Advertisement

Inappropriate pelvic floor muscle activation during forced exhalation and coughing in elderly female inpatients with urinary incontinence

      Abstract

      Background

      Reduced pelvic floor muscle (PFM) contraction strength is a common condition in elderly female patients with urinary incontinence (UI). However, little data exist to demonstrate the importance of appropriate PFM activation during exhaling and coughing.

      Objectives

      To analyse breathing and coughing patterns in elderly female inpatients with UI, and to assess PFM activation patterns during exhalation and coughing.

      Design

      Retrospective chart data analysis.

      Patients and methods

      Data from 177 elderly female inpatients with UI were analysed to determine voluntary PFM contraction strength, as well as PFM activation and displacement of the pelvic floor (PF) and abdominal wall during forced exhalation and coughing. Clinical data were obtained by means of inspection and digital palpation in the course of a routine clinical UI assessment. Data collected were correlated with age, body mass index and number of childbirths, and categorised by predominant UI symptoms, history of previous hysterectomy and history of PFM training.

      Results

      Independent of voluntary PFM contraction strength, nearly all patients (n = 168) demonstrated bulging of the abdominal wall and PF during forced exhalation and coughing instead of contracting the PFMs and consequently lifting the PF, which would be in accordance with physiological breathing synergies. None of the nine women who reflexively contracted the PFM physiologically in accordance with an expiratory breathing pattern complained of symptoms of stress UI alone.

      Conclusion

      A high percentage of elderly females with UI do not activate their PFMs appropriately during forced exhalation and coughing, possibly contributing to or exacerbating UI.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic and Personal
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Physiotherapy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Wagg A.
        • Kung Chen L.
        • Johnson T.
        • Kirschner-Hermanns R.
        • Kuchel G.
        • Markland A.
        • et al.
        Incontinence in frail older persons.
        in: Abrams P. Cardozo L. Wagg A. Wein A. Incontinence, 6th international consultation on incontinence. 2016: 1309-1369 (Tokyo)
        • Resnick N.M.
        • Yalla S.V.
        Detrusor hyperactivity with impaired contractile function. An unrecognized but common cause of incontinence in elderly patients.
        JAMA. 1987; 257: 3076-3081
        • Becher K.
        • Bojack B.
        • Ege S.
        • von der Heide S.
        • Kirschner-Hermanns R.
        • Wiedemann A.
        S2e-Leitlinie Harninkontinenz bei geriatrischen Patienten.
        2019 (Available from: https://www.awmf.org/uploads/tx_szleitlinien/084-001l_S2e_Harninkontinenz_geriatrische_Patienten_Diagnostik-Therapie_2019-01.pdf [accessed 29.11.20])
        • Bø K.
        • Sherburn M.
        Evaluation of female pelvic-floor muscle function and strength.
        Phys Ther. 2005; 85: 269-282
        • Castro Diaz D.
        • Robinson D.
        • Bosch R.
        • Constantini E.
        • Cotterill N.
        • Espuna-Pons M.
        • et al.
        Initial assessment of urinary incontinence in adult male and female patients.
        in: Abrams P. Cardozo L. Wagg A. Wein A. Incontinence, 6th international consultation on incontinence. 2016: 514-520 (Tokyo)
        • Messelink B.
        • Benson T.
        • Berghmans
        • Bo K.
        • Corcos J.
        • Fowler C.
        • et al.
        Standardisation of terminology of pelvic floor muscle function and dysfunction: report from the Pelvic Floor Clinical Assessment Group of the International Continence Society.
        Neurourol Urodyn. 2005; 24: 374-380
        • Bø K.
        Pelvic floor muscle training is effective in treatment of female stress urinary incontinence, but how does it work?.
        Int Urogynecol J. 2004; 15: 76-84
        • Shafik A.
        • Shafik I.A.
        Overactive bladder inhibition in response to pelvic floor muscle exercises.
        World J Urol. 2003; 20: 374-377
        • Bø K.
        • Fernandes A.C.N.L.
        • Duarte T.B.
        • Brito L.G.O.
        • Ferreira C.H.J.
        Is pelvic floor muscle training effective for symptoms of overactive bladder in women? A systematic review.
        Physiotherapy. 2020; 106: 65-76
        • Sapsford R.
        Rehabilitation of pelvic floor muscles utilizing trunk stabilization.
        Man Ther. 2004; 9: 3-12
        • Hodges P.W.
        • Sapsford R.R.
        • Pegel L.H.M.
        Postural and respiratory functions of the pelvic floor muscles.
        Neurourol Urodyn. 2007; 26: 362-371
        • Talasz H.
        • Kremser C.
        • Kofler M.
        • Kalchschmid E.
        • Lechleitner M.
        • Rudisch A.
        Phase-locked parallel movement of diaphragm and pelvic floor during breathing and coughing – a dynamic MRI investigation in healthy females.
        Int Urogynecol J. 2011; 22: 61-68
        • Talasz H.
        • Kofler M.
        • Kalchschmid E.
        • Pretterklieber M.
        • Lechleitner M.
        Breathing with the pelvic floor? Correlation of pelvic floor muscle function and expiratory flows in healthy young nulliparous women.
        Int Urogynecol J. 2010; 21: 475-548
        • Borley N.R.
        Abdomen and pelvis.
        in: Standring S. Gray's anatomy. 39th ed. Elsevier, Edinburgh2005: 1041-1047
        • Gatzoulis M.A.
        Diaphragm.
        in: Standring S. Gray's anatomy. 39th ed. Elsevier, Edinburgh2005: 1007-1012
        • Park H.
        • Han D.
        The effect of the correlation between the contraction of the pelvic floor muscles and diaphragmatic motion during breathing.
        J Phys Ther Sci. 2015; 27: 2113-2115
        • McCool F.
        Global physiology and pathophysiology of cough. ACCP evidence-based clinical practice guidelines.
        Chest. 2006; 129: 48-53
        • Talasz H.
        • Jansen S.C.
        • Kofler M.
        • Lechleitner M.
        High prevalence of pelvic floor muscle dysfunction in hospitalized elderly women with urinary incontinence.
        Int Urogynecol J. 2012; 23: 1231-1237
        • Laycock J.
        • Whelan M.M.
        • Dumoulin C.
        Patient assessment.
        in: Haslam J. Laycock J. Therapeutic management of incontinence and pelvic pain. 2nd ed. Springer, London2008: 57-66
        • Laycock J.
        Concept of neuromuscular rehabilitation and pelvic floor muscle training.
        in: Baesler K. Schuessler B. Burgio K.L. Moore K.H. Norton P.A. Stanton S.L. Pelvic floor re-education. Springer, London2009: 179-180
        • Talasz H.
        • Kremser C.
        • Kofler M.
        • Kalchschmid E.
        • Lechleitner M.
        • Rudisch A.
        Proof of concept: differential effects of Valsalva and straining maneuvers on the pelvic floor.
        Eur J Obstet Gynecol Reprod Biol. 2012; 164: 227-233
        • Bø K.
        • Frawley H.
        • Haylen B.
        • Abramov Y.
        • Almeida F.G.
        • Berghmans B.
        • et al.
        An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for the conservative and non-pharmacological management of female pelvic floor dysfunction.
        Neurourol Urodyn. 2018; 36: 221-244
        • Kruger J.
        • Budgett D.
        • Goodman J.
        • Bø K.
        Can you train the pelvic floor muscles by contracting other related muscles?.
        Neurourol Urodyn. 2019; 38: 677-683
        • Madill S.J.
        • Pontbriand-Drolet S.
        • Tang A.
        • Dumoulin C.
        Effects of PFM rehabilitation on PFM function and morphology in older women.
        Neurourol Urodyn. 2013; 32: 1086-1095
        • Miller J.M.
        • Ashton-Miller J.A.
        • DeLancey J.O.
        A pelvic muscle pre-contraction can reduce cough-related urine loss in selected women with mild SUI.
        J Am Geriatr Soc. 1998; 46: 870-874
        • Bordoni B.
        • Zanier E.
        Anatomic connections of the diaphragm: influence of respiration on the body systems.
        J Multidiscip Health Care. 2013; 24: 281-291
        • Fiammetti R.
        Respiration totale animation.
        2013 (Available from: https://www.youtube.com/watch?v=JexU_-7PYCI [accessed 29.11.20])
        • Kitani L.
        • Apte G.
        • Dedrick G.
        • Sizer P.
        • Brismée J.M.
        Effect of variations in forced expiration effort on pelvic floor activation in asymptomatic women.
        J Womens Health Phys Ther. 2014; 38: 19-27
        • Park H.
        • Hwang B.
        • Kim Y.S.
        The impact of the pelvic floor muscles on dynamic ventilation maneuvers.
        J Physiol Ther Sci. 2015; 27: 3155-3157
        • Emerich Gordon K.
        • Reed O.
        The role of the pelvic floor in respiration: a multidisciplinary literature review.
        J Voice. 2020; 34: 243-249
        • Luginbuehl H.
        • Baeyens J.P.
        • Kuhn A.
        • Christen R.
        • Oberli B.
        • Eichelberger P.
        • et al.
        Pelvic floor muscle reflex activity during coughing – an exploratory and reliability study.
        Ann Phys Rehabil Med. 2016; 59: 302-307
        • Vieira G.F.
        • Saltiel F.
        • Miranda-Gazzola A.P.G.
        • Kirkwood R.N.
        • Figueiredo E.M.
        Pelvic floor muscle function in women with and without urinary incontinence: are strength and endurance the only relevant functions? A cross-sectional study.
        Physiotherapy. 2020; 109: 85-93