"Standardization of terminology of pelvic floor muscle function and"
Neurourology and Urodynamics 24:374^380 (2005) Standardization of Terminology of Pelvic Floor Muscle Function and Dysfunction: Report From the Pelvic Floor Clinical Assessment Group of the International Continence Society Bert Messelink,1* Thomas Benson,2 Bary Berghmans,3 Kari BÖ,4 Jacques Corcos,5 Clare Fowler,6 Jo Laycock,7 Peter Huat-Chye Lim,8 Rik van Lunsen,9 Guus Lycklama a Nijeholt,10 ¤ 11 12 13 14 John Pemberton, Alex Wang, Alain Watier, and Philip Van Kerrebroeck 1 Pelvic Care Center ‘Prinsengracht’, Onze Lieve Vrouwe Gasthuis, Amsterdam, Holland 2 University of Indiana/Methodist Hospital, Indianapolis, Indiana 3 University Hospital Maastricht, Department of Urology, Maastricht, Holland 4 Norwegian University of Sport & Physical Education, Olleval Stadion, Oslo, Norway 5 Jewish General Hospital, Montreal, Canada 6 National Hospital for Neurology and Neurosurgery, London, United Kingdom 7 The Culgaith Clinic, Pea Top Grange, Culgaith, Penrith, United Kingdom 8 Division of Urology, Changi General Hospital, Singapore, Singapore 9 Academic Medical Center, Amsterdam, Holland 10 Leiden University Medical Center, Leiden, Holland 11 Mayo Clinic, Minnesota, Rochester 12 Division of Urogynecology, Chang Gung Memorial Hospital, Tao-Yuan, Taiwan 13 Chus-Hotel Dieu 580, rue Bowen Sud, Sherbrooke, Canada 14 University Hospital Maastricht, Department of Urology, Maastricht, Holland Key words: classi¢cation; dysfunction; function; pelvic £oor muscles; standardization of terminology STANDARDIZATION muscle function and dysfunction, and not on pelvic £oor dis- orders. It contains no terminology on pelvic organ prolapse, This report presents a standardization of terminology of urinary, or fecal incontinence. Other reports refer to these pelvic £oor muscle function and dysfunction. No earlier docu- subjects [Bump, 1996; Weber et al., 2001; Abrams et al., ments contained de¢nitions on this terminology. These de¢ni- 2002a]. This report on terminology of the pelvic £oor muscles tions are descriptive and do not imply underlying assumptions is written for use, in daily clinical practice, by every health that may later prove to be incorrect or incomplete. By follow- care provider working with patients who have pelvic £oor ing this principle, the International Continence Society aims muscle problems. It facilitates the communication between to facilitate comparison of results and enable e¡ective com- di¡erent carers in the ¢eld of pelvic £oor muscle pathology. munication by investigators performing pelvic £oor muscle Because it has been developed by a multidisciplinary group, it studies. It is suggested that acknowledgment of these de¢nitions in Bert Messelink, Jacques Corcos, Peter Huat-Chye Lim, Guus Lycklama, and written publications be indicated by a footnote to the section Philip Van Kerrebroeck are Urologists; Thomas Benson and Alex Wang are ‘‘Materials and Methods’’ or its equivalent, to read as follows: Urogynecologits; Bary Berghmans, Kari BÖ, and Jo Laycock are Physiothera- ‘‘Terminology used is conform the de¢nitions recommended pists; Clare Fowler is Neurologists; Rik van Lunsen is a Sexologist; by the International Continence Society, except where speci- John Pemberton is a Colon and Rectal Surgeon; Alain Watier is a Gastro- ¢cally noted.’’ Enterologist. *Correspondence to: Bert Messelink, Pelvic Care Center Prinsengracht, Prinsengracht 769, 1017 JZ, Amsterdam, Holland. MULTIDISCIPLINARY E-mail: firstname.lastname@example.org Received 10 April 2005; Accepted 26 April 2005 The pelvic £oor is related to more than one organ system. Published online 15 June 2005 inWiley InterScience Dysfunction of the pelvic £oor therefore in£uences di¡er- (www.interscience.wiley.com) ent functions at the same time. This report is on pelvic £oor DOI 10.1002/nau.20144 ß 2005 Wiley-Liss, Inc. Terminology of Pelvic Floor Muscle Function and Dysfunction 375 can be used by di¡erent specialties. This document is based on Terminology our current knowledge of physiology and pathophysiology of At this moment, there is no existing international agree- the pelvic £oor muscles. ment on terminology of pelvic £oor muscle dysfunction. In the literature most studies are clinical studies for example on PELVIC FLOOR the e¡ect of pelvic £oor muscle therapy for urinary inconti- nence. Basic studies on the di¡erent aspects of the pelvic £oor The term pelvic £oor relates to the compound structure, muscles are not available. When considering standardization which closes the bony pelvic outlet. The term pelvic £oor of terminology, many problems have to be faced. The di¡erent muscles refers to the muscular layer of the pelvic £oor.The pelvic aspects of the pelvic £oor muscles and their function are hard £oor consists of di¡erent layers, the most cranial being the peri- to de¢ne. Furthermore even when they can be de¢ned, they toneum of the pelvic viscera and the most caudal being the skin cannot be easily measured. And even when they can be mea- of vulva, scrotum, and perineum [DeLancey, 1992]. The middle sured, there is no agreement as to what is considered to be nor- layers of the pelvic £oor are made up of predominantly muscular mal values. tissue. Apart from the pure pelvic £oor muscles, ¢bro-muscular This report adheres to the ICS principle that symptoms, and ¢brous elements, like the endo-pelvic fascia are found in this signs, and conditions are separate categories and adds a cate- layer. Di¡erent well recognizable muscles together form the gory of additional tests. muscular layer of the pelvic £oor: levator ani, striated urogenital Symptoms associated with pelvic £oor muscle dys- sphincter, external anal sphincter, ischiocavernosus, and bulbos- function. Symptoms are the subjective indicator of a disease pongiosus. All these muscles are working together to seal o¡ the or change in condition as perceived by the patient, carer, or lower aspect of the pelvic cavity. Urethra, vagina, and rectum partner, and may lead him/her to seek help from health care pass through the pelvic £oor and are surrounded by the pelvic professionals. Symptoms are the complaints mentioned by the £oor muscles. The pelvic bones are the structures to which the patient during the patient interview or stated on questionnaires muscular layer is attached. The function of the pelvic £oor is to ¢lledinbythepatient.Symptomsalonecannotbeusedtomakea support the pelvic organs. The function of the pelvic £oor mus- de¢nitive diagnosis nor can they denote the pathophysiological cles is performed by contraction and relaxation. In its resting mechanism. Because the pelvic £oor muscles act as an entity, it state, the pelvic £oor gives support to the pelvic organs.Whether is often the case that dysfunction of the pelvic £oor muscles the support function is normal depends on the anatomical posi- will lead to dysfunction of more than one organ system. tion of the muscles, on the activity of the pelvic £oor muscles at Therefore, in the patient interview it is mandatory to ask about rest (active support) and on the integrity of the fascia (passive symptoms of the di¡erent tracts in£uenced by the pelvic £oor support). During intra-abdominal pressure rise, the pelvic £oor muscles [Abrams et al., 2002b]. During the interview the muscles must contract to maintain the support function of the following categories of questions should be asked: those pelvic £oor. A contraction of the pelvic £oor muscles results in a relating to micturition, defecation,vaginal and sexual function, ventral and cranial movement of the perineum, and an upward andpain. movement of the pelvic organs together with an anterior move- Symptoms associated with pelvic £oor muscle dysfunction ment caused primarily by the vaginal and rectal parts of the leva- are divided into ¢ve groups: lower urinary tract symptoms, tor ani. When the pelvic £oor muscles contract the urethra bowel symptoms, sexual function, prolapse, and pain.2 closes, as do the anus and the vagina. This contraction is impor- Lower urinary tract symptoms. tant in preventing involuntary loss of urine or rectal contents. For women it can also function as a defense mechanism against . urinary incontinence sexual intercourse. For maintaining continence, it is also impor- . urgency and frequency tant to realize that detrusor activity is inhibited by pelvic £oor . slow or intermittent stream and straining muscle contraction. . feeling of incomplete emptying Pelvic £oor muscle relaxation following contraction results Bowel symptoms in a reduction in the support given to the urethra, vagina, and anus. The perineum and the pelvic organs return to their ana- . obstructed defecation3 tomical resting position.The pelvic £oor muscles must relax in . functional constipation4 order to remove the passive continence mechanisms, thereby favoring normal micturition. The same is true for relaxation 2 The de¢nitions of lower urinary tract symptoms, vaginal symptoms, and before and during defecation, allowing the anorectal angle to pain can be found in: The Standardization Report of Terminology of Lower become obtuse, favoring rectal emptying.1 UrinaryTract Function [Abrams et al., 2002a]. 3 Obstructed defecation can be described as having the urge to defecate but being unable to completely empty the rectum with or without straining. 4 Following the diagnostic criteria for functional gastrointestinal disorders 1 In the literature, there is discussion on the action of the pubococcygeal mus- (Rome II), functional constipation presents as persistent di⁄cult, infre- cle as to whether this muscle plays a role in giving rectal support against an quent, or seemingly incomplete defecation [Thompson et al., 1999] (www. increased abdominal pressure [Fucini et al., 2001]. romecriteria.org). 376 Messelink et al. . fecal incontinence5 . Investigators reporting pelvic £oor muscle studies should . rectal/anal prolapse state the position of the patient (supine, lithotomy, lateral, standing) and the time of the day. When appropriate the Vaginal symptoms verbal instructions given to the patient should be literally written down. Also, additional instruments used should be . pelvic organ prolapse6 described. . Inspection of the vulva,12 perineum and anus in women Sexual function and of perineum and anus in men is performed to look for skin pathology and anatomical abnormalities. Test- . in women: dyspareunia7 ing for pelvic organ prolapse13 is an integral part of the . in men: erectile and ejaculatory dysfunction physical examination of every patient with pelvic £oor . in both: orgasmic dysfunction muscle complaints. A vaginal and rectal exam is part of this investigation. Pain . During inspection, the patient is asked to perform a pelvic £oor muscle contraction. Good instruction is man- . chronic pelvic pain8 datory: ask the patient to prevent the escape of gas or . pelvic pain syndrome 9 urine. In the normal situation, a pelvic £oor muscle con- traction will lead to ventral and cranial movement of the perineum. Signs suggestive of pelvic £oor muscle dysfunction. . When the patient is asked to cough, the perineum should Signs are observed by the examiner, including simple means, show no downward movement; ventral movement in order to verify symptoms and quantify them. It should be may occur because of the guarding action of the pelvic £oor remembered that not all signs have associated symptoms (e.g., muscles. pelvic organ prolapse). Some functions of the pelvic £oor . Anal/rectal prolapse can be evaluated by asking the patient muscles can be tested during physical examination. For to strain, as if defecating, while seated on a commode chair. instance a voluntary contraction of the pelvic £oor muscles . Perineal elevation is the inward (cephalad) movement of the can be assessed by inspection and palpation.10 Quanti¢cation vulva, perineum, and anus. of the function of the pelvic £oor muscles is not easy, due to . Perineal descent is the outward (caudal) movement of the the lack of simple to use and reliable measurement techniques, vulva, perineum, and anus. The position of the anus and and the lack of cut-o¡ values for pathological conditions. the perineum should be noted at rest and during straining. Furthermore, the reproducibility of testing is questionable. If perineal descent is seen, when the patient has been asked Visual inspection.11 to contract the pelvic £oor muscles, this indicates that the patient is straining instead of contracting the pelvic £oor muscles. 5 Fecal incontinence in the Rome II criteria is de¢ned as: recurrent uncon- . Extra-pelvic muscle activity is the contraction of muscles trolled passage of fecal material [Whitehead et al., 1999]. other than those that comprise the pelvic £oor, for example 6 Pelvic organ prolapse is frequently associated with a feeling of rectal fullness the abdominal, gluteal and adductor muscles. Extra-pelvic of pelvic heaviness or a bearing down sensation especially when standing [Bump et al., 1996]. muscle activity is needed for maximal pelvic £oor muscle 7 Dyspareunia is the symptom of painful sexual intercourse. e¡ort.14 8 Chronic pelvic pain is non-malignant pain perceived in structures related to the pelvis of either men or women [Fall et al., 2004]. 9 Pelvic pain syndrome is the occurrence of persistent or recurrent episodic pelvic pain associated with symptoms suggestive of lower urinary tract, sexual, bowel, or gynecological dysfunction. There is no proven infection or 12 other obvious pathology [Abrams et al., 2002a]. The condition of the vulva and vagina (atrophy, in£ammation) 10 Apart from contraction and relaxation other terms are also thought to be should be noted. A touch test is advised. In this test, the introitus is appropriate to the pelvic £oor muscles: tone, volume, and force. Tone of the touched lightly with a cotton swab at di¡erent points. Normally this does pelvic £oor muscles is di⁄cult to de¢ne and cannot be measured.The volume not hurt but in patients with a vulval pain syndrome it will be classi¢ed of the pelvic £oor muscles can probably be measured with an MRI but the as painful. 13 de¢nition of what is to be considered as pelvic £oor muscles is not well In female patients, the ICS POPQ system is advised [Bump et al., 1996]. In de¢ned. The force of the pelvic £oor muscle contraction and related terms female and male patients attention should also be focused on the anus, look- like strength, power, endurance, and exhaustion are yet not applicable in ing for rectal or anal prolapse. 14 clinical practice. The two muscle groups, pelvic £oor, and transversus abdominis are now 11 It is mandatory to give the patient a full explanation as to what to expect understood to be part of the local muscle system of lumbo-pelvic stability. during the physical examination, before starting it. An assessment must be The other components are the diaphragm and the deep ¢bers of musculus discontinued if the patient exhibits any symptoms of distress during the multi¢dus. Increase in abdominal muscle activity is synergistic with increase examination. Patient dignity must be considered and maintained at all times in pelvic £oor muscle activity [Sapsford et al., 2001; Neumann and Gill, (www.gmc-uk.org/standards/intimate.htm). 2002]. Terminology of Pelvic Floor Muscle Function and Dysfunction 377 15 19 Digital palpation . The quanti¢cation of a contraction is problematic. There is no validated scale to quantify contractions of the pelvic . Investigators reporting pelvic £oor muscle studies should £oor muscles. Therefore quanti¢cation, more than absent, state the position of the patient (supine, lithotomy, lateral, weak, normal, or strong is not recommended. standing) and the time of the day. When appropriate the . Involuntary contraction of the pelvic £oor muscles is the verbal instructions given to the patient should be literally contraction that takes place preceding an abdominal pres- written down. Also additional instruments used should be sure rise, such as due to a cough, to prevent incontinence. described. In the case of digital palpation, the number of ¢n- An involuntary contraction can be absent or present. 20 gers used should be noted. . Involuntary relaxation of the pelvic £oor muscles is the . Digital palpation of the pelvic £oor muscles is an easy to relaxation that takes place when the patient is asked to perform physical examination. Digital palpation is used to strain as if defecating. An involuntary relaxation can be assess the pelvic £oor muscles and surrounding areas at rest, absent or present. and during contraction and relaxation. The pelvic £oor . Non-contracting pelvic £oor means that during palpa- muscles are palpated circumferentially. tion, there is no palpable voluntary or involuntary contrac- . Digital palpation is also used to test for pain. Digital pres- tion of the pelvic £oor muscles. sure on the pelvic £oor muscles may reproduce or intensify . Non-relaxing pelvic £oor means that during palpation, the patient’s pain. This pain-sign can be unilateral. there is no palpable voluntary or involuntary relaxation of . Voluntary contraction of the pelvic £oor muscles means the pelvic £oor muscles. that the patient is able to contract the pelvic £oor muscles . Non-contracting, non-relaxing pelvic £oor means that on demand. A contraction is felt as a tightening, lifting, and during palpation, there is neither a palpable contraction squeezing action under the examining ¢nger. A voluntary nor a palpable relaxation of the pelvic £oor muscles. contraction can be absent, weak, normal, or strong.16 . If vaginal palpation shows a marked asymmetry in pelvic . Voluntary relaxation of the pelvic £oor muscles means £oor muscle function this should be stated. There can be a that the patient is able to relax the pelvic £oor muscles di¡erence between the posterior and anterior muscles of the on demand, after a contraction has been performed.17 pelvic £oor or between left and right. Relaxation is felt as a termination of the contraction. The pelvic £oor muscles should return at least to their Additional tests for pelvic £oor muscle dysfunction. resting state. A voluntary relaxation can be absent, partial, Additional test can be used to get more, partly indirect or complete.18 information, on the function of the pelvic £oor muscles. Electromyography, pressure measurements, and imaging are the most importantadditionaltests tobe used. EMG 15 The gloved and lubricated index ¢nger of the examiner is introduced into the vagina (women) or the anus (women/men). Digital palpation . Investigators reporting pelvic £oor muscle studies should should be performed with the patient in the supine and standing position. state the position of the patient, the type of electrode, and In the supine position, the hips and the knees should be £exed. If the the recording equipment used.When appropriate the verbal knees are bent, the patient should not hold the legs herself, legs should be relaxed. Palpation is performed with one ¢nger because two ¢ngers may instructions given to the patients should be literally written stretch the pelvic £oor muscles and thereby in£uence the ability to contract. down. It is important to be very clear as to what is expected from the patient. . EMG of the pelvic £oor muscles may be performed using Asking for a pelvic £oor contraction will not be enough in most cases. The surface- or needle-electrodes. The techniques are quite dif- instruction ‘‘lift’’ and ‘‘squeeze’’ are useful. Palpation with two ¢ngers in the ferent, as is the inconvenience for the patient. The results supine position is used to measure the genital hiatus and to get informa- tion on the pelvic organs. For anal palpation, the patient is put in left lateral are also quite di¡erent in nature. Surface electrodes are position. non-selective because of their large surface area; they yield 16 A voluntary contraction can be absent: if no contraction is palpated or pre- information on normal function and dysfunction (either sent: if a contraction is palpated which can be either weak, normal, or strong. neurological or non-neurological). Needle electrodes are If there is no voluntary contraction noted this does not exclude involuntary or unconscious contractions. Contraction should be tested in both the supine 19 and the standing position to see if contraction against gravity is possible. The Oxford scale is used most frequently, but inter-observer variability has 17 Relaxation of the pelvic £oor muscles should be tested after a contraction. been reported to be high. Modi¢ed scales have been used but the simplest Therefore the investigator should always start with a contraction and then classi¢cation is absent, weak, normal, and strong. With every scale one has ask for relaxation. to realize that there is no gold standard to refer to [Bo and Finckenhagen, 18 A voluntary relaxation after a contraction means that this pelvic £oor con- 2001]. 20 traction is terminated. The pelvic £oor will come back to its resting state In an e¡ort to raise abdominal pressure the thoracic, diaphragmatic, and (partial relaxation) or below (complete relaxation). When there is no relaxa- abdominal muscles act together with the pelvic £oor muscles. Anticipatory tion palpable it is called absent; this does not exclude involuntary or uncon- or feed forward contractions help to increase urethral closing pressure before scious relaxations. the increase in abdominal pressure. 378 Messelink et al. more selective and can also be used to assess neurological or perineum. The position of the bladder neck in relation to conditions that may involve the pelvic £oor muscles. the symphisis pubis is an important landmark. During the . Intra-vaginal or intra-anal EMG probes will give the same investigation, the patient can be asked to contract the pelvic (functional) information as surface electrodes. 21 £oor muscles and this can be seen to result in an elevation of . During a voluntary contraction of the pelvic £oor muscles, the bladder neck. Anal ultrasound is used to de¢ne struc- the intensity of the EMG signal should increase. When the tural defects in the anal sphincter. patient is asked to hold the contraction, a sustained high . Fluoroscopy is the oldest technique used to indirectly intensity on the EMG can be observed. At the subsequent image the pelvic £oor and the pelvic organs. Filling of the relaxation, the intensity will fall to or even below baseline. intestine, colon, rectum, and vagina with contrast medium is known as evacuation proctography or defecography. A Pressure measurements lateral projection is important to get the best information. At rest the anatomical position of the pelvic organs and the . Investigators reporting pelvic £oor muscle studies should pelvic £oor can be visualized. Subsequently the patient can state the position of the patient and the type of transducers, be asked to strain and can be asked to contract the pelvic balloons, and EMG was used. £oor muscles. The changes in the anatomical positions can . Urodynamics can be done to obtain insight into the func- then be observed. tion of the lower urinary tract. Special attention should be . Video-urodynamics combines the techniques of uro- paid to the function of the pelvic £oor muscles in relation to dynamics and £uoroscopy. This will give extra insight into the bladder. Simultaneous measurement of the pelvic £oor the relationships between pelvic £oor anatomy and func- EMG, during the micturition phase can demonstrate the tion of the bladder and urethra. mechanism of dysfunctional voiding. . MRI is the newest technique for imaging of the pelvic £oor. . Anorectal manometry assesses continence mechanisms by The use of endoluminal coils is advised in order to obtain determining: (a) rectal volume required for sensation of dis- adequate images of the pelvic £oor and the related struc- tension and urgency to defecate, (b) rectal compliance, tures. Dynamic MRI can be used to observe the movement (c) voluntary contractions of the external anal sphincter, of the pelvic £oor during Valsalva manoeuvre, a defecatory and (d) the resting pressure in the anal canal.Water perfused e¡ort and during pelvic £oor muscles contraction. It can and solid state pressure transducers are used in combina- also be used for the detection of pelvic organ prolapse. tion with a balloon positioned in the anal canal. EMG of . Di¡erent imaging techniques are used for di¡erent the anal canal can be added but should not be used alone. 22 indications. 24 Imaging Other techniques. Several diagnostic tests can be used to get more indirect proof of the function of the pelvic £oor muscles. . Investigators reporting pelvic £oor muscle studies should state the position of the patient and the type of equipment . A bladder diary is an important investigation in lower urin- used. For measurements, it should be stated which referral ary tract symptoms. points and lines are used, and how for example the decent is . A defecation diary will help in investigating anorectal computed. For ultrasound and MRI the type of transducer symptoms. or coil should be stated. When appropriate the verbal . Neurophysiological investigations like pudendal nerve instructions given to the patient should be literally written latency time is used when there is suspicion of a neurologi- down. cal problem causing pelvic £oor muscle dysfunction. . Several imaging techniques are used to assess the pelvic £oor and the organs of the pelvis. Most techniques are radiological and many still have to be classi¢ed as 24 Cystourethrography, the oldest technique used to indirectly image the pel- experimental. 23 vic £oor is especially useful in detecting cystoceles. Evacuation proctography . Ultrasound can be performed with an endovaginal or is used for detecting rectoceles, enteroceles, intussusception, anal prolapse, endoanal probe, or with an external probe on the introitus and obstructive defecation. Ultrasound of bladder and urethra has still not to be seen as a routine investigational technique for pelvic £oor muscle imaging but certainly has advantages: no ionizing radiation and little discomfort for 21 EMG of the pelvic £oor muscles using surface electrodes gives insight into the patient. Ultrasound of the anal sphincter is a cornerstone of the diagnos- the function of the pelvic £oor muscles both to the examiner and to the tic work-up of anal incontinence. Magnetic resonance imaging is the latest patient. It should be kept in mind that with the use of surface electrodes other developed technique and seems to have great ability to image all the di¡erent muscles will contribute to the EMG signal. structures in the pelvis including the pelvic £oor itself. For urinary inconti- 22 For a complete description see the Rome II report: functional disorders of nence none of the imaging techniques plays a cardinal role in the diagnostic the anus and the rectum [Whitehead et al., 1999]. workup. The value of imaging lies in the detection of concomitant anatomical 23 In a state of the art article in Radiology, an overview of the imaging tech- and functional defects. The use of imaging techniques has to be considered niques that are available, their indications and limitations was presented when surgical reconstruction of the pelvic £oor is planned. For anal inconti- [Stoker et al., 2001]. nence, endo-anal ultrasound is the most important single test. Terminology of Pelvic Floor Muscle Function and Dysfunction 379 Conditions. Conditions are de¢ned by the presence of ADDENDUM characteristic symptoms associated with speci¢c signs. Based The ICS Pelvic Floor Clinical Assessment group was on symptoms and signs the following conditions can be announced at the ICS meeting in Denver in 1999. The mem- determined. 25 bers of the committee were invited to be active in the group Normal pelvic £oor muscles. A situation in which the right after that meeting. The members invited are all experts pelvic £oor muscles can voluntarily and involuntary contract on their own ¢eld of healthcare in relation to pelvic £oor and relax. Voluntary contraction will be normal or strong and muscle function. Members are from seven di¡erent disci- voluntary relaxation complete. Involuntary contraction and plines: urology, gynaecology, surgery, gastro-enterology, phy- relaxation are both present. sical therapy, sexology, and neurology. Members came from Overactive pelvic £oor muscles. A situation in which the seven di¡erent countries re£ecting the worldwide covering of pelvic £oor muscles do not relax, or may even contract when the ICS. The group had a yearly discussion during every ICS relaxation is functionally needed for example during micturi- meeting. The ¢rst draft of the report was put on the Internet tion or defecation. This condition is based on symptoms such at the ICS website (www.icso⁄ce.org) in 2001 and presented as voiding problems, obstructed defecation, or dyspareunia in 2002 in Heidelberg. As a result of the discussion with and on signs like the absence of voluntary pelvic £oor muscle the members of ICS, the report was rewritten and made relaxation. more compact. This version was then commented on by 25 Underactive pelvic £oor muscles. A situation in which the ICS members and put on the website. During the meeting in pelvic £oor muscles cannot voluntarily contract when this is Florence in 2003, the new version based on this comments was appropriate. This condition is based on symptoms such as discussed and accepted by the ICS general meeting. The docu- urinary incontinence, anal incontinence, or pelvic organ pro- ment was than again put on the internet for further comments. lapse, and on signs like no voluntary or involuntary contrac- Members of the committee were: John Benson, Bary Bergh- tion of the pelvic £oor muscles. mans, Kari BÖ, Jacques Corcos, Clare Fowler, Jo Laycock, Non-functioning pelvic £oor muscles. 26 A situation in Peter Lim Huat Chye, Rik van Lunsen, Guus Lycklama ¨ Nije- which there is no pelvic £oor muscle action palpable. This con- holt, Bert Messelink (chairman), John Pemberton, Alex Wang, dition can be based on any pelvic £oor symptom27 and on the AlainWatier. sign of a non-contracting, non-relaxing pelvic £oor. The committee wants to say special thanks for their exten- sive and repeated comments to Paul Abrams, Linda Cardozo, Directions for future research. and John DeLancey. The ICS wants to stress the need for future research in the ¢eld of pelvic £oor muscle function and dysfunction. The fol- lowing directions are thought to be important. ACKNOWLEDGMENTS . Studies on inter- and intra-observer variability for testing of We thank the persons who have given their written com- the pelvic £oor muscle signs as described in this report. ments on the document: Walter Artibani,Wendy Bower, Grace . Studies on the development of disease speci¢c pelvic £oor Dorey, Karel Everaert, Jannet Haslam, David Fonda, Helena muscle dysfunction questionnaires. Frawley, Marijke Van Kampen, Francesco Pesce, Pirkko . Studies on the normal values for pelvic £oor muscle func- Raivio, Dirk De Ridder, Ruth Sapsford, Bernard Schuessler, tion when measured with EMG. Mark Vierhout, Ragi Wiygul, Jean Jacques Wyndaele. . Studies on the possibility to measure and quantify pelvic £oor muscle tone, force, and volume. . Studies on the relation of pelvic £oor muscle dysfunction as REFERENCES described in this report and the symptoms mentioned by Abrams P, Cardozo L, Fall M, et al. 2002a. The standardisation of terminol- the patients. ogy of lower urinary tract function: Report from the Standardisation Sub- committee of the International Continence Society. Neurourol Urodyn 25 There is no strict relation between a symptom and the condition of the 21:167^ 78. pelvic £oor muscles. An overactive pelvic £oor muscle can lead to voiding Abrams P, Cardozo L, Khoury S, et al., editors. 2002b. 2nd International problems but in some situation also to incontinence. The examples in this Consultation on Incontinence. 1081p. text are the most common relations. Bo K, Finckenhagen HB. 2001. Vaginal palpation of pelvic £oor muscle 26 Non-functioning means that there is no activity at palpation. This does not strength: Inter-test reproducibility and comparison between palpation exclude activity of the muscles in other situations neither does it rule out and vaginal squeeze pressure. Acta Obstet Gynecol Scand 80:883 ^ 87. activity that is below the detection border of palpation. Bump RC, Mattiasson A, BÖ K, et al. 1996. The standardization of terminol- 27 When there is no contraction or relaxation palpable, it is the resting activity ogy of female pelvic organ prolapse and pelvic £oor dysfunction. Am J of the pelvic £oor muscles that determines the symptoms. When there is a Obstet Gynecol 175:10 ^17. high resting activity the symptoms will likely be: voiding symptoms, DeLancey JOL. 1992. Anatomy of genital support. In: Benson JT, editor. obstructive defecation, or dyspareunia. When the resting activity is low, Female pelvic £oor disorders. NewYork: Norton Medical Books. pp 19^ 26. symptoms like stress urinary incontinence, fecal incontinence, or prolapse Fall M, Baranowski AP, Fowler CJ, et al. 2004. EAU guidelines on chronic may be the complaints presented by the patient. pelvic pain. Eur Urol 46:681^ 89. 380 Messelink et al. Fucini C, Ronchi O, Elbetti C. 2001. Electromyography of the pelvic £oor Stoker J, Halligan S, Bartram CI. 2001. Pelvic £oor imaging. Radiology musculature in the assessment of obstructed defecation symptoms. 218:621^ 41. Dis Colon Rectum 44:1168 ^ 75. ThompsonWG, Longstreth GF, Drossman DA, et al. 1999. Functional bowel Neumann P, Gill V. 2002. Pelvic £oor and abdominal muscle interac- disorders and functional abdominal pain. Gut 45:1143 ^ 47. tion: EMG activity and intra-abdominal pressure. Int Urogynecol J Weber AM, Abrams P, Brubaker L, et al. 2001. The standardization of termi- 13:125 ^32. nology for researchers in female pelvic £oor disorders. Int Urogynecol J Sapsford RR, Hodges PW, Richardson CA, et al. 2001. Co-activation of the Pelvic Floor Dysfunct 12:178 ^ 86. abdominal and pelvic £oor muscles during voluntary exercises. Neurourol Whitehead WE,Wald A, Diamant NE, et al. 1999. Functional disorders of the Urodyn 20:31^ 42. anus and rectum. Gut 45:1155 ^59.