Instruction verbale pour obtenir une contraction des muscles du plancher pelvien. Acceptabilité et compréhension

12 mars 2021

Auteurs : A. Charlanes, C. Chesnel, M. Jousse, F. Le Breton, S. Sheikh Ismael, G. Amarenco, C. Hentzen
Référence : Prog Urol, 2021, 4, 31, 231-237




 




Introduction


Pelvic floor muscles contraction (PFMC) evaluation is usually recommended for evaluation and treatment of pelvic floor disorders. The 6th edition of Incontinence specifies that Pelvic floor muscles (PFM) play an important role in continence and support of the pelvic organs and that voluntary pelvic floor muscle contraction and relaxation should be evaluated during the initial assessment [1]. Indeed, it takes part in the diagnostic and therapeutic orientation by verifying the ability to contract, and on pelvic floor muscle rehabilitation by exercising these muscles. PFMC is also needed in electromyography (EMG) tests to estimate the number of recruitable motor units. So, the way to elicit a PFMC is relevant both for patients and clinicians depending on several factors. In clinical practice, many patients fail to achieve a voluntary PFMC, and only about one-third of women perform an ideal PFMC after brief written or verbal instruction [2, 3]. When no PFMC is elicited, it might be explained by an anatomical or neurological issue but also by a lack of understanding of the instructions and/or poor knowledge of anatomy. The understanding of the instruction is important because the location of the PFM, inside the pelvis, doesn't allow to see if the PFMC is correctly performed neither to do self-correction, contrary to the limb skeletal muscles. Pelvic floor muscles (PFM) evaluation may depend on the method used to elicit and assess the contraction, including verbal instructions that can include taboo terms. Moreover, patients' involvement or behaviour depends on their acceptance - i.e. how the patient experiences the investigations and treatment - and so depends on the instruction used. Deegan recently reported in a review that new methods of measuring PFM strength have emerged. However, there is no current gold standard methodology for quantifying PFM strength and they concluded that the most common methods are digital palpation and perineometry [4]. The verbal instructions used to elicit the PFMC are rarely reported in the studies and there is no standardisation of them. There are few specific works about the instructions, reporting that some specific instructions were most effective in eliciting a correct PFMC in women [5], or that the given instructions may influence the urethral inclination during PFMC [6, 7].


Thus, an appropriate verbal instruction in terms of understanding, acceptability, taking into account the patient anatomical knowledge is necessary, for the clinician to carry out a better evaluation of the PFM, to improve the EMG test, and for patients to facilitate the acceptance of the investigations and to improve the pelvic floor training efficacy.


The purpose of this study is to describe the verbal instructions used to obtain a PFMC, to evaluate the understanding and acceptability of the proposed instructions, and to select the best.


Methods


This was a prospective observational study led in two phases in the neurourology department of a university hospital. A local ethics committee approved this study. Since it was an observational study, the participant received a newsletter. This study was registered on clinicaltrials.gov: NCT03272386.


Phase 1: survey carried out with the health professionals


Members of the scientific committees of national academic societies in neuro-urology, pelvi-perineology, and pelvic floor neurophysiology were invited to answer a questionnaire by mail between December 2016 and March 2017. It included open questions about the most frequently verbal instructions used to elicit a PFMC. These instructions were collected, analysed, and selected for the second phase.


Phase 2: structured interviews with patients and with non-health-professional subjects


Patients and non-health-professional subjects were invited to answer a 3-parts questionnaire based on the gender between July and October 2017:

demographic, social and medical data;
evaluation of the anatomical knowledge of the perineum with a picture of the perineum and a sagittal section of the pelvic area of the corresponding sex;
in the third part, the participants assessed the instructions selected in the first phase according to their understanding and their acceptability (good, intermediate, and poor). They finally have to choose the best instruction i.e. which seems to be the more suitable to obtain a PFMC.


Results


Phase 1


Forty-six experts (40% of women) answered an 8 open questions questionnaire about the most frequently verbal instructions used to elicit a PFMC. They were mostly specialists in physical and rehabilitation medicine, physiotherapists, urologists, and gynaecologists.


Three hundred and fifty-six instructions had been collected and analysed according to their characteristics. Forty-four percent were functional instructions (like "hold a gas"), 40% were anatomical instructions (like "squeeze your anus") and 16% were mixed instructions with an anatomical and a functional part (like "squeeze your anus as you do to hold a gas").


Five experts proposed only anatomical instructions and 4 proposed only functional instructions. Eighty percent of them proposed instructions sometimes functional, sometimes anatomical, and sometimes mixed. The instructions were about the anterior perineum (like "squeeze your vagina" or "hold your urine"), posterior perineum (like "squeeze your anus"), or undifferentiated. It depended on the question of the survey: when "which instruction do you most frequently use in women?" and "[...] in men?" was asked, the answers were mostly undifferentiated instructions then posterior and then anterior instructions. When "which instruction seems to be the most efficient to obtain a contraction of the anus in women?" and "[...] in men?" was asked, the instructions on the posterior perineum clearly predominated. However, for "which instruction seems to be the most efficient to obtain a contraction of the vagina in women?" and "which instruction seems to be the most efficient to obtain a contraction of the anterior perineum in men?", the instructions on the anterior perineum predominated followed by undifferentiated and then the posterior perineum instructions.


The ways to encourage the contraction were picked out: the verbs used were mainly "squeeze" (38%), "hold" (37%), and "contract" (14%).


The most represented instructions were selected in each category (anatomical, functional, or mixed and anterior, posterior, or undifferentiated). It included the main structures (perineum, anus, buttocks, and vagina) for the anatomical instructions and the main functions for the functional instructions.


Although more than 20% of the instructions referred to rectal or vaginal examinations like "squeeze around my finger", they were not selected because inappropriate in a population who mostly never had such an examination.


So, 11 common instructions were selected and 4 specific instructions for women were additionally selected. All of them are reported in the following section.


Phase 2


Thirty-three participants answered the questionnaire (mean age 42, range [22-78]). They were 7 patients (4 women) and 26 non-health-professional persons (13 women). The scholarship level of 2/3 of the participants was at least two years after a bachelor's degree. More than 1/3 of the participant was white-collar and highly-qualified workers. Participants' characteristics are reported in Table 1.


The anatomical evaluation included a picture of a face and a sagittal section of the pelvic area with arrows pointing to the organs. More than 75% of the answers were correct. The mistakes were on the prostate gland and the rectum in men. Women fulfilled incompletely the sagittal section and the mistake were mainly on the urethra, the labia, and then on the clitoris in the picture and in the sagittal section on the rectum, bladder, and anus.


By the common instructions proposed, the understanding and the acceptability were the best for "do as you wish to hold a strong desire to urinate", "contract your anus" and "do as you wish to hold a gas" with respectively 62/66, 58/66 and 57/66 votes for "good" (33 for understanding and 33 for acceptability). Understanding of "squeeze your perineum" and "contract your perineum" was intermediate or poor for more than 50% of participants (respectively 22/33 and 19/33). Acceptability was lower for "do as you contract on your sexual partner" in women with 5/17 poor or intermediate. The best instructions according to interviewees were "contract your anus" and "do as you wish to hold a strong desire to urinate" followed by "squeeze your perineum muscles as to hold a desire to urinate" then "contract your perineum" or "do as you wish to hold a strong desire to defecate". Men preferred "contract your anus" and women preferred "contract your perineum", "do as you wish to hold a strong desire to urinate" and "do as you contract on your sexual partner". All the results are reported in Table 2.


Discussion


PFM, especially in women, have an important role in urinary and faecal continence and probably in sexual physiology. Thus, integrity, strength, resistance, and fatigue of these muscles must be evaluated when there is a pelvic floor disorder as stress and urge urinary incontinence, faecal, or gas incontinence [8]. An extensive French terminology exists concerning the conservative and non-pharmacological management of female pelvic floor dysfunction, gathering the terminology from the International Continence Society (ICS) and the International Urogynecological Association (IUGA) [9]. The assessment of PFMC is reported, with different ways to quantify it. However, the instructions to be given to the patient are not explained, and no examples are given neither. The Pelvic Floor Clinical Assessment Group of the International Continence Society reported that the investigators reporting PFM studies should state the position of the patient, the time of the day, the number of fingers used in the case of digital palpation, and the additional instruments used should be noted and described [10]. When appropriate the verbal instructions given to the patient should be literally written down. They reported that good instruction is mandatory and proposed to ask the patient to "prevent the escape of gas or urine" [10]. Without proper instruction, many women are unable to volitionally contract these muscles on demand because the PFM are situated in a poorly known body area and are seldom used consciously [11]. Thus, verbal instructions are important in the evaluation of the PFMC but there is no standardization of them.


One study reported that urethral inclination in women is influenced by the type of instruction: anterior « squeeze and lift from the front as if stopping the flow of urine », posterior « squeeze and lift from the back as if stopping the escape of wind » and combined « squeeze and lift the front and the back together » [6]. Twenty-three female subjects completed a minimum of 80% of an exercise programme that comprised three maximal PFMC held for 5sec each, using each of the 3 instructions, twice a day for 4 weeks. After 2 weeks, 3 were excluded because the followed instructions did not correlate with a surface EMG feedback analysis. There were differences in the angle of urethral inclination between posterior and anterior cue, combined and anterior cue, but not between posterior and combined cue.


One recent study report that the pattern of urethral movement is also influenced by the instructions used to teach PFM activation in men [7]. They studied the displacement of pelvic floor landmarks in 15 men during sub-maximal PFMC in response to different verbal instructions: "tighten around the anus", "elevate the bladder", "shorten the penis" and "stop the flow of urine". Displacement of pelvic landmarks correlated with the EMG of the muscles predicted anatomically to affect their locations. Greatest dorsal displacement of the mid-urethra and striated urethral sphincter activity was achieved with the instruction "shorten the penis". Instruction to "elevate the bladder" induced the greatest increase in abdominal EMG and intra-abdominal pressure. "Tighten around the anus" induced the greatest anal sphincter activity. Another study showed that some specific instructions were most effective in eliciting a correct PFMC in women [5]. Two hundred fifty women reporting knowledge of PFM exercise or Kegels were asked to perform them. Sixty (24%) incorrectly performed the PFM exercise who's the provider gave a series of explicit instructions to elicit a correct contraction. It included "squeeze the vaginal muscles you use to hold your urine", "squeeze the muscles you use to hold your gas or air", "squeeze the muscle of your vagina around my fingers", and "lift your vaginal muscles inward and upward". "Squeeze the vaginal muscles you use to hold your urine" resulted in correct PFMC performance most often with 50% vs. 8.3%, 11.1%, and 30.6% for respectively "lift your vaginal muscles inward and upward", "squeeze the muscle of your vagina around my fingers", and "squeeze the muscles you use to hold your gas or air". Thus, instruction is important to incorporate into the pelvic examination and good instruction may improve the evaluation of pelvic floor disorders. Sometimes instructions are cited in the studies (Table 3) [2, 5, 7, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23] but none of them investigated the patients' opinion of these instructions. Pelvic floor disorders are still a taboo subject and its evaluation including the PFMC might be distressful and felt as intrusive or humiliating. Acceptability depends on the words used for the instructions and whether the language is too medical, too complicated, or too familiar. Acceptability of the instructions probably varies with age, socio-professional category, religion, and other patient characteristics. We did not demonstrate it because of the small sample size.


In the first part of the study, the large number of instructions proposed by the experts highlights the lack of standardization. The experts were coming from different medical (urologists, gynecologists, and PMR) or paramedical (physiotherapists, and midwives) environments, which allow us to believe that these instructions are representative of those used by those involved in the management of pelvic floor disorders. When we compare to the instructions found in the literature, similar instructions had been cited but the notion of movement was less significant in our instructions.


The instructions must be comprehensible otherwise the patients can't perform a contraction that they do not understand. This is the first study that assesses this dimension, but self-reported understanding may be biased compared to a hetero evaluation. The anatomic knowledge of the main pelvic organs evaluated on figures was good and rendered legitimate our analyse of the understanding of the PFMC instructions by the subjects themselves.


There are three main limitations in our study. First, there is probably a specificity of the vocabulary used the sensitivity of the patients, and the medical practices depending on the countries and thus requiring specific validations according to the language and the customs of life. Secondly, the questionnaire was examined by a small number of subjects. Third, the selected instructions hadn't been assessed with a strength evaluation by digital examination or by EMG techniques, but this will be done on a second part building on this work.


Finally, the multiplicity and the heterogeneity of the instructions show that there is no ideal answer. However, the combination of two simple instructions, one anatomical such as "contract your anus..." and one functional such as "... as if you wanted to hold a gas or a strong urge to urinate", would probably lead to the best PFMC. A further study will explore which is the best instruction by an objective analysis of the PFMC including EMG techniques.


In conclusion, the more understandable and acceptable instruction to assess the PFMC is the association of two simple instructions: one anatomical and one functional. The word "perineum" must be avoided, and "anus" is the best-understood term, shared between men and women.


Compliance with ethical standards


A local ethics committee approved this study (Comité de protection des personnes Île-de-France II; approval number 2015-A00125-44). Since? it was an observational study, the participant received a newsletter. This study was registered on clinicaltrials.gov: NCT03272386.


Disclosure of interest


The authors declare that they have no competing interest.




Table 1 - Participants' characteristics.
  Female 
Male 
  Patient
(n =4) 
Subject
(n =13) 
Patient
(n =3) 
Subject
(n =13) 
Age (mean [SD])  64 (14)  41 (15)  39 (11)  36 (11) 
French native language  12  13 
Level of education         
>2 years after bachelor degree  12 
2 years after bachelor degree 
Bachelor degree 
Certificate of professional competence 
Certificate of general education/no degree 
Unknown 
Socio-professional category         
Highly-qualified workers 
Administrative workers 
Workers/employees 
Student 
No occupation 
Unknown 
History of pelvic floor muscle training 
Urinary incontinence 
Sexual dysfunction 
Bowel dysfunction 
Vaginal delivery (mean [SD])  2.7 (1.9)  1.5 (1.3) 
History of urological or gynecological surgery 
History of proctological surgery 





Table 2 - Phase II: understanding and acceptability of instructions to elicit pelvic floor muscle contraction.
  Understanding 
Acceptability 
  Good  Moderate  Poor  NA  Good  Moderate  Poor  NA 
Anatomical                 
"squeeze your anus"  29    22 
"contract your anus"  29    29 
"squeeze your buttocks"  29    26 
"contract your buttocks"  26  27 
"squeeze your perineum"  11  15    22 
"contract your perineum"  14  14    22 
"squeeze your vagina"    12 
"contract your vagina"  13 
Functional                 
"do as you wish to hold a strong desire to urinate"  31  31 
"do as you contract on your sexual partner"  11    11 
"do as you wish to hold a strong desire to defecate"  28    25 
"do as you wish to hold a gas"  30    27 
Mixed                 
"squeeze your perineum muscles as to hold a desire to urinate"  22    27 
"squeeze your vagina as to hold your urine"    13 
"squeeze your anus as to hold a gas or a stool"  25    26 



Légende :
NA: unanswered.



Table 3 - Instructions cited in the studies.
Anatomical 
"squeeze and lift the pelvic floor muscles (PFM)" 
"tighten and pull the PFM" 
"draw in and lift the PFM" 
"pull the PFM in and up as strongly as possible" 
"contract the pelvic floor muscles" 
"relax your PFM, contract them maximally and hold the contraction (squeezing)" 
"lift your vaginal muscles inward and upward" 
"draw in, close around the vagina and ‘lift' the PF up toward the head" 
"elevate the bladder" 
"shorten the penis" 
"tighten around the anus" 
"squeeze and lift the front and the back together" 
Functional 
"prevent the escape of gas or urine" 
"stop the flow of urine" 
Mixed 
"contract your pelvic floor muscles, as strongly as possible, as if you had gas that you did not want to let go" 
"contract the PFM as you would hold back the passage of gas or a bowel movement" 
"contract the muscles you would use if you were trying to keep from losing your urine or if you were trying to stop your stream after you had started to urinate" 
"squeeze the vaginal muscles you use to hold your urine" 
"squeeze the muscles you use to hold your gas or air" 
"now please squeeze the muscles in the vagina and hold like you are holding urine" 
"squeeze and lift from the front as if stopping the flow of urine" 
"squeeze and lift from the back as if stopping the escape of wind" 
With fingers 
"lift inward and squeeze around the finger" 
"squeeze the muscle of your vagina around my fingers" 
"contract your vagina around the examiner's finger and to pull your vagina inward" 




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