No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Postoperative Activity Restrictions
Abstract
Because of a widespread but untested belief that increased intra-abdominal pressure contributes to pelvic floor disorders, physicians commonly restrict various activities postoperatively. Our aim was to describe intra-abdominal pressures during common physical activities.
Thirty women of wide age and weight ranges who were not undergoing treatment for pelvic floor disorders performed 3 repetitions of various activities while intra-abdominal pressures (baseline and maximal) were approximated via microtip rectal catheters. We calculated median peak and net pressures (centimeters of H(2)O). We assessed correlations between abdominal pressures and body mass index, abdominal circumference, and grip strength (a proxy for overall strength). P < .025 was considered significant.
Median peak abdominal pressures ranged from 48 (lifting 8 lb from a counter) to 150 (lifting 35 lb from the floor), with much variation. Many activities did not raise the intra-abdominal pressure more than simply getting out of a chair, including lifting 8, 13, and 20 lb from a counter, lifting 8 or 13 lb from the floor, climbing stairs, walking briskly, or doing abdominal crunches. Body mass index and abdominal circumference each correlated positively with peak, but not net, pressures. Age and grip strength were not associated with abdominal pressure.
Some activities commonly restricted postoperatively have no greater effect on intra-abdominal pressures than unavoidable activities like rising from a chair. How lifting is done impacts intra-abdominal pressure. Many current postoperative guidelines are needlessly restrictive. Further research is needed to determine whether increased intra-abdominal pressure truly promotes pelvic floor disorders.
III.
... Regarding Theory (b), two exercise modalities may increase IAP to a greater extent than others and, thus, possibly affect the pelvic floor and contribute to the incidence, progression or recurrence of pelvic floor disorders [25]: strength training and high-impact activities. ...
... Subsequently, the superficial EMG of PFM was measured, placing the intravaginal probe with water-based hypoallergenic lubricant and verifying its correct position to prevent EMG signal noise [25]. ...
... In the same line, an interesting study questioned the idea that "safe" exercises for the pelvic floor generate lower IAPs than conventional exercises since no differences were found in the IAP values between the recommended and ill-advised versions of half of the exercises [21]. Another study highlights that the activities that are generally restricted after surgery may generate lower IAP values than non-restricted activities (e.g., the maximum average IAP was higher when the participant stood up from a chair than climbing stairs, doing crunches and lifting weights) [25]. ...
Objectives:
To evaluate the electromyographic (EMG) activity of the pelvic floor musculature (PFM) that takes place when performing the functional movement screen (FMS) exercise, comparing it with the activation in the maximum voluntary contraction of PFM in the supine position (MVC-SP) and standing (MVC-ST).
Material and methods:
A descriptive, observational study conducted in two phases. In the first study phase, the baseline EMG activity of PFM was measured in the supine position and standing during MVC-SP and MVC-ST and during the execution of the seven exercises that make up the FMS. In the second phase of the study, the baseline EMG activity of PFM was measured in the supine position and standing during MVC-SP and MVC-ST and during the FMS exercise that produced the most EMG in the pilot phase: trunk stability push-up (PU). ANOVA, Friedman's and Pearson's tests were used.
Results:
All FMS exercises performed in the pilot phase showed a value below 100% maximum voluntary contraction (MVC) except PU, which presented an average value of 101.3 μv (SD = 54.5): 112% MVC (SD = 37.6). In the second phase of the study, it was observed that there were no significant differences (p = 0.087) between the three exercises performed: MVC-SP, MVC-ST and PU (39.2 μv (SD = 10.4), 37.5 μv (SD = 10.4) and 40.7 μv (SD = 10.2), respectively).
Conclusions:
There is no evidence of the existence of significant differences in EMG activation in PFM among the three exercises analysed: MVC-SP, MVC-ST and PU. The results show better EMG values in the functional exercise of PU.
... These include chronic constipation with straining at stool [3], heavy lifting at work [2,4], high-impact strenuous exercise [5], pulmonary disease [6], and high body mass index (BMI) [7]. The link between IAP and pelvic floor dysfunction is unclear; however, it has been hypothesised that increased downward pressure exerted on weakened pelvic floor structures may result in a widened genital hiatus, increasing the risk of POP [8]. As a result, women before or after vaginal repair surgery or those with pelvic floor dysfunction are often advised to restrict, modify or avoid physical activities that are thought to elevate IAP. ...
... These restrictions may hamper their daily activities and have an adverse effect on their quality of life [9,10]. There is limited evidence available to support these recommendations, which vary considerably, and lack of consensus as to the type of restrictions that may be necessary for women with pelvic floor dysfunction [8,[10][11][12]. Many clinicians recommend restriction of strenuous, high-impact exercise, straining at stool and housework and using stairs, with variations seen in lifting restrictions from 2 to 15 kg [1,9]. ...
... In this symptomatic population, cough generated a larger mean increase in IAP than the abdominal curl, as with previous research in asymptomatic women [8,14,15]. These results support the conclusion that routine recommendations for women undergoing gynaecological surgery and women with symptoms or heightened risk of pelvic floor dysfunction should receive advice to minimise the effects of increased IAP during coughing [8,10,14]. ...
Introduction and hypothesis:
Urinary incontinence (UI) and pelvic organ prolapse (POP) occur in 30-50 % of women. It is proposed that increases in intra-abdominal pressure (IAP) caused by high-intensity activities may contribute to symptoms of pelvic floor dysfunction. There is a lack of consensus as to the type of activity restrictions that may be necessary in this population. The objective was to determine the change in IAP (cm H20) during abdominal curl and cough in patients with UI and POP attending urodynamic evaluation.
Methods:
In this exploratory descriptive study, 30 women with diagnosed POP and/or UI were recruited. IAP was measured by multichannel cystometry whilst participants performed three abdominal curls and three maximal coughs.
Results:
Participants were aged 29-80 (mean 56.2) years, and mean ± standard deviation (SD) body mass index (BMI) was 29.9 (5.2) kg/m(-2). All participants had UI and 12 had POP in addition to UI. IAP increased significantly from rest to abdominal curl and cough (19.6-50.3 and 78.4, respectively; p < 0.001). Greater pressures were generated in the women with POP than in those with UI only (p = 0.02). There were large variations in change in pressure between participants (1.67-159.66 for cough; 4-81.67 for abdominal curl).
Conclusion:
The large variability in IAP generated during abdominal curl and cough suggests some current recommendations may be unnecessarily restrictive in some women but important in others. Advice for women with pelvic floor dysfunction undertaking tasks that increase IAP needs to be individualized.
... These include chronic constipation with straining at stool [3], heavy lifting at work [2,4], high-impact strenuous exercise [5], pulmonary disease [6], and high body mass index (BMI) [7]. The link between IAP and pelvic floor dysfunction is unclear; however, it has been hypothesised that increased downward pressure exerted on weakened pelvic floor structures may result in a widened genital hiatus, increasing the risk of POP [8]. As a result, women before or after vaginal repair surgery or those with pelvic floor dysfunction are often advised to restrict, modify or avoid physical activities that are thought to elevate IAP. ...
... These restrictions may hamper their daily activities and have an adverse effect on their quality of life [9,10]. There is limited evidence available to support these recommendations, which vary considerably, and lack of consensus as to the type of restrictions that may be necessary for women with pelvic floor dysfunction [8,[10][11][12]. Many clinicians recommend restriction of strenuous, high-impact exercise, straining at stool and housework and using stairs, with variations seen in lifting restrictions from 2 to 15 kg [1,9]. ...
... In this symptomatic population, cough generated a larger mean increase in IAP than the abdominal curl, as with previous research in asymptomatic women [8,14,15]. These results support the conclusion that routine recommendations for women undergoing gynaecological surgery and women with symptoms or heightened risk of pelvic floor dysfunction should receive advice to minimise the effects of increased IAP during coughing [8,10,14]. ...
... The activation of the transverse abdominal muscle and body lifting postures that involve contact between the thighs and an abdominal wall has been shown to correlate positively with the generation of intra-abdominal pressure [22]. Weir et al. 2006, has observed changes in intra-abdominal pressure in healthy adults during various activities and found that weightlifting was also positively associated with increased intra-abdominal pressure [24]. ...
... The activation of the transverse abdominal muscle and body lifting postures that involve contact between the thighs and an abdominal wall has been shown to correlate positively with the generation of intra-abdominal pressure [22]. Weir et al. 2006, has observed changes in intra-abdominal pressure in healthy adults during various activities and found that weightlifting was also positively associated with increased intra-abdominal pressure [24]. ...
Obesity is a chronic medical condition characterized by excessive body fat accumulation. It is a primary global health concern associated with various adverse health outcomes. Lack of physical activity is one of the primary reasons for obesity. This study compares the abdominal pressure changes and cardiac parameters between obese individuals with and without powerlifting exercises. This study included 50 individuals divided into 25 in each group. The first group was only obese individuals who weren't doing any exercises, whereas the second group of individuals were participating in the powerlifting exercises. Selection criteria are male powerlifters, obese individuals with a BMI over 30, age group of 25-40 years, and powerlifters doing powerlifting for a minimum of two years without cardiac anomalies, pain, or pulmonary complications. The intra-abdominal pressure and cardiac parameters were measured using the Chattanooga stabilizer pressure feedback device and pulse oximeter.
... Biomechanical studies have shown that the abdominal wall regains its normal resistance to strain after four weeks of normal healing (21)(22)(23)(24). Everyday stresses that cannot easily be voluntarily avoided, such as coughing, pressing to defecate, and standing up from a sitting position, actually put the abdominal wall under greater stress (in terms of dynamics and maximal force development) than the lifting or carrying of moderately heavy objects (25). As early as the 1960s, Bellis and Lichtenstein reported recurrence rates comparable to those seen today with "immediate return to unrestricted work after inguinal herniorrhaphy" (26). ...
... Yet in vivo pressure measurements have shown that the slow lifting of weights of up to 50 mg, in the absence of abdominal pressing, raises the intraabdominal pressure only by a small or marginal amount; thus, the danger of controlled lifting, even of heavy weights, in the postoperative period is apparently exaggerated (39). The intra-abdominal pressure rises many times higher, and more suddenly as well, with jumping, coughing, or pressing-that is, with the scarcely avoidable exertions of everyday life (25,39,40). Abdominal pressing (the Valsalva maneuver) doubles the intra-abdominal pressure (40). ...
Background:
In Germany as elsewhere, standardized recommendations are lacking on the avoidance of physical exertion to protect the abdom - inal wall in patients who have recently undergone abdominal surgery. It is unclear how much stress the abdominal wall can withstand and how long the patient should be exempted from work. The goal of this review is to determine whether there are any standardized, evidence-based recommendations for postoperative care from which valid recommendations for Germany can be derived.
Methods:
We systematically searched the literature for evidence-based recommendations on exertion avoidance after abdominal surgery, as well as for information on the extent to which postoperative abdominal wall stress contributes to incisional hernia formation. We then created a questionnaire on recommendation practices and sent it to all of the chiefs of general and visceral surgery services that were listed in the German hospital registry (1078 chiefs of service as of June 2016).
Results:
All 16 of the included studies on postoperative exertion avoidance contained low-level evidence that could only be used to formulate weak recommendations ("can," rather than "should" or "must"). Some 50 000 incisional hernia repair procedures are performed in Germany each year, with a reported incidence of 12.8% in the first two years after surgery. The scientifically documented risk factors for incisional herniation are related to techniques of wound closure, the suture materials used, wound infections, and the patient risk profile. From the biological point of view, the abdominal wall regains full, normal resistance to exertional stress 30 days after a laparotomy with uncomplicated healing. Most incisional hernias (>50%) arise 18 months or more after surgery; they are more common in patients who have avoided exertion for longer periods of time (more than 8 weeks). Our questionnaire was returned by 386 surgical clinics. The responses showed that 78% of recommendations were based on personal experience only. The recommendations varied widely; exertion avoidance was recommended for as long as 6 months.
Conclusion:
The dilemma of a deficient evidence base for postoperative exertion avoidance to protect the abdominal wall should be resolved with the much higher-quality evidence available from hernia research, which concerns the patient population with the biologically least favorable starting conditions. Based on our analysis of the available literature in light of the biomechanical principles of abdominal wall healing, we propose a new set of recommendations on postoperative exertion avoidance after abdominal surgery, with the goal of eliminating excessively protracted exertion avoidance and enabling a timely return to work.
... The literature suggests that commonly restricted activities have no greater impact on intra-abdominal pressure than normal, unavoidable everyday activities. For example, increases in intra-abdominal pressure incurred by lifting a 13-pound load from the floor and by rising from a standard height chair (a common activity) are comparable [8]. Patients should be advised that walking and climbing stairs is immediately permissible, and that they can resume high-impact aerobic exercise, lifting, and sit-ups as soon as they feel capable. ...
... Of note, the use of haloperidol as an antiemetic and the IV route of administration are off-label. (8) If no prophylaxis was given, first-line treatment should be a low-dose 5HT3 anta'gonist such as 4 mg IV ondansetron [67,68]. (9) If postdischarge nausea and vomiting is anticipated for a patient who is SDD-eligible (e.g., patient with nausea and emesis in PACU despite adequate prophylaxis), consider a discharge prescription for ondansetron 8 mg taken by mouth every 8 hours for 24 hours. ...
This is the first Enhanced Recovery After Surgery (ERAS) guideline dedicated to standardizing and optimizing perioperative care for women undergoing minimally invasive gynecologic surgery (MIGS). The guideline was rigorously formulated by an AAGL taskforce of US and Canadian gynecologic surgeons with special interest and experience in adapting ERAS practices for MIGS patients. It builds on the 2016 ERAS® Society recommendations for perioperative care in gynecologic/oncology surgery[1][2] by serving as a more comprehensive reference for minimally invasive endoscopic and vaginal surgery for both benign and malignant gynecologic conditions. For example, the section on preoperative optimization provides more specific recommendations derived from the ambulatory surgery and anesthesia literature for the management of anemia, hyperglycemia and obstructive sleep apnea. Recommendations pertaining to multimodal analgesia account for the recent FDA warnings about respiratory depression from gabapentinoids. The guideline focuses on workflows important to high value care in minimally invasive surgery (MIS), such as same day discharge (SDD) and tackles controversial issues in MIS, such as thromboprophylaxis. In these ways, the guideline supports the AAGL and our collective mission to elevate the quality and safety of health care for women through excellence in clinical practice.
... Others have also pointed out that activities generally restricted after surgery may generate lower IAPs than unrestricted activities. For example, mean maximal IAP was greater with standing up from a chair than it was for abdominal crunches, climbing stairs, sit-ups and many lifting activities [31]. Similarly, lifting 20 lbs generated less IAP than standing up from a chair [32]. ...
... Examples of mean maximal intra-abdominal pressures generated during dynamic activities a POP pelvic organ prolapse, SUI stress urinary incontinence, N/A not applicable (no range provided) a All pressures were measured using vaginal catheters/sensors with the exception of Weir et al.[31], who measured pressure using a rectal catheter b Unless otherwise specified, participants did not report incontinence ...
More women participate in sports than ever before and the proportion of women athletes at the Olympic Games is nearly 50%. The pelvic floor in women may be the only area of the body where the positive effect of physical activity has been questioned. The aim of this narrative review is to present two widely held opposing hypotheses on the effect of general exercise on the pelvic floor and to discuss the evidence for each. Hypothesis 1: by strengthening the pelvic floor muscles (PFM) and decreasing the levator hiatus, exercise decreases the risk of urinary incontinence, anal incontinence and pelvic organ prolapse, but negatively affects the ease and safety of childbirth. Hypothesis 2: by overloading and stretching the PFM, exercise not only increases the risk of these disorders, but also makes labor and childbirth easier, as the PFM do not obstruct the exit of the fetus. Key findings of this review endorse aspects of both hypotheses. Exercising women generally have similar or stronger PFM strength and larger levator ani muscles than non-exercising women, but this does not seem to have a greater risk of obstructed labor or childbirth. Additionally, women that specifically train their PFM while pregnant are not more likely to have outcomes associated with obstructed labor. Mild-to-moderate physical activity, such as walking, decreases the risk of urinary incontinence but female athletes are about three times more likely to have urinary incontinence compared to controls. There is some evidence that strenuous exercise may cause and worsen pelvic organ prolapse, but data are inconsistent. Both intra-abdominal pressure associated with exercise and PFM strength vary between activities and between women; thus the threshold for optimal or negative effects on the pelvic floor almost certainly differs from person to person. Our review highlights many knowledge gaps that need to be understood to understand the full effects of strenuous and non-strenuous activities on pelvic floor health.
... Because of the assumed relationship among physical activity, intra-abdominal pressure (IAP), and pelvic floor loading clinicians often recommend significant short-and long-term activity restrictions for women with existing PFDs or after surgical repair [5][6][7]. The restrictions are prescribed in an effort to minimize IAP, which is thought to increase the breakdown of surgical repair or further exacerbate the PFD [6]. ...
... To compare IAP during Pilates exercises, and consistent with our previous work, we chose a commonly performed activity not typically restricted after surgery: standing from a seated position [5]. Our group also recently recorded IAP in 57 women during a standard exercise session that included sitto-stand activity and found that this produced a moderate increase in IAP with significant variability [20]. ...
The objective was to describe the intra-abdominal pressures (IAP) generated during Pilates Mat and Reformer activities, and determine whether these activities generate IAP above a sit-to-stand threshold.
Twenty healthy women with no symptomatic vaginal bulge, median age 43 (range 22-59 years), completed Pilates Mat and Reformer exercise routines each consisting of 11 exercises. IAP was collected by an intra-vaginal pressure transducer, transmitted wirelessly to a base station, and analyzed for maximal and area under the curve (AUC) IAP.
There were no statistically significant differences in the mean maximal IAP between sit-to-stand and any of the Mat or Reformer exercises in the study population. Six to twenty-five percent of participants exceeded their individual mean maximal IAP sit-to-stand thresholds for 10 of the 22 exercises. When measuring AUC from 0 cm H2O, half the exercises exceeded the mean AUC of sit-to-stand, but only Pilates Reformer and Mat roll-ups exceeded the mean AUC of sit-to-stand when calculated from a threshold of 40 cm H2O (consistent with, for example, walking).
Our results support recommending this series of introductory Pilates exercises, including five Mat exercises and six Reformer exercises to women desiring a low IAP exercise routine. More research is needed to determine the long-term effects of Pilates exercise on post-surgical exercise rehabilitation and pelvic floor health.
... Mild degrees of prolapse are generally asymptomatic, but in severe cases, the organs may prolapse completely out of the vagina. While pelvic floor muscle weakness and a wide levator hiatus due to childbirth are contributing factors [16,17], raised intra-abdominal pressure due to chronic coughing, straining at stool, obesity and heavy lifting [8,18,19] are commonly considered to be associated with the development and progression of prolapse [9]. ...
... Surgical failure may have an adverse effect on women's ability to engage in heavy lifting activities for the rest of their lives [22,23]. While the factors underlying surgical failure are not clearly understood, women are often advised to restrict physical activities and, in particular, to avoid lifting after prolapse surgery [24,25], although some authors have recently questioned the validity of this instruction [18,26,27]. ...
This is an important and complex issue for manual handling educators requiring further research and discussion. Physiotherapists and manual handling educators should embrace the concept that education about safe manual handling needs to include consideration of the pelvic floor and pelvic organ prolapse, in addition to the more traditional focus on the prevention of musculoskeletal injuries.
... V nízkých polohách bez dalšího zatížení je možné dosáhnout zvýšení nitrobřišního tlaku přibližně na 20-60 cm H 2 O (O'Dell et al., 2007;Strongoli et al., 2010). Srovnatelných nebo vyšších hodnot je dosahováno v aktivitách běžného dne jako je chůze, chůze do schodů, posazování na židli, uklízení (Soucasse et al., 2022;Weir et al., 2006). Při náročnějších pohybových nebo sportovních aktivitách se hodnoty nitrobřišního tlaku násobně zvyšují (Blazek et al., 2019;Dietze-Hermosa et al., 2020). ...
... In an overview of short-term exercises Bø and Nygaard [7] reported variable increases in IAP during curl-up between 7 and 100 cmH 2 0, sit-up between 14 and 133 cmH 2 O and the plank between 23 and 95 cm H 2 O from different studies. Interestingly, Weir et al. [43] measured IAP during different exercises in 30 women and concluded that abdominal crunches, climbing stairs, walking on a treadmill, and many lifting activities did not increase IAP significantly more than standing up from a chair. This was confirmed by the study of O'Dell et al. [41]. ...
Introduction and hypothesis:
High-intensity physical activity and exercise have been listed as possible risk factors for pelvic organ prolapse (POP). The aim of the present study is to conduct a literature review on the prevalence and incidence of POP in women who engage in regular physical activity. In addition, we review the effects of a single exercise or a single session of exercise on pelvic floor support. Finally, the effect of exercises on POP in the early postpartum period is reviewed.
Methods:
This is a narrative scoping review. We searched PubMed and Ovid Medline, the Physiotherapy Evidence Database (PEDro), and the Cochrane Database of Systematic Reviews up to May 2022 with the following MeSH terms: "physical activity" AND "exercise" AND "pelvic floor" AND "pelvic organ prolapse".
Results:
Eight prevalence studies were retrieved. Prevalence rates of symptomatic POP varied between 0 (small study within different sports) and 23% (Olympic weightlifters and power lifters). Parity was the only factor associated with POP in most studies. Three studies evaluated the pelvic floor after a single exercise or one session of exercise and found increased vaginal descent or increased POP symptoms. One prospective cohort study reported the development of POP after 6 weeks of military parashot training, and one randomized trial reported increased POP symptoms after transverse abdominal training. There is scant knowledge on exercise and POP in the postpartum period.
Conclusions:
Prevalence of POP in sports varies widely. Experimental and prospective studies indicate that strenuous exercise increased POP symptoms and reduced pelvic floor support.
... [6][7][8] IAP during exercises is most often measured using vaginal or rectal sensor. [9][10][11][12] Coughing, Valsalva maneuver, and jumping have been described as the most hyperpressive exercises 9,13 and are avoided as much as possible in post-partum. ...
Aims:
Low intra-abdominal pressure (IAP) and high perineal pressure (PP) are safe conditions for pelvic floor. This study aims to measure IAP and PP in Beninese post-partum women during abdominal exercises and determine what exercise presents less risk for pelvic floor after delivery.
Methods:
IAP and PP were measured at rest and during exercises performed in random order: Cough, pelvic floor contraction (PFC), Curl-up, diaphragmatic aspiration (DA), Drawing-in, DA + Curl-up and Drawing-in+Curl-up, using a Micro-Full biofeedback PHENIX-Vivaltis with dual-channel probe. Results were presented as change from rest (maximal value during exercise minus value at rest) and expressed in percentage of this change for the reference exercise, Cough for IAP and PFC for PP. The ANOVA repeated measures test was used to compare pressures between exercises.
Results:
Seventeen postpartum women participated to this study. The maximal IAP and PP change were the highest (100%), respectively, during cough and PFC. During DA, IAP was the lowest (-7%) and PP was 51%. During Curl-up, IAP was moderate (43%) and significantly higher than during PFC (33%), Drawing-in (16%) and DA. PP was low (29%) and similar to that during Drawing-in (23%). Compared to Curl-up, Drawing-in+Curl-up increased PP (50%) but did not decrease IAP (40%). DA + Curl-up increased PP (58%) and decreased IAP (31%) compared to Curl-up but not compared to DA.
Conclusion:
DA is safe and Curl-up presents little risk for the pelvic floor. According to interindividual variations observed in IAP and PP, intrinsic factors should be considered in future studies.
... Postoperative activity restrictions have shown little effect on surgical outcomes, leading many clinicians to question whether postoperative restrictions make sense (Mueller et al. 2017). Many restricted activities do not raise IAP more than unavoidable activities, such as getting out of a chair, but how these restricted activities are executed can affect the IAP produced (Weir et al. 2006;Guttormson et al. 2008;Yamasato et al. 2014). ...
Pelvic floor disorders affect 24% of US women, and elevated intra-abdominal pressure may cause pelvic injury through musculoskeletal strain. Activity restrictions meant to reduce pelvic strain after traumatic events, such as childbirth, have shown little benefit to patients. Reported high variability in abdominal pressure suggests that technique plays a substantial role in pressure generation. Understanding these techniques could inform evidence-based recommendations for protective pelvic care. We hypothesized use of a motion-capture methodology could identify four major contributors to elevated pressure: gravity, acceleration, abdominal muscle contraction, and respiration. Twelve women completed nineteen activities while instrumented for whole body motion capture, abdominal pressure, hip acceleration, and respiration volume. Correlation and partial least squares regression were utilized to determine primary technique factors that increase abdominal pressure. The partial least squares model identified two principal components that explained 59.63% of relative intra-abdominal pressure variability. The first component was primarily loaded by hip acceleration and relative respiration volume, and the second component was primarily loaded by flexion moments of the abdomen and thorax. While reducing abdominal muscle use has been a primary strategy in protective pelvic floor care, the influence of hip acceleration and breathing patterns should be considered with similar importance in future work.
... Of course, physical activity and lifting weights can easily be adapted in the postoperative period, but the effect of these restrictions should be questioned and the impact of lifting weights on intraabdominal pressure and fascial shear stress might be overestimated. Some studies found involuntary actions such as coughing, wheezing, or defecation to cause faster and more significant increases of intraabdominal pressure, which were way higher than that caused by physical activity or lifting [14,15]. ...
Background
There are no valid recommendations or reliable guidelines available to guide patients how long they should refrain from lifting weights or returning to heavy physical labor after abdominal or hernia surgery. Recent studies found that surgeons’ recommendations not to be evidence-based and might be too restrictive considering data on fascial healing and incisional hernia development. It is likely that this impairs the patient’s quality of life and leads to remarkable socio-economic costs. Hence, we conducted this survey to gather international expert’s opinions on this topic.
Materials and methods
At the 41st Annual International Congress of the EHS, attending international experts were asked to complete a questionnaire concerning recommendations on given proposals for postoperative refrain from heavy work or lifting after abdominal surgery and also after hernia repairs.
Results
In total, 127 experts took part in the survey. 83.9% were consultants with a mean experience since specialization of more than 11 years. Two weeks of no heavy physical strain after laparoscopic surgery were considered sufficient by more than 50% of the participants. For laparotomy, more than 50% rated 4 weeks appropriate. For mesh-augmented sublay and IPOM repair of ventral or incisional hernias, more than 50% rated 4 weeks of rest appropriate. For complex hernia repair, 37% rated 4 weeks reasonable. Two weeks after, groin hernia surgery was considered sufficient by more than 50% of the participants.
Conclusion
Following groin hernia repair (Lichtenstein/endoscopic technique) and laparoscopic operation, the majority agreed on the proposal of 2 weeks refraining from physical strain. Four weeks of no physical strain were considered appropriate by a majority after laparotomy and open incisional hernia repair. However, the results showed substantial variation in the ratings, which indicates uncertainty even in this selected cohort of hernia surgery experts and emphasizes the need for further scientific evaluation. This is particularly remarkable, because a lack of evidence that early postoperative strain leads to higher incisional hernia rates.
Trial registration
Number DRKS00023887.
... This advice is based on the idea that increases in intraabdominal pressure (IAP) and subsequent transmission of pressure to pelvic organ support structures during lifting contributes to pelvic floor dysfunction (PFD) [4]. Physiological studies examining IAP during physical activities in women have found a positive association with lifting weights and increases in IAP [5][6][7][8]; however, the relationship between heavy lifting and symptoms of POP has not been investigated in epidemiological studies. ...
Introduction and hypothesis
The aim of the study was to determine the prevalence of symptoms of pelvic organ prolapse (POP), defined as the sensation of a vaginal bulge, and associated risk factors in women over 18 years of age who lift light (≤15 kg), moderate (16–50 kg), and heavy (>50 kg) weights for exercise, and those who do not lift weights for exercise.
Methods
Women completed an online survey about risk factors for pelvic floor dysfunctions, physical activity history, and pelvic floor symptoms. A question about a vaginal bulge sensation from the validated Pelvic Floor Distress Inventory (PFDI-20) was used to indicate symptoms of POP. Relationships between symptoms of POP and possible risk factors were assessed through logistic regression analysis.
Results
Of the 3,934 survey participants, the total prevalence of POP symptoms was 14.4% (n = 566). Category of weight lifted, age, vaginal parity, history of constipation or hemorrhoids, and family history of POP were significantly associated with symptoms. Physically active women lifting weights ≤15 kg were more likely to report symptoms of pelvic organ prolapse than women lifting weights greater than 50 kg (59.7% vs 15.2%; adjusted odds ratio 2.1; 95% confidence interval 1.7–3.4). There was no relationship between POP symptoms and body mass index, forceps delivery, cesarean section, hysterectomy, or menopausal status.
Conclusion
Physically active women who lift heavy weights for exercise do not have an increased prevalence of POP symptoms. Advice on the contribution of heavy weight lifting as part of a physical activity regime to the pathophysiology of POP requires further investigation.
... This IAP is higher than values previously reported during exercises, as seen in Table 1. [12][13][14][15] Our data show that IAPs have variable trends, increasing through repetitions in some exercises and decreasing in others. It is possible that changes in breathing, overall fatigue, or fatigue of the focused muscle groups could contribute to this variation. ...
To determine intraabdominal pressure (IAP) in women during CrossFit and to determine whether parity, age, or CrossFit experience affects IAP during CrossFit exercises, we evaluated 10 women: 5 experienced and active CrossFitters and 5 who were not regularly engaged in CrossFit. A Laborie urodynamics abdominal pressure probe with the Goby wireless system measured IAP during 10 repetitions of 13 different CrossFit exercises. Women had a mean age of 36 years. A significant difference was found between mean peak IAP of the 5 parous vs the 5 nulliparous women (P = 0.009). Experience with CrossFit did not affect mean peak IAP achieved with exercise. In some exercises, there was a significant change in IAP as participants progressed through repetitions (P = 0.003 for back squats and 0.04 for sit-ups). Participants achieved IAP values that were markedly higher than those previously published.
... 11 Several researchers have questioned the validity of these recommendations, noting that IAPs during restricted activities are often less than those during unrestricted ones (such as getting up from a chair). [12][13][14] If IAP is found to be an established risk factor for POP, then it makes sense to attempt to decrease activities that raise IAP, as suggested by the American Urogynecologic Society, to the extent possible. In particular, it seems logical to do this during 1 particularly vulnerable time for the pelvic floor: the postpartum period following vaginal childbirth. ...
Objectives:
Intra-abdominal pressure (IAP) may contribute to pelvic floor health, although the direction and magnitude of such an effect, if any, are not yet known. Identifying individual characteristics, and in particular modifiable factors, associated with higher IAP during recovery from vaginal childbirth might serve to mitigate early pelvic floor dysfunction. The aim of this study was to identify characteristics associated with maximal IAP during lifting in postpartum primiparous women who delivered vaginally.
Methods:
At 6 to 10 weeks postpartum, we measured maximal IAP, assessed via an upper vaginal sensor, as participants (enrolled in an ongoing cohort study) lifted a weighted car seat (12.5 kg). We evaluated whether the following independent variables were associated with maximal IAP: age, ethnicity, body mass index, height, abdominal circumference, weight gain during pregnancy, lifting time, breath holding during lifting, lifting technique, measures of muscular fitness, and days since delivery.
Results:
In the 206 participants, weight, waist circumference, body mass index, and days since delivery were positively associated with mean maximal IAP during lifting, whereas IAP decreased as height increased. As the duration of the lifting task increased, mean maximal IAP during lifting also increased, but there were no associations between lifting technique or breath holding during lifting and IAP. Neither pelvic floor muscle strength nor abdominal muscle endurance was associated with IAP during lifting.
Conclusions:
Other than measures of body habitus and lifting duration, we did not identify modifiable factors that could mitigate maximal pressures experienced by the pelvic floor during the early postpartum period.
... However, multiple studies have shown that many unavoidable activities in a woman's day-today life create a greater increase in intra-abdominal pressure than the arbitrary weight-lifting limits that are often imposed on patients (i.e., no lifting greater than 8 lbs) during convalescence. As an example, getting out of a chair does not increase intra-abdominal pressure any more than lifting 20 lbs from a counter, lifting 13 lbs from the floor, climbing stairs, or walking briskly [16]. Coughing generates intravesical pressure similar to that of lifting 35 lbs from the floor [17]. ...
Purpose of review:
A common concern regarding pelvic floor surgery is the relatively high risk of recurrence. In an effort to minimize this risk, many surgeons instruct their patients to avoid certain activities during the healing process so as not to damage the repair before proper healing has occurred. However, many of these restrictions have been historically based on little to no hard evidence. The purpose of this review is to present the latest evidence-based recommendations regarding restrictions and limitations after pelvic floor surgery.
Recent findings:
The current review covers postoperative activities that could impact proper healing of a vaginal incision and of the strength of the reconstruction itself. It also looks at safety of the patient and those around her as she heals. Topics include pelvic rest, swimming, lifting exercising, working, and driving. Observational research suggests that many unavoidable activities of daily living may have as great, if not an even greater, risk of impacting the healing process than many of the modifiable activity restrictions that are commonly imposed on patients. This may explain why recent clinical trials show no greater problem with healing in patients randomized to less strict postoperative restrictions than the standard.
Summary:
Although further research is necessary, it appears that patients are more satisfied with less strict postoperative limitations, and this less restrictive activity may not have any significant negative impact on the healing process.
... Besides genetic and other variables affecting the pelvic support structures, the differential in the increase in IAP secondary to various life tasks is not well understood. One study questioning the routine postoperative activity restrictions concluded that lifting 20 lb (9 kg) from a counter, climbing stairs or doing abdominal crunches do not involve a larger increase in IAP than simply getting out of a chair [85]. ...
Introduction and hypothesis:
Pelvic floor disorders (PFD), including urinary incontinence, anal incontinence, and pelvic organ prolapse, are common and have a negative effect on the quality of life of women. Treatment is associated with morbidity and may not be totally satisfactory. Prevention of PFDs, when possible, should be a primary goal. The purpose of this paper is to summarise the current literature and give an evidence-based review of the prevention of PFDs METHODS: A working subcommittee from the International Urogynecological Association (IUGA) Research and Development (R&D) Committee was formed. An initial document addressing the prevention of PFDs was drafted, based on a review of the English-language literature. After evaluation by the entire IUGA R&D Committee, revisions were made. The final document represents the IUGA R&D Committee Opinion on the prevention of PFDs.
Results:
This R&D Committee Opinion reviews the literature on the prevention of PFDs and summarises the findings with evidence-based recommendations.
Conclusions:
Pelvic floor disorders have a long latency, and may go through periods of remission, thus making causality difficult to confirm. Nevertheless, prevention strategies targeting modifiable risk factors should be incorporated into clinical practice before the absence of symptomatology.
... IAP has been studied during activities performed by women tethered to a urodynamics machine. (1)(2)(3) To overcome limitations of such wired devices and to improve participant comfort, we developed a wireless vaginal (rather than rectal) pressure transducer to measure IAP during physical activities. (4)(5)(6) In the laboratory, this transducer has an accuracy of 0.7 ± SD 3.35 cm H 2 0 when compared against a reference pressure transducer with a NIST-traceable calibration over the measurement range of 0-350 cm H 2 o.) (5,6) There are many potential sources of variation when measuring IAP in a laboratory protocol. ...
In the urodynamics laboratory setting, a wireless pressure transducer, developed to facilitate research exploring intra-abdominal pressure (IAP) and pelvic floor disorders, was highly accurate. We aimed to study reproducibility of IAP measured using this transducer in women during activities performed in an exercise science laboratory.
Fifty-seven women (mean ± SD, age 30.4 ±9.3 years; body mass index, 22.4 ± 2.68 kg/m) completed 2 standardized activity sessions using the same transducer at least 3 days apart. Pressure data for 31 activities were transmitted wirelessly to a base station and analyzed for mean net maximal IAP, area under the curve, and first moment of the area. Activities included typical exercises, lifting 13.6 to 18.2 kg, and simulated household tasks. Analysis for test-retest reliability included Bland-Altman plots with absolute limits of agreement, Wilcoxon signed rank tests to assess significant differences between sessions, intraclass correlations, and κ statistics to assess intersession agreement in highest versus other quintiles of maximal IAP.
Few activities exhibited significant differences between sessions in maximal IAP, or in area under the curve and first moment of the area values. For 13 activities, the agreement between repeat measures of maximal IAP was better than ±10 cm H20; for 20 activities, better than ±15 cm H20. The absolute limits of agreement increased with mean IAP. The highest quintile of IAP demonstrated fair/substantial agreement between sessions in 25 of 30 activities.
Reproducibility of IAP depends on the activity undertaken. Interventions geared toward lowering IAP should account for this, maximize efforts to improve IAP reproducibility.
... Postoperative advice given to women aims to restrict activities; however, this advice is inconsistent and not evidence-based. Data from previous studies demonstrate that some activities restricted post-operatively (such as lifting 5 or 10 kg) do not increase P abd as much as coughing or straining [5,6]. Similarly, there is uncertainty as to which activities cause the greatest increase in P abd . ...
Introduction and hypothesis:
A wireless intravaginal pressure sensor (IVPS) has been developed to quantify abdominal pressure (P(abd)) changes during exercise and activities of daily living to guide post-operative advice given to women. In this pilot study, we aimed to compare IVPS performance, comfort, retention, and acceptability to a standard fluid-filled intrarectal pressure catheter currently used to measure P(abd) during routine urodynamics.
Methods:
A Life-Tech 3-mm urodynamic intrarectal catheter and IVPS were inserted concurrently in volunteers attending a urodynamics clinic. The IVPS was positioned above the levator plate and the intrarectal catheter positioned in routine fashion well above the anal sphincter. Routine urodynamics was undertaken, with women asked to perform star jumps if coughing or Valsalva did not invoke leakage. Subjects rated device comfort using a visual analogue scale (0-10). Repeated measures Bland-Altman analysis determined level of agreement (LOA) between the two devices for peak pressures for each activity.
Results:
Twenty-seven women were recruited, 67% of the participants preferred the IVPS, 18% the intrarectal catheter, while 15% had no preference. Mean comfort score was 0.9 ± 1.7 and 2.1 ± 2.6 (p = 0.049) for the IVPS and intrarectal catheter respectively. Bland-Altman analysis demonstrated minimal bias for cough and Valsalva, however LOA were wide. Differences were more prominent during star jumps where rapid dynamic pressure changes occurred.
Conclusions:
The IVPS had a higher comfort score and was well retained. The LOA between the two systems was moderate, but the high sampling rate and lower susceptibility to motion artefacts of the IVPS may provide more accurate information that will be important clinically.
... We used results from an unpublished pilot study, in which 18 clinicians specializing in pelvic floor disorders identified activities that they believed might cause, promote or hasten recurrence of pelvic floor disorders, and from previous work of intra-abdominal pressures during various activities. 50 We assigned all activities listed on the LPAQ a categorical value from 1 to 4 using methods established in the validation and scoring of the Occupation Questionnaire. A score of "1" indicated no relationship, "2" probably no, "3" possibly, and "4" a highly likely relationship with promoting pelvic floor disorders (based on the expert panel). ...
One in four women has moderate to severe symptoms of at least one pelvic floor disorder. Lifetime physical activity, a modifiable risk factor, may theoretically predispose women to, or protect them from, developing pelvic floor disorders. It is neither feasible nor ethical to test this association using the most rigorous (level I) study design.
The aim of this manuscript is to describe the methods for the PHysical ACtivity Study (PHACTS), which encompasses two case-control studies and the development of a registry, and to describe challenges and solutions to study progress to date. For each of the case-control studies, the primary aims are to determine, compared to controls with neither pelvic organ prolapse nor urinary incontinence, whether 1) pelvic organ prolapse or 2) stress urinary incontinence is associated with a) increased or decreased current leisure activity or b) increased or decreased overall lifetime activity (including leisure, household, outdoor, and occupational) measured in MET-hours per week, as well as in strenuous hours per week.
To obtain 175 pelvic organ prolapse cases, 175 stress urinary incontinence cases, and an equal number of age, body mass index and recruitment site matched controls, we plan to enroll 1500 women from about 20 primary care level clinics.
We have encountered various challenges leading to lessons learned about minimizing bias, recruitment from community clinics, the lifetime physical activity instrument used, and data management.
Our experiences can help guide future investigators studying risk factors, particularly physical activity, and pelvic floor disorders.
Importance
Restricting activity after midurethral slings is an unproven practice.
Objective
The objective of this study was to evaluate the effect of postoperative activity restriction on satisfaction and outcomes after slings.
Study Design
This was a multicenter, 2-arm, noninferiority randomized controlled trial. Patients aged 18–85 years undergoing treatment with a midurethral sling were randomized 1:1 to postoperative activity restriction or liberal activity. Restrictions included avoidance of strenuous exercise and heavy lifting. The liberal group was allowed to resume activity at their discretion. Our primary outcome was satisfaction with postoperative instruction at 2 weeks. Secondary outcomes included surgical failure, mesh exposure rates, and other adverse events.
Results
In total, 158 patients were randomized with 80 to the liberal group and 78 to the restricted group. At 2 weeks, 54 (80.6%) of patients in the liberal group and 48 (73.9%) of patients in the restricted group were satisfied. We found statistical evidence supporting the hypothesis that postoperative liberal activity instruction is noninferior to activity restriction with regard to patient satisfaction ( P = 0.0281). There was no significant difference in strenuous activity at 2 weeks ( P = 0.0824). The liberal group reported significantly more moderate activity at 2 weeks ( P = 0.0384) and more strenuous activity at 6 weeks and 6 months ( P = 0.0171, P = 0.0118, respectively). The rate of recurrent or persistent stress incontinence for liberal versus restricted groups was 18.52% versus 23.53% ( P = 0.635). There were no statistically significant differences in complication rates.
Conclusions
Postoperative liberal activity was noninferior to activity restriction with regard to patients’ satisfaction. There was no evidence supporting a statistically significant association between postoperative instruction and negative surgical outcomes.
Gynecologic surgeons have traditionally restricted the physical activity of postoperative patients. Minimally invasive surgery and enhanced recovery after surgery programs have contributed to decreased hospital stays and more expeditious recovery. In this narrative review, we review the current state of postoperative activity restrictions in gynecology and other specialties, the purported risks and potential benefits of postoperative activity, the available evidence to refute or support activity in the postoperative activity, and, finally, the potential benefit of added activity in the postoperative period.
Importance:
Restrictions on postoperative activity following pelvic organ prolapse (POP) surgery are not evidence based. Nonetheless, many pelvic surgeons place lifting and activity restrictions on patients following surgery.
Objective:
To evaluate whether expedited activity results in noninferior anatomic and symptomatic outcomes compared with standard activity restrictions after POP surgery.
Design, setting, and participants:
This randomized noninferiority clinical trial included patients undergoing vaginal or laparoscopic apical reconstructive surgery for POP between July 1, 2020, and October 31, 2021, at a single academic tertiary referral center in Durham, North Carolina. Anatomic outcomes were assessed by masked examiners, and subjective outcomes were assessed via validated surveys, both completed at 3 months postoperatively. Patients meeting minimum physical activity criteria with at least stage II bothersome POP were eligible. A total of 218 patients were approached, of whom 123 were randomly assigned and 107 had complete outcome data and were included in the analysis.
Interventions:
Patients were randomly assigned to receive standard restrictions vs expedited postoperative activity instructions.
Main outcomes and measures:
The anatomic coprimary outcome was maximum anatomic POP support loss (SLmax), which is the most distal point of pelvic organ support loss according to the Pelvic Organ Prolapse Quantification System (noninferiority margin, 1.0 cm). The symptomatic coprimary outcome was the Pelvic Organ Prolapse Distress Inventory (POPDI) symptom score (noninferiority margin, 34.3 points). Differences between outcomes were assessed using linear regression models controlling for baseline SLmax and POPDI, respectively.
Results:
Of 123 participants randomized, 107 had complete 3-month outcome data and were included in the analysis. Mean (SD) age was 62.8 (10.1) years. At 3 months, mean (SD) SLmax was -1.7 (1.4) cm in the expedited group and -1.5 (1.4) cm in the standard group (P = .44). After adjusting for baseline SLmax, the mean maximum support loss was 0.18 cm higher within the vaginal canal in the expedited group (95% CI, -0.68 to 0.33 cm). The coprimary outcome of POPDI score was a mean (SD) 23.7 (41.8) points in the expedited group vs 25.7 (39.3) points in the standard group (P = .80). After adjusting for baseline scores, mean POPDI scores were 5.79 points lower in the expedited group (95% CI, -20.41 to 8.84).
Conclusions and relevance:
The findings demonstrate that expedited activity after prolapse surgery results in noninferior anatomic and symptomatic prolapse outcomes. It is reasonable to instruct patients undergoing minimally invasive prolapse surgery to resume physical activities ad lib postoperatively.
Trial registration:
ClinicalTrials.gov Identifier: NCT04329715.
Parastomal hernia is a postoperative complication for stoma patients. Early physiotherapy-guided rehabilitation is important for patients to return to their daily lives. Optimized therapy options improve healing and allow increasing performance and resumption of physical activities after surgery. The aim is to improve patientsʼ body awareness of the stability of the abdominal wall and to effectively reactivate posture and movement patterns. Therefore, in order to prevent postoperative hernia, education of posture and movements in daily life, such as standing up or coughing, should take place with timely coordinated centring of intraabdominal pressure (IAP). An individualised rehabilitation concept contributes significantly to improving the quality of life of stoma carriers.
Background
In Germany, standardized and evidence-based recommendations for activity and resting after abdominal and hernia surgery are lacking. Moreover, very little is known about the ability to strain and the duration of sick leave.Materials and methodsThe results of surveys of all German surgical departments and the participants of the 2019 Annual Meeting of the European Hernia Society in Hamburg were pooled and compared with the data from a literature review.ResultsThe literature review did not reveal binding recommendations on postoperative strain or justify prolonged resting compared with the survey’s consensus. The risk of incisional hernia development depends on surgical technique, suture material, surgical site infections, and patient-specific risk factors. The native biomechanical stability is restored in laparotomy wounds after 30 days of unimpaired healing. According to the survey, 74.6% of all participants considered a resting period of up to 2 weeks after laparoscopic surgery as sufficient. After midline laparotomies, up to 4 weeks were considered appropriate by over half of participants (57.3%). The survey of German surgical departments revealed an agreement of 60.2% for longer resting duration, whereas the international survey participants endorsed this in only 31.5% of cases (p = 0.000).Conclusions
The weak data basis regarding postoperative refrain from straining of the abdominal wall is heterogeneous. Thus, a proposal of recommendations on postoperative activity is presented to avoid unjustified prolonged resting periods and sick leave.
Zusammenfassung
Einleitung Narbenhernien (NH) sind häufige Komplikationen nach abdominalchirurgischen Eingriffen und beeinflussen die postoperative Phase der Schonung, indem eine frühe Belastung mit traditionell einem erhöhten NH-Risiko in Verbindung gebracht wird. Evidenz hierzu fehlt jedoch. Einen Zusammenhang zwischen der postoperativen körperlichen Aktivität nach abdominellen Operationen und der Entwicklung von NH untersucht diese Studie.
Material und Methoden Patienten, die 2009 – 2016 eine Laparoskopie (LS) oder Laparotomie (LT) aufgrund einer viszeralchirurgischen Indikation erhielten, wurden mittels eines Fragebogens zur Belastung, zu Beschwerden und zum Auftreten von NH sowie zur Lebensqualität postoperativ befragt. Komplizierte Verläufe (Clavien-Dindo > III), Laparostomaanlagen und Eingriffe im Zusammenhang mit Hernienrekonstruktionen wurden ausgeschlossen.
Ergebnisse 393 Patienten beantworteten den Fragebogen (43,6%) vollständig, dabei waren 274 LS und 128 LT. Die NH-Inzidenz betrug 5,2% (LS) und 18,0% (LT, p = 0,001). NH-Patienten waren jünger und häufiger Männer. Patienten mit NH erreichten in 30,5% postoperativ keine Vollbelastung. Die Verwendung einer Abdominalbandage hatte keinen Einfluss auf die NH-Rate. Die Lebensqualität war für die NH-Gruppe eingeschränkt, sowohl auf psychischer als auch physischer Ebene.
Schlussfolgerung Die frühe schmerzadaptierte Belastung nach abdominalchirurgischen Eingriffen stellt in dieser Studie keinen Risikofaktor für die Entwicklung von Narbenhernien dar. Die prospektive Evaluation liberaler postoperativer Aufbelastungsregime ist notwendig.
Introduction:
The evidence regarding the effect of exercise, specifically Modified Pilates (MP), on pelvic floor muscles (PFMs) is limited. We report our pilot study using the MAPLe® device to assess the effect of MP type exercises on PFM electomyographic (EMG) activity and whether PFM contraction could be performed during specific MP exercises.
Methods:
The MAPLe® device was used to measure EMG activity of PFMs in healthy volunteers in different MP positions. Positions were divided into 'neutral', 'core' and 'plank' and EMG readings were taken at rest, during Valsalva and during active contraction.
Results:
Twenty volunteers were recruited. The median age was 35 (IQR 27-39.5) years. Higher EMG readings were seen in 'core' and 'plank' positions at rest. No position inhibited a conscious contraction and positions which engaged core muscles provoked an augmented contraction.
Conclusion:
This is the first study to show that when MP positions are held for short periods of time, in asymptomatic women, the changes in PFM EMG are higher. This suggests that a stronger muscle contraction can be achieved when the core is co-contracted. Higher EMG readings were seen during 'core' and 'plank' positions; despite this, further activation with a conscious PFM contraction was still achievable.
Introduction and hypothesis:
There is little information on the impact that postoperative instructions have on physical activity to help guide physicians in providing these recommendations after surgery. Our study objective was to evaluate the impact of postoperative instructions on physical activity. We hypothesized that there would be no differential effect of instructions on activity.
Methods:
In this randomized controlled trial, patients undergoing prolapse repair were randomized to receive either liberal or restricted postoperative activity instructions between February 2017 and February 2019. Physical activity was measured using the Activities Assessment Scale (AAS) and tri-axial accelerometers measured at baseline and 2 and 6 weeks after surgery. A sample size of 146 patients was planned to compare these activity measurements. AAS scores and accelerometer readings of the two groups were compared using separate variance t tests.
Results:
A total of 157 women were recruited between February 2017 and February 2019, including 146 patients with completed study data (n = 72 liberal, n = 74 restricted). There was no difference in physical activity at 2 weeks between the liberal and the restricted instruction groups, as measured by AAS scores (70.47 ± 12.83, 69.54 ± 12.22, p = 0.66), total steps (4,582.20 ± 2,164.5, 5,014.47 ± 3,025.46, p = 0.32), active minutes (4.22 ± 6.17, 4.96 ± 9.65, p = 0.25), and 10-min intervals (0.76 ± 1.11, 0.77 ± 0.93, p = 0.95) respectively. Similarly, there was no difference in activity at 6 weeks between the liberal and the restricted instruction groups. as measured by AAS scores (81.86 ± 8.25, 81.31 ± 10.31, p = 0.72), total steps (6,316.25 ± 3,173.53, 6,589.94 ± 3,826.43, p = 0.64), active minutes (8.79 ± 10.5,11.36 ± 18.18, p = 0.98), and 10-min intervals (1.37 ± 1.34, 1.34 ± 1.40, p = 0.89) respectively.
Conclusion:
Postoperative instructions do not have an impact on physical activity measures in patients who have undergone pelvic reconstructive surgery.
Introduction and hypothesis
The objective was to determine if a bowel preparation prior to minimally invasive sacrocolpopexy (MIS) influences post-operative constipation symptoms. We hypothesized that women who underwent a bowel preparation would have an improvement in post-operative defecatory function.
Methods
In this randomized controlled trial, women undergoing MIS received a pre-operative bowel preparation or no bowel preparation. Our primary outcome was post-operative constipation measured by the Patient Assessment of Constipation Symptoms (PAC-SYM) 2 weeks post-operatively. Secondary outcomes included surgeon’s perception of case difficulty. Both intention-to-treat (ITT) and per-protocol analyses (PPA) were performed. Analyses were carried out using t test, Fisher’s exact test, the Wilcoxon test and the Chi-squared test.
Results
Of 105 enrolled women, 95 completed follow-up (43 preparation and 52 no preparation). Baseline characteristics and rates of complications were similar. No differences were noted on ITT. The post-operative abdominal PAC-SYM subscale was closer to baseline for women who received a bowel preparation on PPA (change in score 0.74 vs 1.08, p = 0.045). Women who underwent a preparation were less likely to report strain (6.0% vs 26.7%, p = 0.009) or type 1 Bristol stool on their first post-operative bowel movement (4.3% vs 17.5%, p = 0.047). Surgeons were more likely to rate the complexity of the case as “more difficult than average” (54.4% vs 40.1%, p = 0.027) in those without a bowel preparation.
Conclusions
Although there was no difference in ITT analysis, women who underwent a bowel preparation prior to MIS demonstrated benefit to post-operative defecatory function with a corresponding improvement in surgeon’s perception of case complexity.
Background:
Postoperative activity restrictions are designed to prevent undue stress on a recent repair and minimize the risk of surgical complication, however, there is little evidence to support certain restrictions in clinical practice. For the pediatric population, there is a paucity of formal evaluations of postoperative activity restrictions, and little is known about current practice patterns among pediatric surgeons. This study aimed to describe national practice patterns of pediatric surgeons for postoperative activity recommendations following three common general surgical procedures.
Methods:
A 7-item survey was sent to all American Pediatric Surgical Association (APSA) members regarding surgeon practice of recommended activity restrictions for school attendance, participation in playground or gym, participation in contact sports, and heavy lifting in children following 3 procedures: exploratory laparotomy, laparoscopic appendectomy, and inguinal hernia repair. Information on type and duration of clinical practice was also collected for each surgeon. Descriptive and bivariate analyses were performed.
Results:
The survey was completed by 293 pediatric surgeons for a response rate of 28.9%. There was wide national variability in the recommended activity restrictions for children <12 years old among pediatric surgeons. Following laparoscopic appendectomy, 30.7%, 51.9% and 47.8% of surgeons recommends restriction of gym, contact sports, and heavy lifting for 2-3 weeks respectively, but 26.7%, 19.8%, and 22.2% do not recommend any restriction whatsoever of these three activities. Following inguinal hernia repair, 31.7%, 49.1% and 44.4% of surgeons recommend restriction of gym, contact sports, and heavy lifting for 2-3 weeks, but 30.8%, 30.8%, and 29.2% do not recommend any restriction of these three activities. Only 22% of surgeons change their activity restriction recommendations for children ≥12 years old, this decision was not associated with surgeon years in practice or type of practice.
Conclusions:
There is considerable variability in surgeon recommendations for activity restrictions following three general surgery procedures in children. While activity restrictions are rooted in the physiology of wound healing, there is little evidence to support the benefit of these restrictions in clinical practice. In addition, activity restriction may have unintended deleterious effects on a child's psychosocial well-being and quality of life. Further investigation should be pursued to understand the utility of activity restrictions in children and their impact on clinical outcomes and patient quality of life.
Type of study:
Treatment study.
Level of evidence:
Level V, expert opinion.
An enterocele is a herniation of the pelvic peritoneum and/or small bowel beyond the normal boundaries of the cul-de-sac. Endopelvic fascia supporting the anterior, apical or posterior vagina is deficient, allowing the vagina to prolapse and small bowel to fill the hernia sac. An enterocele classically causes apical and/or posterior vaginal wall prolapse as the small bowel dissects into the rectovaginal space. Anterior and/or posterior vaginal wall prolapse without concomitant apical prolapse is uncommon. Therefore, apical prolapse repair should be included in the majority of enterocele repairs. Outcome studies also show that restoration of the apex corrects nearly half of anterior vaginal wall defects and one-third of posterior defects.
Objective:
To assess the relationship between prescribed postoperative activity recommendations (liberal compared with restricted) after reconstructive prolapse surgery and patient satisfaction and pelvic floor symptoms.
Methods:
In our multicenter, randomized, double-blind clinical trial, women undergoing reconstructive prolapse surgery were randomized to liberal compared with restricted postoperative activity recommendations. Liberal recommendations instructed women to resume postoperative activity at the woman's own pace with no restrictions on lifting or high-impact activities. Conversely, restricted recommendations instructed women to avoid heavy lifting or strenuous exercise for 3 months. The primary outcome, patient satisfaction, was assessed on a 5-point Likert scale at 3 months postoperatively with the question, "How satisfied are you with the result of your prolapse surgery?" Secondary outcomes included anatomic outcomes and pelvic floor symptoms.
Results:
From September 2014 to December 2015, 130 women were screened and 108 were randomized. Ultimately, 95 were allocated to study intervention (n=45 liberal, n=50 restricted) and completed the primary outcome. Baseline characteristics (including pelvic organ prolapse quantification stage and demographics) and surgical intervention did not differ between groups. Most women underwent a minimally invasive sacrocolpopexy (58) followed by vaginal suspension (27) or vaginal closure procedures (nine). Rates of satisfaction were similarly high in the liberal and restricted recommendations groups (98% compared with 94%, odds ratio 0.36 [0.036-3.55], P=.619). Anatomic outcomes did not differ between groups; however, fewer pelvic floor symptoms were reported in the liberal group.
Conclusion:
Satisfaction was equally high 3 months after prolapse surgery in women who were instructed to liberally resume activities compared with those instructed to restrict postoperative activities. Women who liberally resumed their activities reported fewer prolapse and urinary symptoms and had similar short-term anatomic outcomes suggesting that allowing women to resume their normal activities postoperatively may result in improved pelvic floor outcomes.
Clinical trial registration:
ClinicalTrials.gov, www.clinicaltrials.gov, NCT02138487.
Disclaimer: The work involved no external funding. Both Dr Iyer AND Prof Rane act as Consultants to the American Medical Systems but receive no royalties from the company.. Aim: The aim of this study is to assess the effect of early physical activity on objective and subjective cure rates after a mid-urethral sling. Methods: This is a pilot study in which 50 patients with primary urodynamic stress incontinence underwent sling surgery and were assigned to either the Early Physical Activity(EPA) or NO Physical Activity(NPA) groups. All patients were evaluated at 3 months with urodynamic studies and questionnaire. Results: The objective cure rate in the early activity and no activity group were 76% and 88% respectively (p=0.465). Meanwhile, the subjective cure rate in the activity group was 56% compared to 68% in the control group (p=0.56). Conclusion: There was no statistically significant difference in subjective or objective cure rates between the two groups at three months.
Operationen am unteren Gastrointestinaltrakt können eine Fülle langfristiger Konsequenzen haben. Malnutrition, Durchfälle, künstlicher Darmausgang und die psychische Belastung müssen vom Hausarzt wahrgenommen und entsprechend behandelt werden. In dieser CME-Übersicht lernen Sie, worauf Sie im Einzelnen achten sollten.
Objective:
To quantify and compare intraabdominal pressures (IAPs) in women with pelvic floor dysfunction during standard activities.
Study design:
Eligible subjects were women with pelvic organ prolapse and/or urinary incontinence presenting for urodynamic evaluation. IAPs were recorded for the following tasks: (1) standing up from a chair, (2) coughing, (3) lifting 10 lb (4.54 kg), (4) lifting 20 ;b (9.07 kg), and (5) pushing 20 lb (9.07 kg). Net pressures were compared by activity, age, and body mass index (BMI).
Results:
We enrolled 147 subjects. The mean net IAPs generated were as follows: pushing 20 lb (11.6 cm H2O), lifting 10 lb (11.9 cm H2O), lifting 20 lb (19.6 cm H2O), standing up (36.8 cm H2O), and coughing (80.4 cm H2O). Coughing and standing up generated significantly more pressure than lifting either 10 or 20 lb (p < 0.001). IAPs were significantly lower for standing up in patients > or = 70 years old (p = 0.01) but otherwise did not vary by age. Obese subjects (BMI > or = 30.0) generated significantly more pressure than did normal-weight subjects (BMI 18.5-24.9) during all activities.
Conclusion:
Common activities such as standing up and coughing generate significantly more IAP than lifting up to 20 lb. This may have implications for postoperative restrictions in patients with pelvic floor dysfunction.
Abstract Strenuous physical activity has been linked to pelvic floor disorders in women. Using a novel wireless intra-vaginal pressure transducer, intra-abdominal pressure was measured during diverse activities in a laboratory. Fifty-seven women performed a prescribed protocol using the intra-vaginal pressure transducer. We calculated maximal, area under the curve and first moment of the area intra-abdominal pressure for each activity. Planned comparisons of pressure were made between levels of walking and cycling and between activities with reported high pressure in the literature. Findings indicate variability in intra-abdominal pressure amongst individuals doing the same activity, especially in activities that required regulation of effort. There were statistically significant differences in maximal pressure between levels of walking, cycling and high pressure activities. Results for area under the curve and first moment of the area were not always consistent with maximal pressure. Coughing had the highest maximal pressure, but had lower area under the curve and first moment of the area compared to most activities. Our data reflect novel findings of maximal, area under the curve and first moment of the area measures of intra-abdominal pressure, which may have clinical relevance for how physical activity relates to pelvic floor dysfunction.
Die vaginale Hysterektomie ist in der Gynäkologie ein Standardeingriff. Nach der Darstellung der Studienlage zur Indikation und Komplikationen wird die Operationstechnik in den einzelnen Operationsschritten erklärt. Auch Uteri mit Myomen können vaginal durch ein Morcellement entfernt werden, als Appendix sind auch die Operationsschritte der vaginalen Adnektomie erläutert. Die abdominale Hysterektomie ist einer der häufigsten operativen Eingriffe weltweit. Ihr Vorteil wird vor allem bei zu erwartenden Adhäsionen oder zusätzlichen Adnextumoren gesehen. Es wird eine völlig neue Präparationsmethode dargestellt, die Elemente der laparoskopischen Hysterektomietechnik mit der Laparotomie verbindet.
Sollte eine vaginale Hysterektomie technisch nicht möglich oder kontraindiziert sein, so stellen laparoskopische Hysterektomieverfahren eine sinnvolle Alternative zu abdominalen Verfahren mit einer deutlich geringeren postoperativen Morbidität dar. Bei vergleichbaren Komplikationsraten zeichnen sie sich allerdings durch eine sehr viel längere Lernkurve aus.
Im Abschnitt Kolpopexie wird schließlich die Wiederherstellung der Aufhängung des vaginalen mittleren Kompartiments durch Fixation des Scheidengrunds beschrieben, entweder von vaginal nach Amreich und Richter am sakrospinalen oder sakrotuberalen Ligament oder von abdominal über 2 lateral gestielte Faszienzügelstreifen aus der Externusaponeurose des M. rectus abdominis. Die Indikation ist der Partial- oder Totalprolaps des Uterus und/oder der Vagina mit Beschwerdesymptomatik.
Introduction and hypothesis:
The influence of intra-abdominal pressure (IAP) on prolapse development is poorly understood. Nonetheless, chronic cough, high BMI, or heavy lifting predisposes women to pelvic organ prolapse (POP). This study aims to develop and test a novel, wireless intra-vaginal pressure sensor (IVPS) to quantify intra-abdominal pressure changes across a range of well-defined activities.
Methods:
The IVPS shape was based on silicone moulds of the vagina and was designed to sit in the proximal vagina. It is thin, compliant and negligibly distorts the surrounding tissues. Repeatability was assessed in 14 volunteers performing three sets of activities (cycles). Each cycle consisted of 18 activities. The IVPS was removed and reinserted after completing either the first or second of the three-cycle exercise routine (order). Participants independently inserted and removed the device. A nested split-plot, factorial ANOVA determined the effect of order using mean IAP increase (mean) and peak-to-peak fluctuations in IAP (amplitude) as dependent variables. Descriptive analysis examined the relative change in IAP across the activities. Cronbach's alpha) determined repeatability.
Results:
All women found the IVPS comfortable and easy to insert. There was excellent correlation between cycles across all variables, r > 0.935 (mean) and r > 0.964 (amplitude). The order was not statistically significant, demonstrating a highly repeatable measurement.
Conclusion:
This is the first device to measure IAP at high frequency with the freedom of a wireless system. The IVPS aims to provide information to advise women better on suitable pre- and post-operative activities.
Pelvic organ prolapse is a common gynaecological problem and the mechanisms underlying prolapse development are not yet clear but it is thought that increases in abdominal pressure, such as those routinely involved in heavy lifting and long periods of standing, may cause progressive pelvic floor damage over time. The aim of this study was to investigate the effects of strenuous physical activity on the development of prolapse. A narrative literature review was carried out to investigate the effects of occupation and recreational activity on the pathogenesis of pelvic organ prolapse. A marked paucity of literature relevant to the research question makes it difficult to draw firm conclusions. Further research is greatly needed to explore potentially preventable factors in this frequently occurring condition. The review reveals some evidence linking strenuous physical activity with pelvic organ prolapse but this is neither consistent nor adequately powered to reach any firm conclusions.
Activities thought to induce high intra-abdominal pressure (IAP), such as lifting weights, are restricted in women with pelvic floor disorders. Standardized procedures to assess IAP during activity are lacking and typically only focus on maximal IAP, variably defined. Our intent in this methods paper is to establish the best strategies for calculating maximal IAP and to add area under the curve and first moment of the area as potentially useful measures in understanding biologic effects of IAP. Thirteen women completed a range of activities while wearing an intra-vaginal pressure transducer. We first analyzed various strategies heuristically using data from 3 women. The measure that appeared to best represent maximal IAP was an average of the three, five or ten highest values, depending on activity, determined using a top down approach, with peaks at least 1 second apart using algorithms written for Matlab computer software, we then compared this strategy with others commonly reported in the literature quantitatively using data from 10 additional volunteers. Maximal IAP calculated using the top down approach differed for some, but not all, activities compared to the single highest peak or to averaging all peaks. We also calculated area under the curve, which allows for a time component, and first moment of the area, which maintains the time component while weighting pressure amplitude. We validated methods of assessing IAP using computer-generated sine waves. We offer standardized methods for assessing maximal, area under the curve and first moment of the area for IAP to improve future reporting and application of this clinically relevant measure in exercise science.
Many surgeons recommend rest and restricting activities to their patients after surgery. The aim of this review is to summarize the literature regarding types of activities gynecologic surgeons restrict and intra-abdominal pressure during specific activities and to provide an overview of negative effects of sedentary behavior (rest). We searched PubMed and Scopus for years 1970 until present and excluded studies that described recovery of activities of daily living after surgery as well as those that assessed intra-abdominal pressure for other reasons such as abdominal compartment syndrome and hypertension. For our review of intra-abdominal pressure, we excluded studies that did not include a generally healthy population, or did not report maximal intra-abdominal pressures. We identified no randomized trial or prospective cohort study that studied the association between postoperative activity and surgical success after pelvic floor repair. The ranges of intra-abdominal pressures during specific activities are large and such pressures during activities commonly restricted and not restricted after surgery overlap considerably. There is little concordance in mean peak intra-abdominal pressures across studies. Intra-abdominal pressure depends on many factors, but not least the manner in which it is measured and reported. Given trends towards shorter hospital stays and off work intervals, which both predispose women to higher levels of physical activity, we urge research efforts towards understanding the role of physical activity on recurrence of pelvic organ prolapse and urinary incontinence after surgery.
When rats are subjected to chemical hepatocarcinogenesis according to the protocol of D. Solt and E. Farber ((1976) Nature (London)263, 701–703), the liver exhibits elevated levels of tyrosine protein kinase activity as early as 3 weeks after the injection of diethylnitrosoamine. A more striking elevation in tyrosine protein kinase activity is noted in rat hepatomas induced by administration of chemical carcinogens, in particular that of 3′-methyl-4-dimethylaminoazobenzene (3′-Me-DAB). Tyrosine protein kinase solubilized from the particulate fraction of 3′-Me-DAB-induced hepatoma has a molecular weight identical to that of p60v-src, cross-reacts with p60v-src immunologically, phosphorylates the heavy chain of anti-p60v-src IgG, and probably belongs to a family of p60c-src. The tyrosine protein kinase from the particulate fraction of normal rat liver is indistinguishable from the hepatoma kinase in these properties; thus it apparently differs only in the level of activity. Whether the liver and hepatoma kinases differ merely quantitatively or whether they differ even qualitatively, however, remains to be elucidated.
Guidelines on contraindications for lung function tests have been based on expert opinion from >30 years ago. High-risk contraindications to lung function testing are associated with cardiovascular complications such as myocardial infarct, pulmonary embolism or ascending aortic aneurysm. Slightly less risky but still serious contraindications are predominantly centred on recovery from major thoracic, abdominal or head surgery. Less serious surgical procedures will present a possible risk, but the RR depends upon whether the lung function is essential or can wait until the patient's condition improves. In recent decades there have been moves towards less invasive surgical techniques, keyhole surgery and new technology such as laser surgery which minimise the amount of collateral damage to surrounding tissues. In thoracic surgery there is a shift in emphasis to quicker postsurgical mobility. Furthermore there has been little analysis of the scientific facts behind the current recommendations and contraindications. The principle absolute and relative contraindications are in need of revision, and recommended times of abstaining from lung function tests needs to be reviewed. This review aims to outline the key issues and suggests newer recommendations for contraindications for performing lung function using a risk matrix, as well as offering alternative approaches to testing patients who may be at risk of complication from testing. In general, the previous recommendation of waiting for 6 weeks after surgical procedures or medical complications before performing lung function can often now be reduced to <3 weeks with modern less invasive surgical techniques.
To determine the incidence of surgically managed pelvic organ prolapse and urinary incontinence in a population-based cohort, and to describe their clinical characteristics.
Our retrospective cohort study included all patients undergoing surgical treatment for prolapse and incontinence during 1995; all were members of Kaiser Permanente Northwest, which included 149,554 women age 20 or older. A standardized data-collection form was used to review all inpatient and outpatient charts of the 395 women identified. Variables examined included age, ethnicity, height, weight, vaginal parity, smoking history, medical history, and surgical history, including the preoperative evaluation, procedure performed, and details of all prior procedures. Analysis included calculation of age-specific and cumulative incidences and determination of the number of primary operations compared with repeat operations performed for prolapse or incontinence.
The age-specific incidence increased with advancing age. The lifetime risk of undergoing a single operation for prolapse or incontinence by age 80 was 11.1%. Most patients were older, postmenopausal, parous, and overweight. Nearly half were current or former smokers and one-fifth had chronic lung disease. Reoperation was common (29.2% of cases), and the time intervals between repeat procedures decreased with each successive repair.
Pelvic floor dysfunction is a major health issue for older women, as shown by the 11.1% lifetime risk of undergoing a single operation for pelvic organ prolapse and urinary incontinence, as well as the large proportion of reoperations. Our results warrant further epidemiologic research in order to determine the etiology, natural history, and long-term treatment outcomes of these conditions.
The purpose of this study was to describe the prevalence of and correlates for pelvic organ prolapse.
This was a cross-sectional analysis of women who enrolled in the Women's Health Initiative Hormone Replacement Therapy Clinical Trial (n = 27,342 women). Baseline questionnaires ascertained demographics and personal habits. A baseline pelvic examination assessed uterine prolapse, cystocele, and rectocele. Descriptive statistics and logistic regression models were used to investigate factors that were associated with pelvic organ prolapse.
In the 16,616 women with a uterus, the rate of uterine prolapse was 14.2%; the rate of cystocele was 34.3%; and the rate of rectocele was 18.6%. For the 10,727 women who had undergone hysterectomy, the prevalence of cystocele was 32.9% and of rectocele was 18.3%. After controlling for age, body mass index, and other health/physical variables, African American women demonstrated the lowest risk for prolapse. Hispanic women had the highest risk for uterine prolapse. Parity and obesity were strongly associated with increased risk for uterine prolapse, cystocele, and rectocele.
Pelvic organ prolapse is a common condition in older women. The risk for prolapse differs between ethnic groups, which suggests that the approaches to risk-factor modification and prevention may also differ. These data will help address the gynecologic needs of diverse populations.
Objective: To assess the frequency and nature of postoperative activity restriction among gynecologists who perform hysterectomy, colporrhaphy, or retropubic urethropexy.
Methods: Gynecologists attending three large obstetrics and gynecology meetings during 1998 completed a questionnaire detailing surgical practice and postoperative restrictions. Data were analyzed for frequencies, central tendencies, and comparisons among groups.
Results: Most gynecologists restrict vaginal intercourse, vaginal devices, driving, and high-impact exercise. There was great variation in lifting restrictions, with the duration ranging from 1 to 104 weeks and the weight range from 1 to 50 pounds. Bathing was restricted by fewer than half of the physicians, and stair climbing was not commonly restricted (22%).
Conclusion: Gynecologists commonly recommend physical limitations following hysterectomy, colporrhaphy, and retropubic urethropexy. The inconsistency of these recommendations suggests an uncertain scientific footing and deserves further study.
The weight of the upper part of the trunk is partially transmitted to the pelvis via the vertebral column. If the muscle walls around the abdominal cavity are contracted, a high pressure can be generated within the cavity (greater than 200 mmHg). The abdominal space can them transmit part of weight to, e.g., the upper part of the body, Intra-abdominal pressure recordings have been performed during locomotion and other natural movements with intragastric pressure recordings. With each step, there is a phasic variation in pressure, with its peak coinciding with that of the peak vertical force exerted by the leg against the ground. The peak values increase progressively with the speed of walking/running up to a mean of 38 mmHg and with trough values of 16 mmHg. The phasic variations with each step is due to a phasic activation of the abdominal muscles, with an EMG activity starting 50 ms or more before foot contact. If an extra load is put on the back, the posture changes and at the highest speed of running the pressure values are significantly higher than without this additional load. After a jump down from a moderate height of 0.4 m, the average increase is 89 mmHg and can often exceed 100 mmHg. These pressure changes are large and will presumably act to unload the spine under the prevailing biomechanical conditions and, in addition, there will no doubt be an effect on the circulatory system.
In order to investigate intra-thoracic pressure (ITP) and intra-abdominal pressure (IAP) during lifting and jumping, 11 males were monitored as they performed the dead lift (DL), slide row (SR), leg press (LP), bench press (BP), and box lift (BL) at 50, 75 and 100% of each subject's four-repetition maxima, the vertical jump (VJ), drop jump (DJ) from 0.5 and 1.0 m heights, and Valsalva maneuver (VM). Measurements were made of peak pressure, time from pressure rise to switch-marked initiation of body movement, and time from the movement to peak pressure. The highest ITP and IAP occurred during VM (22.2 +/- 6.0 and 26.6 +/- 6.7 kPa, respectively) with one individual reaching 36.9 kPa (277 mm Hg) IAP. In ascending order of peak ITP during the highest resistance sets, the activities were SR, BP, VJ, DJ, DL, BL, LP, and VM, while the order for IAP was BP, VJ, DJ, BL, DL, LP, SR, and VM. Pressures significantly (P less than 0.05) increased with amount of weight lifted, rising before and peaking after the weight moved. IAP generally rose earlier and was of greater magnitude than ITP. For the jumps, pressure rose and diminished before the feet lost contact with the ground. Drop-jump height did not affect pressure. Correlation of pressure with weight lifted was fair to good for most activities.
Reproducibility of intra-abdominal pressure (IAP) variation was investigated in fifteen young male subjects when lifting three loads, 49, 98 and 147 N, with three speeds of movement, slow, fast and spontaneous, and starting from four standing postures: trunk erect, trunk forward flexed at 30, 60, and 90 degrees of dorsolumbar inclination. Each lift was replicated five times successively and the whole protocol was replicated at one a week interval. The intra-individual variability in IAP response was assessed using the standard deviation of each series of ten lifts. Results showed that variability of peak IAP increased with the load and with the lifting speed. This effect of speed was especially observed for light loads and in forward bending postures. Trunk posture had in itself no significant effect on IAP reproducibility. However, when the variations in the moment acting at lumbar level were taken into account by considering the IAP to moment ratio, the reproducibility of the response was not affected by the load but only by the trunk posture. Reproducibility was lower in the erect posture than in the three flexed positions. It is suggested that this difference relates to the importance in each posture of the moment acting at the shoulder with respect to the total moment acting at lumbar level.
A study of 12 women undergoing laparoscopy revealed that measurement of rectal pressure at a depth greater than 10 cm accurately reflects changes in intra-abdominal pressure. Measuring rectal pressure at a depth of less than 10 cm results in overestimation of intra-abdominal pressure changes. The diagnostic implications of this effect are discussed.
Intra-abdominal pressure (IAP), force and electromyographic (EMG) activity from the abdominal (intra-muscular) and trunk extensor (surface) muscles were measured in seven male subjects during maximal and sub-maximal sagittal lifting and lowering with straight arms and legs. An isokinetic dynamometer was used to provide five constant velocities (0.12-0.96 m.s-1) of lifting (pulling against the resistance of the motor) and lowering (resisting the downward pull of the motor). For the maximal efforts, position-specific lowering force was greater than lifting force at each respective velocity. In contrast, corresponding IAPs during lowering were less than those during lifting. Highest mean force occurred during slow lowering (1547 N at 0.24 m.s-1) while highest IAP occurred during the fastest lifts (17.8 kPa at 0.48-0.96 m.s-1). Among the abdominal muscles, the highest level of activity and the best correlation to variations in IAP (r = 0.970 over velocities) was demonstrated by the transversus abdominis muscle. At each velocity the EMG activity of the primary trunk and hip extensors was less during lowering (eccentric muscle action) than lifting (concentric muscle action) despite higher levels of force (r between -0.896 and -0.851). Sub-maximal efforts resulted in IAP increasing linearly with increasing lifting or lowering force (r = 0.918 and 0.882, respectively). However, at any given force IAP was less during lowering than lifting. This difference was negated if force and IAP were expressed relative to their respective lifting and lowering maxima.(ABSTRACT TRUNCATED AT 250 WORDS)
Lifting of heavy burdens increases the intra-abdominal pressure, and may induce an increased risk of prolapse of the female internal genitals. While taking care of patients, the nursing staff in hospitals and nursing homes are exposed to heavy lifting. Scientifically uncontrolled causal observations among assistant nurses gave rise to the assumption of an increased risk. To test this hypothesis, a register study was carried out to investigate the risk of genital prolapse among assistant nurses compared with the female Danish population in general. For validation, the incidence of operation due to herniated lumbar disc was investigated. Two registers were used for the analyses, a pension fund register and the Danish National Registry of Hospitalized Patients. Some 28,619 assistant nurses, aged 20-69 years, and 1,652,533 controls of similar age were included. Operations due to genital prolapse and herniated lumbar disc were recorded during one year. The odds ratio (OR) with 95 per cent confidence intervals for the risk of operation due to genital prolapse was significantly increased among assistant nurses, OR = 1.6 (1.3-1.9), P < 0.0001. Correspondingly, the risk of operation for herniated lumbar disc was significantly increased for assistant nurses, OR = 1.6 (1.2-2.2), P < 0.01. We conclude that operations due to genital prolapse are more common among assistant nurses than among the overall female population. Based on this finding, we hypothesize that heavy lifting at work may be the underlying cause. This study confirmed the suggestion of previous epidemiological studies that herniated lumbar disc is associated with heavy lifting at work.
The aim of the study was to identify the possible relationship between body mass index and intra-abdominal pressure as measured by multichannel cystometry. A retrospective chart review of patients presenting for urodynamic evaluation between January 1995 and March 1996 was carried out. Variables identified included weight, height, intra-abdominal pressure and intravesical pressure as recorded on multi-channel cystometrogram at first sensation in the absence of detrusor activity. Body mass index was defined as weight in kilograms divided by height in square meters. Intra-abdominal pressure was measured intravaginally except in those cases of complete procidentia or severe prolapse, where it was measured transrectally. Adequate data were available on 136 patients. The mean age was 60.6 years (range 30–91); mean body mass index was 27.7 kg/m2 (range 12.7–47.7); and mean intra-abdominal pressure was 27.5 cmH2O (range 9.0–48.0). A strong association between intra-abdominal pressure and body mass index was demonstrated, with a Pearson coefficient correlation value of 0.76 (PP2O), and 18 (13.2%) with detrusor instability. The remaining 13.2% had severe prolapse. Our data demonstrate a significant correlation between body mass index and intra-abdominal pressure. These findings suggest that obesity may stress the pelvic floor secondary to chronic state of increased pressure, and may represent a mechanism which supports the widely held belief that obesity is a common factor in the development and recurrence of GSUI.
Our objective was to study the prevalence of genital prolapse and possible related factors in a general population of women 20 to 59 years of age.
Of 641 eligible women in a primary health care district, 487 (76%) answered a questionnaire and accepted an invitation to a gynecologic health examination.
The prevalence of any degree of prolapse was 30.8%. Only 2% of all women had a prolapse that reached the introitus. In a set of multivariate analyses, age (P <.0001), parity (P <.0001), and pelvic floor muscle strength (P <.01)-and among parous women, the maximum birth weight (P <.01)-were significantly and independently associated with presence of prolapse, whereas the woman's weight and sustained hysterectomy were not.
Signs of genital prolapse are frequently found in the female general population but are seldom symptomatic. Of factors associated with genital prolapse found in this study, pelvic floor muscle strength appears to be the only one that could be affected.
We conducted a case-control study to analyze risk factors for urogenital prolapse requiring surgery.
Cases were 108 women with a diagnosis of II or III degree uterovaginal prolapse and/or third degree cystocele. Controls were 100 women admitted to the same hospitals as the cases, for acute, non-gynecological, non-neoplastic conditions.
Occupation showed an association with urogenital prolapse: in comparison with professional/managerial women, housewives had an odds ratios (OR) of urogenital prolapse of 3.1 (95% confidence interval (CI), 1.6-8.8). Compared with nulliparae, parous women tended to have a higher risk of genital prolapse (OR 2.6, 95% CI 0.9-7.8). In comparison with women reporting no vaginal delivery, the ORs were 3.0 for women reporting one vaginal delivery (95% CI 1.0-9.5), and 4.5 (95% CI 1.6-13.1) for women with two or more vaginal deliveries. Forceps delivery and birthweight were not associated with risk of prolapse after taking into account the effect of number of vaginal deliveries. The risk of urogenital prolapse was higher in women with mother or sisters reporting the condition: the ORs were, respectively, 3.2 (95% CI 1.1-7.6) and 2.4 (95% CI 1.0-5.6) in comparison with women whose mother or sisters reported no prolapse.
Our data support the clinical suggestion that parous women are at a higher risk of prolapse and the risk increases with number of vaginal deliveries. First-degree family history of prolapse seems to increase the risk of prolapse.
In humans, intra-abdominal pressure (IAP) is elevated during many everyday activities. This experiment aimed to investigate the extent to which increased IAP--without concurrent activity of the abdominal or back extensor muscles--produces an extensor torque. With subjects positioned in side lying on a swivel table with its axis at L3, moments about this vertebral level were measured when IAP was transiently increased by electrical stimulation of the diaphragm via the phrenic nerve. There was no electromyographic activity in abdominal and back extensor muscles. When IAP was increased artificially to approximately 15% of the maximum IAP amplitude that could be generated voluntarily with the trunk positioned in flexion, a trunk extensor moment (approximately 6 Nm) was recorded. The size of the effect was proportional to the increase in pressure. The extensor moment was consistent with that predicted from a model based on measurements of abdominal cross-sectional area and IAP moment arm. When IAP was momentarily increased while the trunk was flexed passively at a constant velocity, the external torque required to maintain the velocity was increased. These results provide the first in vivo data of the amplitude of extensor moment that is produced by increased IAP. Although the net effect of this extensor torque in functional tasks would be dependent on the muscles used to increase the IAP and their associated flexion torque, the data do provide evidence that IAP contributes, at least in part, to spinal stability.
Objective. This study was designed to help interpret the biomechanical role of intraabdominal pressure during lifting type motions of the trunk. Design. An in vivo study was performed in which intra-abdominal pressure was observed as subject trunks were subjected to different dynamic trunk loading conditions common during industrial lifting. Background. There is a little consensus as to the biomechanical role of intra-abdominal pressure during lifting. Previous studies have suggested that: it may assist in load relief when lifting, may be involved in trunk stability, and/or may be used as a measure fo spine loading. Thus, in general, our understanding of intra-abdominal pressure is rather poor. Methods. In this study intra-abdominal pressure was monitored using a radio pill in 114 subjects over a series of four experiments. Subject's trunks were subjected to different dynamic trunk symmetric and asymmetric trunk loading conditions that are common during industrial lifting tasks. Results. The results indicated that (1) intra-abdominal pressure increased to significant levels (above 10 mmHg) only when more than 54 Nm of trunk torque were supported; (2) intra-abdominal pressure increases monotonically (up to 150 mmHg) as a function of trunk velocity; and (3) under concentric conditions intra-abdominal pressure increases as a function of greater asymmetry, whereas, under eccentric conditions the response changes to a much lesser extent as asymmetry changes. Conclusions. These findings suggest that intra-abdominal pressure appears to be more a by-product of trunk muscle coactivation. Any mechanical advantage gained from intraabdominal pressure might be in the form of a preparatory action resulting from muscle coactivation that stiffens the trunk just prior to a rapid trunk extension exertion. This function may reinforce previous hypotheses regarding the stability role of intra-abdominal pressure.
To investigate the association between parity and urinary incontinence, including subtypes and severity of incontinence, in an unselected sample, with special emphasis on age as a confounder or effect modifier.
This was a cross-sectional study (response rate 80%) with 27,900 participating women. Data on parity and urinary leakage, type, frequency, amount, and impact of incontinence were recorded by means of a questionnaire. A validated severity index was used. Relative risks (RR) with nulliparous women as reference were used as an effect measure.
Incontinence was reported by 25% of participants. Prevalences among nulliparous women ranged from 8% to 32%, increasing with age. Parity was associated with incontinence, and the first delivery was the most significant. The association was strongest in the age group 20-34 years with RR 2.2 (95% confidence interval [CI] 1.8, 2.6) for primiparous women and 3.3 (2.4, 4.4) for grand multiparous women. A weaker association was found in the age group 35-64 years (RRs between 1.4 and 2.0), whereas no association was found among women over 65 years. For stress incontinence in the age group 20-34 years, the RR was 2.7 (2.0, 3.5) for primiparous women and 4.0 (2.5, 6.4) for grand multiparous women. There was an association with parity also for mixed incontinence, but not for urge incontinence. Severity was not clinically significantly associated with parity.
Parity is an important risk factor for female urinary incontinence in fertile and peri- and early postmenopausal ages. Only stress and mixed types of incontinence are associated with parity. All effects of parity seem to disappear in older age.
We examined the relationships among urethral hypermobility, intrinsic sphincter deficiency and incontinence in women.
A total of 65 consecutive women with stress urinary incontinence and 28 with lower urinary tract symptoms not associated with stress urinary incontinence were evaluated with videourodynamics, 24-hour voiding diaries and pad tests, vesical leak point pressure measurement and the cotton swab test.
A total of 93 patients with a mean age +/- SD of 63 +/- 13 years were studied, including 65 who presented with stress urinary incontinence and 28 who presented with lower urinary tract symptoms without stress urinary incontinence. The incidence of urethral hypermobility was 32% in the stress urinary incontinence group and 36% in the lower urinary tract symptoms group (p = 0.46). When stress urinary incontinence cases were stratified according to a vesical leak point pressure of 0 to 60, 60 to 90 and greater than 90 cm. H2O, urethral hypermobility was noted in 25%, 31% and 41%, respectively, a difference that was not statistically significant (p = 0.6). Overall incontinent patients with and without urethral hypermobility had the same median number of incontinence episodes (5, range 1 to 13 versus 7, range 1 to 15, p = 0.39) and median pad weight (39.5 range 1 to 693 gm. versus 33.5, range 1 to 751, p = 0.19). When patients with intrinsic sphincter deficiency, defined as vesical leak point pressure less than 60 cm. H2O, were divided into those with and without urethral hypermobility, there were no differences in the mean number of incontinence episodes (9.4 +/- 3 versus 6 +/- 3.6, p = 0.17) or median pad weight (90 gm., range 10 to 348 versus 86, range 30 to 81, p = 0.76). The degree of change in the urethral angle did not correlate with vesical leak point pressure (r = 0.16, p = 0.24) or with pad weight (r = -0.23, p = 0.1).
Urethral hypermobility was equally common in this group of women with lower urinary tract symptoms and stress urinary incontinence. Intrinsic sphincteric deficiency and urethral hypermobility may coexist and they do not define discrete classes of patients with stress urinary incontinence. Urethral hypermobility did not appear to have an independent effect on the frequency or severity of incontinence. Patients with stress urinary incontinence can still be characterized by vesical leak point pressure and change in the urethral angle, although these variables do not always define discrete classes.
To examine whether modifiable lifestyle factors such as smoking, obesity, physical activity and intake of alcohol or caffeinated drinks were associated with urinary incontinence in women.
Cross sectional population-based study.
The Norwegian Epidemiology of Incontinence in the County of Nord-Trøndelag (EPINCONT) Study is part of a large survey performed in a county in Norway during 1995-1997.
Women >/=20 years (n = 34,755, 75% of the invited) attended the first part of the survey and received the questionnaire. There were 27,936 (80% of source population) women who completed the incontinence part of the questionnaire.
Questionnaire covering several health topics including urinary incontinence was received at a screening station. Logistic regression analysis was used to adjust for confounding and to establish associations with the different outcomes under investigation: any incontinence, severe incontinence and stress, urge and mixed subtypes.
Effect measure were odds ratios with corresponding 95% confidence intervals.
Former and current smoking was associated with incontinence, but only for those who smoked more than 20 cigarettes per day. Severe incontinence was weakly associated with smoking regardless of number of cigarettes. The association between increasing body mass index and incontinence was strong and present for all subtypes. Increasing levels of low intensity physical activity had a weak and negative association with incontinence. Tea drinkers were at slightly higher risk for all types of incontinence. We found no important effects of high intensity physical activity, intake of alcohol or coffee.
Several potentially modifiable lifestyle factors are associated with urinary incontinence. Highest odds ratios were found for body mass index, heavy smoking and tea drinking.
In the past decade hernia surgery has been challenged by two new technologies: by laparoscopy, which has attempted to change the traditional open operative techniques, and by prosthetic mesh, which has achieved much lower recurrence rates. The demand by health care providers for increasingly efficient and cost-effective surgery has resulted in modifications to pathways of care to encourage more widespread adoption of day case, outpatient surgery, and local anaesthesia. In addition, the UK National Institute for Clinical Excellence has recommended strategies for bilateral and recurrent hernias. Here, we discuss these strategies and review some neglected aspects of hernia management such as trusses, antibiotic cover, return to work and activity, and emergency surgery. Many of the principles of management apply equally to inguinal and incisional hernias. We recommend that the more difficult and complex of the procedures be referred to specialists.
This was a repeated measures study examining 11 asymptomatic subjects while performing dynamic lifting using various postures, loads, and breath control methods.
To examine the effects of breath control on magnitude and timing of intra-abdominal pressure during dynamic lifting.
Intra-abdominal pressure has been shown to increase consistently during static and dynamic lifting tasks. The relationship between breath control and intra-abdominal pressure during lifting is not clear.
Eleven healthy subjects were tested using lifting trials consisting of two levels of posture and load and four levels of breath control (natural breathing, inhalation-hold, exhalation-hold, inhalation-exhalation). Intra-abdominal pressure was measured using a microtip pressure transducer placed within the stomach through the nose. Timing of intra-abdominal pressure was determined relative to lift-off of the weights. Repeated measures analysis of variance was used to determine the effect of breath control, posture, and load on intra-abdominal pressure magnitude and timing.
There was a significant effect of breath control (P < 0.018) and load (P < 0.002), but not of posture (P < 0.434), on intra-abdominal pressure magnitude. The inhalation-hold form of breath control produced significantly greater peak intra-abdominal pressure than all other forms of breath control (P < 0.000 for all comparisons). No other comparisons among levels of breath were significantly different. No significant main effects of breath control were found relative to intra-abdominal pressure timing.
Breath control is a significant factor in the generation of intra-abdominal pressure magnitude during lifting tasks. The effects of respiration should be controlled in studies analyzing intra-abdominal pressure during lifting.
Convalescence after inguinal herniorrhaphy is usually 3-4 weeks and is an important outcome parameter of hernia surgery. The aim of this study was to describe in detail the consequences of recommending a short convalescence, including the risk of recurrence.
This was a multicentre prospective questionnaire study in patients given a recommendation for short convalescence (1 day); information was recorded on expected length of convalescence, employment status, physical workload and limiting factors. The reoperation rate in patients included in the study (group 1, n = 1059) was compared with that for comparable patients treated in participating departments but not part of the study group (group 2, n = 1306) and patients in the Danish Hernia Database (group 3, n = 8297).
The median time off work was 7 days and the time interval before carrying out the most strenuous leisure activity was 14 days. After 30 days, 6.8 per cent of patients had not resumed employment and 17.0 per cent had not yet resumed strenuous leisure activity. Important reasons for not resuming work and leisure activity were pain (approximately 60 per cent of patients) and wound problems (approximately 20 per cent). The reoperation rate in group 1 at the median observation time was 0.7 per cent, which was no different to that in group 2 (1.6 per cent) (P = 0.186) or group 3 (1.4 per cent) (P = 0.092).
Reduced convalescence after inguinal herniorrhaphy may be recommended without incurring a risk of higher reoperation rates. Pain and wound problems remain the most important factors for not resuming work or leisure activity as recommended.
Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence
- A Olsen
- V Smith
- J Bergstrom
- J C Colling
- A L Clark
Olsen A, Smith V, Bergstrom J, Colling JC, Clark AL. Epidemiology of surgically managed pelvic organ prolapse and
urinary incontinence. Obstet Gynecol 1997;89:501-6.
Pelvic organ prolapse in the Women's Health Initiative: gravity and gravidity
- Sl Hendrix
- A Clark
- I Nygaard
- A Aragaki
- V Barnabei
- A Mctiernan
Hendrix SL, Clark A, Nygaard I, Aragaki A, Barnabei V,
McTiernan A. Pelvic organ prolapse in the Women's Health
Initiative: gravity and gravidity. Am J Obstet Gynecol 2002;
186:1160–6.