal (não expulsiva) e instruiremos as 3319 voluntárias a contrair os músculos do assoalho pélvico o mais forte que puderem, sustentando essa 3320 contração por 10 segundos. Serão realizadas três contrações sustentadas de 10 segundos, com intervalo 3321 de um minuto entre as contrações. Por fim, após um intervalo de dois minutos, as voluntárias realizarão 3322 10 contrações rápidas controladas por um metrônomo (uma contração por segundo) (figura 2). Após 3323 utilização, o probe será higienizado conforme orientação da Comissão de Infecção Hospitalar e do 3324 fabricante. 3325

Inserção!do!probe!vaginal! ! Coleta!da!força!passiva!(10s)! ! Verificação!da!adequada! contração!perineal!(5min)! ! Coleta!da!contração! Repouso! Coleta!da!contração! Repouso! Coleta!da!contração! sustentada!(10s)! (1min)! sustentada!(10s)! (1min)! sustentada!(10s)!

Repouso! (2min)! ! 10!contrações!rápidas!(10s)! ! 3326 Figura 2- Fluxograma das etapas da coleta de dados. 3327

4.6. ANÁLISE MATEMÁTICA 3328

A aquisição, processamento e a exportação dos dados em ASCII será realizado por meio do 3329 software da Novel, Munique, Alemanha, e o tratamento matemático dos dados será feito por meio de 3330 uma rotina matemática em linguagem Matlab elaborada para este fim. As séries temporais de força e 3331 pressão serão analisadas separadamente para 8 áreas selecionadas (figura 3) e variáveis discretas 3332 calculadas, como a força e pressão máximas, integrais, taxas de força e forças relativas. 3333

Cranial' Cranial' Cranial' Cranial' anterior' esquerda' posterior' direita'

Caudal' Caudal' Caudal' Caudal' anterior' esquerda' posterior' direita' 3334 ' Figura 3. Regiões selecionadas para análise temporal da força e pressão da parede vaginal: anterior, 3335 posterior, esquerda e direita, todas elas divididas em nas regiões cranial e caudal 3336

4.7. ANÁLISE ESTATÍSTICA 3337

A priori, será verificada a normalidade dos dados por meio do teste de aderência de Shapiro Wilk. 3338 Com a finalidade de descrever o perfil da amostra, serão feitas tabelas de frequência para as variáveis 3339 categóricas e estatísticas descritivas para as variáveis biomecânicas estudadas. A posteriori, será 3340 realizada uma análise de variância one-way sendo o fator independente o grupo, seguidas de testes post 3341 hoc de Newman-Keuls. Serão consideradas as diferenças estatísticas com nível de significância igual a 3342 5% (α = 0,05). O tratamento estatístico será realizado no programa Statistica v.10 (Statsoft Inc.). 3343 3344

5. ETAPAS PARA O DESENVOLVIMENTO DO PROJETO - CRONOGRAMA 3345

O projeto será desenvolvido em 4 anos: 3346 Tabela 1 - Cronograma para as etapas do projeto. 3347

2º sem 1º sem 2º sem 1º sem 2º sem 1º sem Atividade Período 2013 2014 2014 2015 2015 2016 Revisão e atualização de literatura X X X X X X Importação do equipamento de pressão X Treinamento da equipe no equipamento X Definição do protocolo de coleta de dados X Experimento piloto X Coleta de dados X X Análise matemática e estatística das variáveis X Interpretação e discussão dos resultados X X Elaboração de artigos e textos de divulgação X X Elaboração do texto final e relatório final X 3348

6. REFERÊNCIAS BIBLIOGRÁFICAS 3349

1. Sapsford R. Rehabilitation of pelvic floor muscles utilizing trunk stabilization. Man Ther. 2004;9(1):3- 3350 12. 3351 2. Ashton-Miller JA, Delancey JOL. Functional anatomy of the female pelvic floor. Reproductive 3352 Biomechanics. 2007;1101:266-96. 3353 3. Kim KJ, Ashton-Miller JA, Strohbehn K, DeLancey JO, Schultz AB. The vesico-urethral pressuregram 3354 analysis of urethral function under stress. J Biomech. 1997;30(1):19-25. 3355 4. Rud T, Andersson KE, Asmussen M, Hunting A, Ulmsten U. Factors maintaining the intraurethral 3356 pressure in women. Invest Urol. 1980;17(4):343-7. 3357 5. Strohbehn K, Quint LE, Prince MR, Wojno KJ, Delancey JO. Magnetic resonance imaging anatomy of 3358 the female urethra: a direct histologic comparison. Obstet Gynecol. 1996;88(5):750-6. 3359 6. Kearney R, Sawhney R, DeLancey JO. Levator ani muscle anatomy evaluated by origin-insertion pairs. 3360 Obstet Gynecol. 2004;104(1):168-73. 3361 7. Wallner C, Dabhoiwala NF, DeRuiter MC, Lamers WH. The anatomical components of urinary 3362 continence. Eur Urol. 2009;55(4):932-43. 3363 8. Schaer GN, Koechli OR, Schuessler B, Haller U. Perineal ultrasound for evaluating the bladder neck in 3364

urinary stress-incontinence. Obstetrics and Gynecology. 1995;85(2):220-4. 3365 9. Azpiroz F, Fernandez-Fraga X, Merletti R, Enck P. The puborectalis muscle. Neurogastroenterol Motil. 3366 2005;17 Suppl 1:68-72. 3367 10. Fernandez-Fraga X, Azpiroz F, Malagelada JR. Significance of pelvic floor muscles in anal 3368 incontinence. Gastroenterology. 2002;123(5):1441-50. 3369 11. Voorham-van der Zalm PJ, Lycklama A Nijeholt GA, Elzevier HW, Putter H, Pelger RC. "Diagnostic 3370 investigation of the pelvic floor": a helpful tool in the approach in patients with complaints of 3371 micturition, defecation, and/or sexual dysfunction. J Sex Med. 2008;5(4):864-71. 3372 12. Talasz H, Himmer-Perschak G, Marth E, Fischer-Colbrie J, Hoefner E, Lechleitner M. Evaluation of 3373 pelvic floor muscle function in a random group of adult women in Austria. Int Urogynecol J Pelvic 3374 Floor Dysfunct. 2008;19(1):131-5. 3375 13. Abrams P, Andersson KE, Birder L, Brubaker L, Cardozo L, Chapple C, et al. Fourth International 3376 Consultation on Incontinence Recommendations of the International Scientific Committee: 3377 Evaluation and treatment of urinary incontinence, pelvic organ prolapse, and fecal incontinence. 3378 Neurourol Urodyn. 2010;29(1):213-40. 3379 14. Freeman RM. The role of pelvic floor muscle training in urinary incontinence. BJOG. 2004;111 Suppl 3380 1:37-40. 3381 15. Dumoulin C, Hay-Smith J. Pelvic floor muscle training versus no treatment, or inactive control 3382 treatments, for urinary incontinence in women. Cochrane Database Syst Rev. 2010(1):CD005654. 3383 16. Hunskaar S, Burgio K, Diokno A, Herzog AR, Hjalmas K, Lapitan MC. Epidemiology and natural history 3384 of urinary incontinence in women. Urology. 2003;62(4A):16-23. 3385 17. Donaldson MM, Thompson JR, Matthews RJ, Dallosso HM, McGrother CW, Group LMIS. The natural 3386 history of overactive bladder and stress urinary incontinence in older women in the community: a 3- 3387 year prospective cohort study. Neurourol Urodyn. 2006;25(7):709-16. 3388 18. Quartly E, Hallam T, Kilbreath S, Refshauge K. Strength and endurance of the pelvic floor muscles in 3389 continent women: an observational study. Physiotherapy. 2010;96(4):311-6. 3390 19. Chiarelli P, Brown W, McElduff P. Leaking urine: prevalence and associated factors in Australian 3391 women. Neurourol Urodyn. 1999;18(6):567-77. 3392 20. Wilson PD, Herbison RM, Herbison GP. Obstetric practice and the prevalence of urinary incontinence 3393 three months after delivery. British Journal of Obstetrics and Gynaecology. 1996;103(2):154-61. 3394 21. Subak LL, Richter HE, Hunskaar S. Obesity and urinary incontinence: epidemiology and clinical 3395 research update. J Urol. 2009;182(6 Suppl):S2-7. 3396 22. Richter HE, Kenton K, Huang L, Nygaard I, Kraus S, Whitcomb E, et al. The impact of obesity on 3397 urinary incontinence symptoms, severity, urodynamic characteristics and quality of life. J Urol. 3398 2010;183(2):622-8. 3399 23. Kearney R, Miller JM, Ashton-Miller JA, DeLancey JOL. Obstetric factors associated with levator ani 3400 muscle injury after vaginal birth. Obstetrics and Gynecology. 2006;107(1):144-9. 3401 24. Baracho SM, Barbosa da Silva L, Baracho E, Lopes da Silva Filho A, Sampaio RF, Mello de Figueiredo E. 3402 Pelvic floor muscle strength predicts stress urinary incontinence in primiparous women after vaginal 3403 delivery. Int Urogynecol J. 2012;23(7):899-906. 3404 25. Persson J, Wolner-Hanssen P, Rydhstroem H. Obstetric risk factors for stress urinary incontinence: a 3405 population-based study. Obstet Gynecol. 2000;96(3):440-5. 3406 26. Viktrup L, Rortveit G, Lose G. Risk of stress urinary incontinence twelve years after the first 3407 pregnancy and delivery. Obstet Gynecol. 2006;108(2):248-54. 3408 27. King JK, Freeman RM. Is antenatal bladder neck mobility a risk factor for postpartum stress 3409 incontinence? Br J Obstet Gynaecol. 1998;105(12):1300-7. 3410 28. Snooks SJ, Swash M, Setchell M, Henry MM. Injury to innervation of pelvic floor sphincter 3411 musculature in childbirth. Lancet. 1984;2(8402):546-50. 3412

29. Weidner AC, Jamison MG, Branham V, South MM, Borawski KM, Romero AA. Neuropathic injury to 3413 the levator ani occurs in 1 in 4 primiparous women. Am J Obstet Gynecol. 2006;195(6):1851-6. 3414 30. DeLancey JO, Kearney R, Chou Q, Speights S, Binno S. The appearance of levator ani muscle 3415 abnormalities in magnetic resonance images after vaginal delivery. Obstet Gynecol. 2003;101(1):46- 3416 53. 3417 31. Dietz HP, Lanzarone V. Levator trauma after vaginal delivery. Obstet Gynecol. 2005;106(4):707-12. 3418 32. Shek KL, Dietz HP. Intrapartum risk factors for levator trauma. BJOG. 2010;117(12):1485-92. 3419 33. Dietz HP, Bond V, Shek KL. Does childbirth alter the reflex pelvic floor response to coughing? 3420 Ultrasound Obstet Gynecol. 2012;39(5):569-73. 3421 34. Heilbrun ME, Nygaard IE, Lockhart ME, Richter HE, Brown MB, Kenton KS, et al. Correlation between 3422 levator ani muscle injuries on magnetic resonance imaging and fecal incontinence, pelvic organ 3423 prolapse, and urinary incontinence in primiparous women. Am J Obstet Gynecol. 3424 2010;202(5):488.e1-6. 3425 35. Bo K, Lilleas F, Talseth T, Hedland H. Dynamic MRI of the pelvic floor muscles in an upright sitting 3426 position. Neurourology and Urodynamics. 2001;20(2):167-74. 3427 36. Sherburn M, Murphy CA, Carroll S, Allen TJ, Galea MP. Investigation of transabdominal real-time 3428 ultrasound to visualise the muscles of the pelvic floor. Aust J Physiother. 2005;51(3):167-70. 3429 37. Lose G, Fantl JA, Victor A, Walter S, Wells TL, Wyman J, et al. Outcome measures for research in adult 3430 women with symptoms of lower urinary tract dysfunction. Acta Obstetricia Et Gynecologica 3431 Scandinavica. 2001;80(11):981-5. 3432 38. Laycock J, Jerwood D. Pelvic floor muscle assessment: The PERFECT scheme Physiotherapy. 3433 2001;87(12):631-42. 3434 39. Eckardt VF, Kanzler G. How reliable is digital examination for the evaluation of anal-sphincter tone. 3435 International Journal of Colorectal Disease. 1993;8(2):95-7. 3436 40. Bø K, Talseth T. Long-term effect of pelvic floor muscle exercise 5 years after cessation of organized 3437 training. Obstet Gynecol. 1996;87(2):261-5. 3438 41. Bo K, Finckenhagen HB. Vaginal palpation of pelvic floor muscle strength: inter-test reproducibility 3439 and comparison between palpation and vaginal squeeze pressure. Acta Obstetricia Et Gynecologica 3440 Scandinavica. 2001;80(10):883-7. 3441 42. Rahmani N, Mohseni-Bandpei MA. Application of perineometer in the assessment of pelvic floor 3442 muscle strength and endurance: a reliability study. J Bodyw Mov Ther. 2011;15(2):209-14. 3443 43. Dorey G, Speakman M, Feneley R, Swinkels A, Dunn C, Ewings P. Randomised controlled trial of 3444 pelvic floor muscle exercises and manometric biofeedback for erectile dysfunction. Br J Gen Pract. 3445 2004;54(508):819-25. 3446 44. Friedman S, Blomquist JL, Nugent JM, McDermott KC, Muñoz A, Handa VL. Pelvic muscle strength 3447 after childbirth. Obstet Gynecol. 2012;120(5):1021-8. 3448 45. Theofrastous JP, Wyman JF, Bump RC, McClish DK, Elser DM, Bland DR, et al. Effects of pelvic floor 3449 muscle training on strength and predictors of response in the treatment of urinary incontinence. 3450 Neurourol Urodyn. 2002;21(5):486-90. 3451 46. Constantinou CE, Omata S. Direction sensitive sensor probe for the evaluation of voluntary and 3452 reflex pelvic floor contractions. Neurourol Urodyn. 2007;26(3):386-91. 3453 47. Morin M, Dumoulin C, Gravel D, Bourbonnais D, Lemieux MC. Reliability of speed of contraction and 3454 endurance dynamometric measurements of the pelvic floor musculature in stress incontinent parous 3455 women. Neurourol Urodyn. 2007;26(3):397-403; discussion 4. 3456 48. Morin M, Dumoulin C, Bourbonnais D, Gravel D, Lemieux MC. Pelvic floor maximal strength using 3457 vaginal digital assessment compared to dynamometric measurements. Neurourology and 3458 Urodynamics. 2004;23(4):336-41. 3459 49. Morin M, Bourbonnais D, Gravel D, Dumoulin C, Lemieux MC. Pelvic floor muscle function in 3460

continent and stress urinary incontinent women using dynamometric measurements. Neurourol 3461 Urodyn. 2004;23(7):668-74. 3462 50. Miller JM, Ashton-Miller JA, Perruchini D, DeLancey JO. Test-retest reliability of an instrumented 3463 speculum for measuring vaginal closure force. Neurourol Urodyn. 2007;26(6):858-63. 3464 51. Bø K, Sherburn M. Evaluation of female pelvic-floor muscle function and strength. Phys Ther. 3465 2005;85(3):269-82. 3466 52. Haylen BT, de Ridder D, Freeman RM, Swift SE, Berghmans B, Lee J, et al. An International 3467 Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the 3468 terminology for female pelvic floor dysfunction. Neurourol Urodyn. 2010;29(1):4-20. 3469 53. Berghmans B. [The role of the pelvic physical therapist]. Actas Urol Esp. 2006;30(2):110-22. 3470 54. Boyle R, Hay-Smith EJC, Cody JD, Morkved S. Pelvic floor muscle training for prevention and 3471 treatment of urinary and faecal incontinence in antenatal and postnatal women. Cochrane Database 3472 of Systematic Reviews. 2012(10). 3473 55. Neumann PB, Grimmer KA, Deenadayalan Y. Pelvic floor muscle training and adjunctive therapies for 3474 the treatment of stress urinary incontinence in women: a systematic review. BMC Womens Health. 3475 2006;6:11. 3476 56. Bø K, Talseth T, Vinsnes A. Randomized controlled trial on the effect of pelvic floor muscle training 3477 on quality of life and sexual problems in genuine stress incontinent women. Acta Obstet Gynecol 3478 Scand. 2000;79(7):598-603. 3479 57. Barber MD, Dowsett SA, Mullen KJ, Viktrup L. The impact of stress urinary incontinence on sexual 3480 activity in women. Cleve Clin J Med. 2005;72(3):225-32. 3481 58. Bø K. Pelvic floor muscle training is effective in treatment of female stress urinary incontinence, but 3482 how does it work? Int Urogynecol J Pelvic Floor Dysfunct. 2004;15(2):76-84. 3483 59. Braekken IH, Hoff Braekken I, Majida M, Engh ME, Bø K. Morphological changes after pelvic floor 3484 muscle training measured by 3-dimensional ultrasonography: a randomized controlled trial. Obstet 3485 Gynecol. 2010;115(2 Pt 1):317-24. 3486 60. Delancey JOL. Structural aspects of urethrovesical function in the female. Neurourology and 3487 Urodynamics. 1988;7(6):509-19. 3488 61. Peschers UM, Vodusek DB, Fanger G, Schaer GN, DeLancey JOL, Schuessler B. Pelvic muscle activity in 3489 nulliparous volunteers. Neurourology and Urodynamics. 2001;20(3):269-75. 3490 62. Miller JM, Sampselle C, Ashton-Miller J, Hong GR, DeLancey JO. Clarification and confirmation of the 3491 Knack maneuver: the effect of volitional pelvic floor muscle contraction to preempt expected stress 3492 incontinence. Int Urogynecol J Pelvic Floor Dysfunct. 2008;19(6):773-82. 3493 63. Shafik A, Shafik IA. Overactive bladder inhibition in response to pelvic floor muscle exercises. World J 3494 Urol. 2003;20(6):374-7. 3495 64. Reilly ET, Freeman RM, Waterfield MR, Waterfield AE, Steggles P, Pedlar F. Prevention of postpartum 3496 stress incontinence in primigravidae with increased bladder neck mobility: a randomised controlled 3497 trial of antenatal pelvic floor exercises. BJOG. 2002;109(1):68-76. 3498 65. Sahakian J. Stress incontinence and pelvic floor exercises in pregnancy. Br J Nurs. 2012;21(18):S10, 3499 S2-5. 3500 66. Shek KL, Chantarasorn V, Langer S, Phipps H, Dietz HP. Does the Epi-No Birth Trainer reduce levator 3501 trauma? A randomised controlled trial. Int Urogynecol J. 2011;22(12):1521-8. 3502 67. Ruckhäberle E, Jundt K, Bäuerle M, Brisch KH, Ulm K, Dannecker C, et al. Prospective randomised 3503 multicentre trial with the birth trainer EPI-NO for the prevention of perineal trauma. Aust N Z J 3504 Obstet Gynaecol. 2009;49(5):478-83. 3505 68. Hillebrenner J, Wagenpfeil S, Schuchardt R, Schelling M, Schneider KT. [Initial experiences with 3506 primiparous women using a new kind of Epi-no labor trainer]. Z Geburtshilfe Neonatol. 3507 2001;205(1):12-9. 3508

69. Svabík K, Shek KL, Dietz HP. How much does the levator hiatus have to stretch during childbirth? 3509 BJOG. 2009;116(12):1657-62. 3510 70. Hilde G, Stær-Jensen J, Siafarikas F, Engh ME, Brækken IH, Bø K. Impact of childbirth and mode of 3511 delivery on vaginal resting pressure and on pelvic floor muscle strength and endurance. Am J Obstet 3512 Gynecol. 2013;208(1):50.e1-7. 3513 71. Hansen BB, Svare J, Viktrup L, Jørgensen T, Lose G. Urinary incontinence during pregnancy and 1 year 3514 after delivery in primiparous women compared with a control group of nulliparous women. 3515 Neurourol Urodyn. 2012;31(4):475-80. 3516 72. Rosenbaum TY. Physiotherapy treatment of sexual pain disorders. J Sex Marital Ther. 3517 2005;31(4):329-40. 3518 73. Glazer HI, Rodke G, Swencionis C, Hertz R, Young AW. Treatment of vulvar vestibulitis syndrome with 3519 electromyographic biofeedback of pelvic floor musculature. J Reprod Med. 1995;40(4):283-90. 3520 74. Zahariou AG, Karamouti MV, Papaioannou PD. Pelvic floor muscle training improves sexual function 3521 of women with stress urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct. 2008;19(3):401-6. 3522 75. Alves S. Pompoar a arte de amar. 1 ed. São Paulo, SP. Brazil2006. 3523 76. Petrofsky JS, Phillips CA. The effect of elbow angle on the isometric strength and endurance of the 3524 elbow flexors in men and women. J Hum Ergol (Tokyo). 1980;9(2):125-31. 3525 77. Sarwar R, Niclos BB, Rutherford OM. Changes in muscle strength, relaxation rate and fatiguability 3526 during the human menstrual cycle. J Physiol. 1996;493 ( Pt 1):267-72. 3527 78. Ortiz OC, Nuñes FC, Ibañez G. Evaluacion funcional del piso pelviano femenino. Boletim de La 3528 Sociedad Latinoamericana de Uroginecologia y Cirugia Vaginal. 1996;3 e 4:5-9. 3529 79. Bø K. Pressure measurements during pelvic floor muscle contractions. Neurourol Urodyn. 1992;11:6. 3530 80. Kelleher CJ, Cardozo LD, Khullar V, Salvatore S. A new questionnaire to assess the quality of life of 3531 urinary incontinent women. Br J Obstet Gynaecol. 1997;104(12):1374-9. 3532 81. Tamanini JT, D'Ancona CA, Botega NJ, Rodrigues Netto N. [Validation of the Portuguese version of 3533 the King's Health Questionnaire for urinary incontinent women]. Rev Saude Publica. 2003;37(2):203- 3534 11. 3535 82. Abdo CHN. Elaboração e validação do quociente sexual - versão feminina: uma escala para avaliar a 3536 função sexual da mulher. Rev Bras Med. 2006;63(9):477-82. 3537 3538

APPENDIX B – ETHICS COMMITTEE APPROVAL 3539

3540

FACULDADE DE MEDICINA DA UNIVERSIDADE DE SÃO PAULO - FMUSP

PARECER CONSUBSTANCIADO DO CEP

DADOS DO PROJETO DE PESQUISA

Título da Pesquisa: ANÁLISE DA DISTRIBUIÇÃO MULTIVETORIAL DE CARGAS DO ASSOALHO PÉLVICO FEMININO EM DIFERENTES POPULAÇÕES Pesquisador: Isabel C. N. Sacco Área Temática: Versão: 3 CAAE: 17787813.1.0000.0065 Instituição Proponente: Faculdade de Medicina da Universidade de São Paulo Patrocinador Principal: FUNDACAO DE AMPARO A PESQUISA DO ESTADO DE SAO PAULO

DADOS DO PARECER

Número do Parecer: 667.528 Data da Relatoria: 29/05/2014

Apresentação do Projeto: Não foi realizada nenhuma alteração do Projeto. Apenas foi selecionada a segunda opção de submissão de emenda segundo orientação da Instituição Coparticipante, para que eles possam visualizar a documentação

Objetivo da Pesquisa: Conforme parecer anterior Avaliação dos Riscos e Benefícios: Conforme parecer anterior Comentários e Considerações sobre a Pesquisa: Conforme parecer anterior Considerações sobre os Termos de apresentação obrigatória: Conforme parecer anterior Recomendações: Conforme parecer anterior Conclusões ou Pendências e Lista de Inadequações: Conforme parecer anterior

Endereço: DOUTOR ARNALDO 251 21º andar sala 36 Bairro: PACAEMBU CEP: 01.246-903 UF: SP Município: SAO PAULO Telefone: (11)3893-4401 E-mail: [email protected]

Página 01 de 02 3541

FACULDADE DE MEDICINA DA UNIVERSIDADE DE SÃO PAULO - FMUSP

Continuação do Parecer: 667.528

Situação do Parecer: Aprovado Necessita Apreciação da CONEP: Não Considerações Finais a critério do CEP: Conforme parecer anterior

SAO PAULO, 29 de Maio de 2014

Assinado por: Roger Chammas (Coordenador)

Endereço: DOUTOR ARNALDO 251 21º andar sala 36 Bairro: PACAEMBU CEP: 01.246-903 UF: SP Município: SAO PAULO Telefone: (11)3893-4401 E-mail: [email protected]

Página 02 de 02 3542

APPENDIX C - AWARDS 3543

3544

3545

3546

3547

3548