Pelvic-floor muscle function in women with pelvic organ prolapse.

Pelvic organ prolapse is the descent of the apex of the vagina or cervix (or vaginal vault after hysterectomy), anterior vaginal wall (previously referred to as "cystocele"), or posterior vaginal wall (previously called "rectocele"). (1) As prolapse progresses, organs can protrude outside the vaginal canal. This condition is common, with some degree of prolapse seen in 94% of women. (2) The lifetime risk of tmdergoing surgery for prolapse or urinary incontinence is approximately 11.1% by age 80 years. (3) Women with advanced pelvic organ prolapse are more likely to feel self-conscious and less physically and sexually attractive than women without this condition. In addition, they score poorer on both generic and condition-specific quality-of-life (QOL) scales. (4) About one third of sexually active women with pelvic organ prolapse report that their condition interferes with sexual function. (5,6)

Normal support of the pelvic organs depends on the integrity of the pelvic-floor muscles, the supportive connective tissue of the vagina (the endopelvic fascia and the uterosacral and cardinal ligaments), and normal innervation. (7) The pelvic-floor muscles include the pubococcygeus, puborectalis, and iliococcygeus (collectively known as the levator ani muscles). (8) When functioning properly, tonic and voluntary activity of the levator ani muscles narrows the urogenital hiatus and draws the urethra, vagina, and rectum toward the pubic bone. In this situation, the supporting connective tissues experience minimal tension. Loss of levator ani muscle function has been proposed as a mechanism for prolapse. (7) As muscular support is lost, the urogenital hiatus widens and connective tissue support, under tension, become stretched or torn, thus leading to prolapse. (7)

Loss of pelvic-floor muscle support is only one of the many risk factors for developing prolapse. (9,10) Samuelsson et a1 (11) investigated factors related to prolapse in 487 Swedish women who were receiving gynecologic care. Among multiple variables, age, parity, and pelvic-floor muscle strength (force-generating capacity, as estimated by vaginal palpation) were associated with prolapse. However, only 2% of the women in the study by Samuelsson et al had pelvic organ prolapse severe enough to reach the vaginal introitus.

In a study of 358 women after prolapse surgery, Vakili et al (12) found that women with greater preoperative pelvic-floor muscle strength (as assessed by vaginal palpation) had less recurrent prolapse and were less likely to have repeat surgery. Because of the retrospective nature of this study, missing data led to the elimination of some cases, potentially introducing a selection bias. Given the limitations of both studies, (11,12) further investigation toward understanding the relationship between pelvic-floor muscle function and pelvic organ prolapse and its effect on QOL and sexual function is needed.

Understanding the degree of risk that a given factor contributes to the etiology of prolapse is important in both prevention and intervention. A recent randomized controlled study including pelvic floor muscle exercise as an adjunct to surgery for pelvic organ prolapse or urinary incontinence demonstrated improvements in continence status, diurnal urinary frequency, pelvic floor muscle strength, and QOL. (13) However, the effectiveness of pelvic floor muscle exercise alone as an intervention for pelvic organ prolapse had not been determined. (14) Exploring the relationship of pelvic-floor muscle function and prolapse is a preliminary step toward answering this question. The aim of this prospective study was to determine whether prolapse severity; pelvic symptoms; condition-specific, health-related QOL; and sexual function differ based on pelvic-floor muscle strength in women who are planning to have surgery for prolapse. We hypothesized that women with better pelvic-floor muscles function would have less severe prolapse, fewer pelvic symptoms, and better QOL and sexual function.

Method

Subjects

This study was conducted by the Pelvic Floor Disorders Network (PFDN), sponsored by the National Institute for Child Health and Human Development. Data for this study came from preoperative assessments that were conducted in 317 of the 322 women enrolled in a multicenter randomized surgical trial, Colpopexy and Urinary Reduction Efforts (CARE); data were not available for 5 subjects. (15) The CARE trial sought to determine whether adding Burch colposuspension to abdominal sacrocolpopexy for prolapse is associated with decreased postoperative urinary stress incontinence in women without preoperative stress incontinence.

To be defined as stress continent for study eligibility, women were screened at the clinical sites by completing the Medical, Epidemiologic, and Social Aspects of Aging (MESA) questionnaire (16) and answering "never" or "rarely" to the stress incontinence questions. However, at subsequent telephone interviewing, about 20% of the eligible subjects did experience some level of stress incontinence. In addition, women could experience urge incontinence and still be eligible for the study. The institutional review board at each PFDN clinical site and the data coordinating center at the University of Michigan approved the protocol, and all participants provided written informed consent.

Procedure

Prolapse stage and pelvic-floor muscle function data were obtained by the site research nurse or surgeon investigator according to standardized criteria documented in the study procedural manual. Staff from the central telephone interviewing facility at the University of Michigan administered baseline symptom, QOL, and sexual function questionnaires to participants.

Pelvic organ prolapse stage. The International Continence Society, the American Urogynecologic Society, and the Society of Gynecologic Surgeons have agreed on a standardized system to describe pelvic support in women known as the Pelvic Organ Prolapse Quantification (POP-Q). (17) For the POP-Q examination, women were in dorsal lithotomy position. Maximal extent of prolapse was measured (in centimeters) using defined vaginal points relative to the hymen. Points above (or inside) the hymen were negative numbers (eg, -3 cm), and points below (or outside) the hymen were positive numbers (eg, +3 cm); points at the hymen were 0 cm. All vaginal points were measured with maximal valsalva effort except for total vaginal length, which was measured at rest. Genital hiatus was measured at rest and with maximal valsalva effort.

The POP-Q measures (Fig. 1) included in the analyses, in addition to ordinal prolapse stage, were: (1) greatest descent of the anterior vagina (point "Ba") and posterior vagina (point "Bp"); (2) the cervix or the vaginal cuff in women without a uterus (point "C"); (3) for women with a uterus, the posterior fornix (point "D"); (4) total vaginal length (ie, the greatest depth of the vagina when point "C" or "D" was reduced to normal position); and (5) genital hiatus (ie, the distance from the middle of the external urethral meatus to the inferior hymenal ring).(17) Intra observer reliability coefficients (r) for the POP-Q measures have been reported to range from .522 (point "C") to .912 (genital hiatus). Interobserver reliability coefficients (r) ranged from .765 (point "C") to .934 (point "Ba"). (18)

[FIGURE 1 OMITTED]

According to POP-Q definitions, prolapse is stage II when the vagina is prolapsed between 1 cm above the hymen (-1 cm) but not more than 1 cm below (outside) the hymen (+ 1 cm). Prolapse more than 1 cm beyond the hymen but no farther than 2 cm less than total vaginal length is stage III prolapse. Stage IV prolapse is complete vaginal eversion extending beyond the hymen to a distance equal to the total vaginal length ([+ or -] 2 cm). Intraobserver and interobserver reliability coefficients (r) reported for staging of prolapse were .712 and .70, respectively. (18)

Pelvic-floor muscle function.

Pelvic-floor muscle function is defined as the ability to perform a correct contraction, meaning a squeeze around pelvic openings and an inward, upward movement (lift) of the pelvic floor. (19) Pelvic-floor muscle function was examined by vaginal palpation and quantified using the standardized Brink scale. (20) The Brink scale considers 3 dimensions to evaluate the pelvic-floor muscle contraction: (1) squeeze pressure felt around the examiner's fingers, (2) duration, and (3) vertical displacement of the examiner's fingers. Each dimension or subscale is rated separately on a 4-point categorical scale, and the ratings then are summed for a composite score ranging from 3 to 12, with a higher score indicating better muscle function (Tab. 1.)

Brink et al (20) reported test-retest (with an intertest interval of 2-7 weeks) reliability coefficients (r) of .54, .51, and .53 for the squeeze pressure, vertical displacement, and contraction duration subscale scores, respectively, and .65 for the total score. Interrater reliability coefficients (r) were .74, .67, and .52 for the squeeze pressure, vertical displacement, and contraction duration subscale scores, respectively. Hundley et a1 (21) reported good interrater reliability for the squeeze pressure subscale and total Brink scale score (r=.68), with lower coefficients for vertical displacement (r=.58) and contraction duration (r=.44). Good correlations (r=.68 and .71 for 2 examiners) were found between the Brink scale squeeze pressure subscale score and maximal squeeze pressure scores obtained using a perineometer.

Examiners followed standardized criteria for pelvic-floor muscle examination and Brink scale scoring specified in the study policy and procedure manual. The pelvic-floor muscle examinations were performed with women positioned supine with their hips flexed and slightly abducted and knees flexed. An examiner's gloved and lubricated index and middle fingers, oriented vertically, were inserted along the posterior vagina to the level of the examiner's proximal interphalangeal joints. Women were asked to contract their pelvic-floor muscles following the instruction: "Squeeze around my fingers as hard and as long as you can, as if you are trying to hold back the passage of gas or a bowel movement."

If a subject performed the contraction incorrectly (by straining or contracting her hip muscles instead of her pelvic-floor muscles), the examiner did not rate or record a Brink scale score for this contraction but provided feedback to the subject on how to contract her muscles correctly and then asked her to perform another pelvic-floor muscle contraction. If the contraction was performed correctly, the examiner rated the squeeze pressure and vertical displacement dimensions according to Brink scale criteria. (20) Muscle contraction duration was determined and rated during a separate pelvic-floor muscle contraction. Examiners timed the contraction using a stopwatch. The stopwatch was stopped when the contraction weakened, or if the subject maintained the contraction beyond 8 seconds. Subjects were cautioned not to "bear down" or perform a Valsalva maneuver during all pelvic-floor muscle contractions. A brief rest period (20-30 seconds) was given between contractions.

Symptom burden, quality of life, and sexual function. The Pelvic Floor Distress Inventory (PFDI) (22) assesses pelvic-floor symptoms across 3 subscales: the Urinary Distress Inventory (UDI), the Pelvic Organ Prolapse Distress Inventory (POPDI), and the Colorectal-anal Distress Inventory (CRADI). In completing the PFDI, subjects are asked to indicate whether they have a particular symptom and, if so, to assess how much it bothers them on a 4-point scale ranging from 1 ("not at all") to 4 ("quite a bit"). Scores for the UDI and the POPDI range from 0 to 300, and scores for the CRADI range from 0 to 400.

Higher scores indicate more symptoms and worse symptom bother.

The effect of pelvic symptoms on QOL was assessed using the Pelvic Floor Impact Questionnaire (PFIQ). (22) The PFIQ also contains 3 subscales: the Urinary Impact Questionnaire (UIQ), the Pelvic Organ Prolapse Impact Questionnaire (POPIQ), and the Colo-Rectal-Anal Impact Questionnaire (CRAIQ). The degree to which pelvic symptoms affect QOL, in particular physical activity, social relationships, travel, and emotional health, is rated on a categorical scale, with scores ranging from 1 (activity/ feeling affected "not at all") to 4 (activity/feeling affected "quite a bit"). Each subscale of the PFIQ is rated from 0 to 300, with higher scores indicating a worse effect on QOL. Both the PFDI and the PFIQ have been tested for internal consistency, reproducibility, and validity. (22)

To assess sexual function, subjects were asked to respond to the Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ12), (23) which measures sexual function across 3 factors: behavioral/ emotive, physical, and partner-related. The PISQ-12 scores can be reported as scores for individual items or as a total score, ranging from 0 to 48, with higher scores indicating better sexual function. Test-retest reliability and validity of the PISQ-12 have been reported for sexually active women. (23) A PISQ-12 score can be computed only for women who complete at least 11 of the 12 items. (23)

Data Analysis

We aimed, a priori, to compare women with the best and worst pelvic-floor muscle function with respect to prolapse severity and QOL. All hypotheses assumed that the greatest difference would be found between subjects with the highest and lowest Brink scale quartiles. Because we aimed to assess whether prolapse severity, POP-Q, and QOL outcomes differed as a function of Brink scale score, we chose to present the outcome scores according to Brink scale scoring categories. Therefore, Brink scale scores were categorized into low, medium, and high quartiles for analysis.

Treating Brink scale scores as categorical, we first grouped subjects based on approximate Brink scale quartiles, representing 25% of the study population with the lowest scores (3-6), 50% of subjects in the middle range (7-9), and the remaining 25% with the highest scores (1012). If the distribution by scores had been perfectly even, the number of subjects in each quartile would be 80 (25% of 320); however, because the distribution was not perfect, the resultant groups contained 56, 186, and 75 subjects, respectively. The Fisher exact test was used to compare women in the highest and lowest Brink scale quartiles on menopausal status and POP-Q stage, and an age-adjusted analysis of variance (ANOVA) was used to compare POP-Q points. The 2-tailed Wilcoxon rank sum test was used for comparisons of PFDI, PFIQ, and PISQ scores due to their skewed distributions.

We also aimed to determine whether Brink scale scores differed by prolapse stage. For these analyses, Brink scale scores were treated as continuous. A 2-sample t test was used for comparisons of Brink subscale scores between women with stage IV versus stage II prolapse. The total Brink scale scores of women with stage IV versus stage II prolapse were compared by age-adjusted ANOVA.

With 56 and 75 subjects in the 2 Brink scale quartiles being compared, there was 80% power to identify an effect size of 0.5 (ie, a difference of 0.5 standard deviations). In addition, there was 80% power to identify a difference between proportions of 50% and 75%, or of similar magnitude.

Results

Among the 317 participants, mean age ([+ or-] SD) was 61.6 [+ or-] 10.2 years. Median parity was 3 (range=0-11). Most women (88.4%) were postmenopausal. Forty-two women (13%) had stage II prolapse, 214 (68%) had stage III, and 61 (19%) had stage IV prolapse.

Age, serf-reported menopausal status, POP-Q stage, and selected POP-Q points are presented in Table 2. Menopausal status and POP-Q stage did not differ between Brink scale quartiles. Age decreased from the lowest to the highest Brink scale quartile, but the difference was only marginally statistically significant (P=.05). Mean genital hiatus with maximal strain was 0.8 cm smaller in the women in the highest Brink scale quartile compared with those in the lowest Brink scale quartile (P=.O1). Other POP-Q measures did not differ between Brink scale quartiles.

Considering Brink scale scores as a continuous variable, we observed small differences in mean Brink scores between women with stage II versus stage IV prolapse. Figure 2 shows that women with stage II prolapse had higher Brink scores (P=.04). However, the difference in scores occurred only in the vertical displacement subscale (P=.03). That is, women with a lower stage of prolapse were able to elevate the pelvic floor somewhat better during pelvic-floor muscle contraction.

[FIGURE 2 OMITTED]

Scores for PFDI (pelvic-floor symptoms and bother), PFIQ (pelvic-floor symptom impact on QOL), and PISQ-12 (sexual function) are presented by Brink scale quartile in Table 3. The PFIQ and PISQ-12 scores did not differ significantly between women in the upper versus lower Brink scale quartiles. The PFDI subscale scores differed only with regard to urinary symptoms. Women in the lowest Brink scale quartile had higher UDI scores (ie, more urinary symptoms and bother) than women in the upper Brink scale quartile (P=.016).

Discussion and Conclusions

We observed 2 potentially important relationships between pelvic-floor muscle function and prolapse in this study. First, women with less advanced prolapse had higher Brink scale scores, primarily due to the vertical displacement component. That is, women with less advanced prolapse were somewhat better able to elevate their pelvic floor during pelvic muscle contraction than women with more advanced prolapse. Second, women in the lower Brink scale quartile had larger genital hiatus measurements when straining. Both observations are consistent with an etiologic theory of prolapse that incriminates poor pelvic-floor muscle function as one of the inciting or contributory factors in the development of prolapse, although the magnitude of the differences was relatively small.

Another plausible explanation is that prolapse contributes to pelvic-floor muscle weakness. Advancing prolapse could cause passive stretch and impaired contractility of the pelvic-floor muscles. (24) It is possible that pelvic-floor muscle dysfunction could both contribute to the development of prolapse and represent a consequence of prolapse. By the time women reach clinical care for prolapse, it is not possible to determine which came first. Longitudinal studies would help to determine the temporal relationship between pelvic-floor muscle weakness and prolapse.

It is noteworthy that, despite the differences observed, Brink scale quartiles did not distinguish between stages of prolapse. It may be that, once prolapse of a certain degree (eg, stage II) develops, pelvic-floor muscle function is not further impaired. That is, the reason that the Brink scale quartiles were similar across stages of prolapse may be that a certain level of pelvic-floor muscle dysfunction had been reached and, regardless of further advancement of the prolapse itself, the level of pelvic-floor muscle function (or dysfunction) remained stable.

We selected vaginal palpation to assess pelvic-floor muscle function because of its practicality in both research and clinical settings. The standardized Brink scale was desirable as an evaluation scale because of its demonstrated interrater reproducibility, test-retest reliability, and [validity.sup.20] and because of its prior use in research related to pelvic-floor disorders. (21) It is possible, however, that the Brink method of assessing pelvic-floor muscle function is not sufficiently precise to demonstrate a clear association with prolapse severity.

Physical therapists may be more familiar with other pelvic-floor muscle grading scales, such as the Oxford or Laycock scale, (25) which evaluates strength of contraction on a 6-point scale ranging from 0 (no contraction) to 5 (strong contraction). In contrast, the Brink scale measures 3 different aspects of pelvic-floor muscle function: squeeze pressure, duration of contraction, and vertical displacement. In this study, we assigned categorization to the total Brink scale score, with the connotation of poor pelvic-floor muscle function for the low scores and good, or at least better, pelvic-floor muscle function to the high scores. This categorization is relatively arbitrary and has not been separately validated.

Studies are needed to compare various scales for evaluating pelvic-floor muscle function based on digital examination with each other and with other means of assessing pelvic-floor muscle function, such as pressure perineometry or force measurements. In addition, pelvic-floor muscle function tests and measures have not been adequately evaluated for construct validity, particularly with regard to identifying aspects of muscle physiology that are most critical to providing pelvic support. Thus, there is no consensus as to how to "best" assess pelvic-floor muscle function, and overcoming this current limitation should be a high priority for future research.

Although we found a statistically significant association between prolapse severity and Brink scale scores, we observed considerable overlap in Brink scale scores across prolapse stages (Fig. 2), and comparisons by Brink scale quartiles and prolapse stage were not statistically significant (Tab. 2). These findings are not surprising, given the multifactorial etiology of prolapse. However, they do limit the clinical interpretation of our findings, especially in the absence of comparison data from women without prolapse. Regardless, we suggest that it is prudent to consider all known risk factors when determining a physical therapist prognosis and plan of care for a woman with pelvic organ prolapse.

We also observed a statistically significant association between Brink scale quartile and UDI score, which reflects the number of urinary symptoms and their associated bother. Again, the magnitude of the difference between the lower and upper Brink scale quartiles was modest: a 17-point difference between the means, in a subscale with an upper limit of 300 points. Poor pelvic-floor muscle function has been correlated with urinary incontinence. Women with stress incontinence have weaker pelvic-floor muscles, (26-28) and pelvic-floor muscle exercise is an effective intervention for stress and urge incontinence. (29) In our study, women who reported stress incontinence on the MESA questionnaire were excluded by study design; yet, we still observed a small increase in UDI scores among women with poor pelvic-floor muscle function. This finding suggests that pelvic-floor muscle weakness may predispose women to other urinary symptoms besides stress incontinence; whether prolapse is a key feature of this association or not is unknown.

Other than urinary incontinence, Brink scale quartiles were not associated with other pelvic-floor symptoms. For example, we did not see an association between pelvic-floor muscle function and severity of prolapse symptoms (ie, POPDI and POPIQ scores), colorectal symptoms (ie, CRADI and CRAIQ scores), or sexual function (PISQ-12 scores). Pelvic symptoms have correlated poorly, if at all, with clinical measurements of prolapse severity. (30-32) The findings of our study support the perception of prolapse symptoms and their associated bother as complex and incompletely understood at the current time. Other demographic, etiologic, and psychosocial variables may play a greater role in symptom bother and effect on QOL than pelvic-floor muscle function in women with prolapse.

A limitation of this study was that we included only women who had prolapse bothersome enough to seek treatment. In addition, only women who were eligible and who agreed to enroll in a randomized surgical trial for prolapse contributed data to this study, potentially limiting the generalizability of our findings. The cross-sectional nature of this study also precludes us from determining a causal or temporal relationship between pelvic-floor muscle function and prolapse.

This study's results cannot be used directly to support the potential preventative role of pelvic-floor muscle exercise for women with prolapse. Recent research has begun to examine whether pelvic-floor muscle exercise is effective as a primary or secondary prevention for pelvic organ prolapse. (13) Certainly, pelvic-floor muscle exercise has a well-established role in the prevention and management of other pelvic-floor disorders, including urinary and fecal incontinence. (29) Further research is needed to investigate the potential for physical therapy interventions in the prevention and rehabilitation of pelvic organ prolapse.

Dr Borello-France, Dr Goode, and Dr Kreder provided concept/idea/research design. Dr Borello-France, Dr Handa, Dr Goode, Dr Kreder, and Dr Weber provided writing. Dr Handa provided data collection. Dr Brown, Dr Goode, and Dr Kreder provided data analysis. Dr Weber provided project management. Dr Goode provided fund procurement and institutional liaisons. Dr Handa and Dr Kreder provided subjects. Dr Kreder provided facilities/equipment. Dr Brown, Dr Kreder, Ms Scheufele, Dr Weber provided consultation (including review of manuscript before submission). The authors thank Dr Robert Park, Chair of the Pelvic Floor Disorders Network Steering Committee, for his contributions to the network (2001-2006).

Pelvic Floor Disorders Network Members: University of Alabama at Birmingham--Holly E Richter, PhD, MD (Principal Investigator), Kathryn L Burgio, PhD (Co-Principal Investigation, Patricia S Goode, MD (Co-Investigator), R Edward Varner, MD (Co-Investigator), Velria Willis, RN, BSN (Research Coordinator); Baylor College of Medicine--Paul M Fine, MD (Principal Investigator), Rodney A Appell, MD (Co-Principal Investigator), Peter K Thompson, MD (Co-Investigator), Peter M Lotze, MD (Co-Investigator), Naomi Frierson (Research Coordinator); University of Iowa--Ingrid Nygaard, MD (Principal Investigator), Debra Brandt, RN (Research Coordinator), Denise Haury, RN (Research Coordinator), Karl Kreder, MD (Co-Investigator), Catherine Bradley, MD (Co-Investigator), Satish Rao, MD (Co-Investigator); Johns Hopkins Medical Institutes--Geoffrey Cundiff, MD (Principal Investigator), Victoria Handa, MD (Co-Investigator), Robert Gutman, MD (Co-Investigator), Mary Elizabeth Sauter, NP (Research Coordinator), Jamie Wright, MD (Co-Investigator); Loyola University, Chicago--Linda Brubaker, MD (Principal Investigator), Mary Pat Fitzgerald, MD (Co-Principal Investigator), Kimberly Kenton, MD (Co-Investigator), Dorothea Koch, RN (Research Coordinator), Charity Ball, RN (Research Coordinator); University of North Carolina at Chapel Hill Anthony G Visco, MD (Principal Investigator), Anna-Marie Connolly, MD (Co-Investigator), John Lavelle, MD (Co-Investigator), Mary J Loomis, RN (Research Coordinator), Anita K Murphy, NP (Research Coordinator), Ellen C Wells, MD (Co-Investigator), William E Whitehead, PhD (Co-Investigator); University of Pittsburgh/Magee-Womens Hospitals--Halina Zyczynski, MD (Principal Investigator), Diane Borello-France, PhD (Co-Investigator), Judy A Gruss, BS, MS (Research Coordinator), Wendy Leng, MD (Co-Investigator), Pamela A Moalli, MD, PhD (Co-Investigator), Elizabeth Sagan, MD (Co-Investigator), Arnold Wald, MD (Co-Investigator); Data Coordinating Center, University of Michigan--Morton B Brown, PhD (Principal Investigator), John T Wei, MD, MS (Co-Principal Investigator), Beverley Marchant, RN (Project Manager), John OL De-Lancey, MD (Co-Investigator), Nancy K Janz, PhD (Co-Investigator), Dean G Smith, PhD (Co-Investigator), Patricia A Wren, PhD (Co-Investigator), Li Peng, MS (Statistician), James Imus, MS (Statistician), Yang Wang Casher, MS (DatabaseProgrammer); Steering Committee Chairman--Robert Park, MD; NIH Project Scientist--Anne M Weber, MD, MS.

A poster presentation of this research was given at the 2005 American Urogynecologic Society Meeting; September 15-17, 2005; Atlanta, Ga.

This article reflects work performed by the Pelvic Floor Disorders Network, supported by the National Institute of Child Health and Human Development (grants U01 HD41249, U10 HD41268, U10 HD41248, U10 HD41250, U10 HD41261, U10 HD41263, U10 HD41269, and U10 HD41267).

This article was received June 12, 2006, and was accepted December 2 I, 2006.

DOI: 10.2522/ptj.20060160

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Diane F Borello-France, Victoria L Handa, Morton B Brown, Patricia Goode, Karl Kreder, Laura L Scheufele, Anne M Weber; for the Pelvic Floor Disorders Network

DF Borello-France, PT, PhD, is Assistant Professor, Department of Physical Therapy, 111 Health Sciences Bldg, Duquesne University, Pittsburgh, PA 15282 (USA). Address all correspondence to Dr Borello-France at: borellofrance @duq.edu.

VL Handa, MD, is Associate Professor, Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Md.

MB Brown, PhD, is Professor, Department of Biostatistics, University of Michigan, Ann Arbor, Mich.

P Goode, MD, MSN, is Associate Director for Clinical Programs, Geriatric Research, Education, and Clinical Center, Birmingham Veterans Affairs Medical Center, and Professor of Medicine, University of Alabama at Birmingham, Birmingham, Ala.

K Kreder, MD, is Professor and Vice Chair, Department of Urology, University of Iowa, Iowa City, Iowa.

LL Scheufele, PT, BScPT, BCIAPMDB, GCFP, is Pelvic Floor Physical Therapist, Johns Hopkins Bayview Medical Center, Baltimore, Md.

AM Weber, MD, MS, is Project Scientist, Pelvic Floor Disorders Network, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Md.

Pelvic Floor Disorders Network (see listing of member sites and investigators on page 406)

[Borello-France DF, Handa VL, Brown MB, et al; for the Pelvic Floor Disorders Network. Pelvic-floor muscle function in women with pelvic organ prolapse. Phys Ther. 2007;87:399-407.]

Table 1.
Brink Scoring System (20)

Muscle Function      Score
Dimension

Squeeze pressure     1 = none
                     2 = weak squeeze, felt as a flick at various
                       points along finger surface; not all the way
                       around
                     3 = moderate squeeze; felt all the way around
                       finger surface
                     4 = strong squeeze; full circumference of fingers
                       compressed
Muscle contraction   1 = none
  duration           2 = less than 1 second
                     3 = greater than 1 second; less than 3 seconds
                     4 = greater than 3 seconds
Vertical             1 = none
  displacement       2 = finger bases move anteriorly (pushed up by
                       muscle bulk)
                     3 = whole length of fingers moves anteriorly
                     4 = whole fingers move anteriorly, are gripped
                       and pulled in
Total                Range = 3-12

Table 2.
Comparison of Characteristics Between Women in the Lowest Versus the
Highest Quartile of Brink Scale Scores

Variable                       Brink Scale Quartile (a)

                               Lower                Middle
                               (Score = 3-6)        (Score = 7-9)
                               (n = 56)             (n = 186)

Age (y), [bar.X] [+ or -] SD   63.2 [+ or -] 10.5   61.7 [+ or -] 10.4
Menopausal status, (b) n (%)
  Postmenopausal (n = 274)     52 (19.0)            158 (57.7)
  Premenopausal (n = 36)        3 (8-3)              23 (63.9)
Prolapse stage, (c) n (%)
  II (n = 42)                   4 (9.5)              24 (57.1)
  III (n = 214)                38 (17.8)            127 (59-3)
  IV (n = 61)                  14 (22.9)             35 (57.4)
Genital hiatus, (d) no          4.6 [+ or -] 1.9      4.4 [+ or -] 1.4
  strain (cm), [bar.X]
  [+ or -] SD
Genital hiatus, with strain     5.8 [+ or -] 1.8      5.6 [+ or -] 1.5
  (cm), [bar.X] [+ or -] SD
Maximal prolapse (e) (cm),      4.4 [+ or -] 2.5      3.9 [+ or -] 2.4
  [bar.X] [+ or -] SD

Variable                       Brink Scale Quartile (a)

                               Upper                P
                               (Score = 10-12)      (Lower Quartile vs
                               (n = 75)             Higher Quartile)

Age (y), [bar.X] [+ or -] SD   59.8 [+ or -] 9.3    .05
Menopausal status, (b) n (%)                        .15
  Postmenopausal (n = 274)     64 (23.3)
  Premenopausal (n = 36)       10 (27.8)
Prolapse stage, (c) n (%)                           .11
  II (n = 42)                  14 (33.3)
  III (n = 214)                49 (22.9)
  IV (n = 61)                  12 (19.7)
Genital hiatus, (d) no          4.0 [+ or -] 1.5    .09
  strain (cm), [bar.X]
  [+ or -] SD
Genital hiatus, with strain     5.0 [+ or -] 1.5    .01
  (cm), [bar.X] [+ or -] SD
Maximal prolapse (e) (cm),      3.8 [+ or -] 2.5    .43
  [bar.X] [+ or -] SD

(a) The Brink scale quartiles were based on the approximate
distribution of the subjects across Brink scale scores.

(b) Menopausal status data were available only for 310 women.

(c) Stage II prolapse = the vagina has prolapsed to the level between
1 cm above the hymen (-1 cm) but not more than 1 cm below (outside)
the hymen (+1 cm), stage III prolapse = prolapse more than 1 cm beyond
the hymen but no farther than 2 cm less than total vaginal length, and
stage IV prolapse = complete vaginal eversion extending to total
vaginal length ([+ or -] 2 cm).

(d) Genital hiatus = the distance from the middle of the external
urethral meatus to the inferior hymenal ring.

(e) Maximal prolapse = the leading edge of prolapse (ie, at maximal
descent relative to the hymen), regardless of which vaginal point or
points involved; can be point "Ba," "Bp," "C," or "D."

Table 3.
Comparison of Pelvic Symptoms and Bother, Quality-of-Life Impact,
and Sexual Function Between Women in the Lowest Versus the Highest
Quartiles of Brink Scale Scores (a)

Variable                     Brink Scale Quartile

                             Lower                 Middle
                             (Score = 3-6)         (Score = 7-9)
                             (n = 56)              (n = 182)

Symptoms and bother: PFDI
    subscales, [bar.X]
    [+ or -] SD
  UDI (range = 0-300)         70.2 [+ or -] 42.7    61.1 [+ or -] 41.9
  POPDI (range = 0-300)      108.2 [+ or -] 61.2   110.0 [+ or -] 70.7
  CRADI (range = 0-400)       74.3 [+ or -] 72.6    73.5 [+ or -] 66.8
Quality-of-life impact:
    PFIQ subscales,
    [bar.X] [+ or -] SD
  UIQ (range = 0-300)         47.0 [+ or -] 44.3    51.6 [+ or -] 53.7
  POPIQ (range = 0-300)       41.7 [+ or -] 47.2    48.1 [+ or -] 62.7
  CRAIQ (range = 0-300)       23.8 [+ or -] 34.2    34.8 [+ or -] 56.0
Sexual function: PISQ-12,    n = 23                n = 96
  (b) (range = 0-48),
  [bar.X] [+ or -] SD
                              33.7 [+ or -] 6.3     33.8 [+ or -] 7.1

Variable                     Brink Scale Quartile

                             Upper                 P
                             (Score = 10.12)       (Lower Quartile vs
                             (n = 71)              Higher Quartile)

Symptoms and bother: PFDI
    subscales, [bar.X]
    [+ or -] SD
  UDI (range = 0-300)        53.4 [+ or -] 34.7    .016
  POPDI (range = 0-300)      95.9 [+ or -] 60.9    .20
  CRADI (range = 0-400)      63.1 [+ or -] 62.1    .53
Quality-of-life impact:
    PFIQ subscales,
    [bar.X] [+ or -] SD
  UIQ (range = 0-300)        39.0 [+ or -] 47.2    .12
  POPIQ (range = 0-300)      43.0 [+ or -] 55.1    .61
  CRAIQ (range = 0-300)      25.6 [+ or -] 53.9    .27
Sexual function: PISQ-12,    n = 39
  (b) (range = 0-48),
  [bar.X] [+ or -] SD
                             33.8 [+ or -] 7.4     .96

(a) PFDI = Pelvic Floor Distress Inventory, UDI = Urinary Distress
Inventory, POPDI = Pelvic Organ Prolapse Distress Inventory, CRADI =
Colorectal-anal Distress Inventory, PFIQ = Pelvic Floor Impact
Questionnaire, UIQ = Urinary Impact Questionnaire, POPIQ = Pelvic
Organ Prolapse Impact Questionnaire, CRAIQ = Colo-Rectal-Anal Impact
Questionnaire, PISQ-12 = Pelvic Organ Prolapse/Urinary Incontinence
Sexual Function Questionnaire-12. Quality-of-life data were obtained
on only 309 of the 317 subjects.

(b) Completed by women who were sexually active with a partner.