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Pelvic Floor EMG: Principles, Techniques, and Applications

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Childbirth-Related Pelvic Floor Dysfunction

Abstract

The external anal sphincter (EAS) and the puborectalis are the most important muscles providing fecal continence. Their innervation can be observed with intra-anal probes (no needles). Knowledge of the innervation pattern of the EAS allows proper planning of episiotomy and reduction of EAS denervation cases with likely reduction of subsequent incontinence.

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References

  1. Enck P, Franz H, Azpiroz F, Fernandez-Fraga X, Hinninghofen H, Kaske-Bretag K, Bottin A, Martina S, Merletti R (2004) Innervation zones of the external anal sphincter in healthy male and female subjects. Digestion 69:123–130

    Article  CAS  PubMed  Google Scholar 

  2. Enck P, Hinninghofen H, Wietek H, Becker HD (2004) Functional asymmetry of pelvic floor innervation and its role in the pathogenesis of fecal incontinence. Digestion 69:102–111

    Article  PubMed  Google Scholar 

  3. Cescon C, Bottin A, Azpiroz F, Merletti R (2008) Detection of individual motor units of the puborectalis muscle by non-invasive EMG electrode arrays. J Electromyogr Kinesiol 28(3):382–389

    Article  Google Scholar 

  4. Cescon C, Raimondi EE, Začesta V, Drusany-Starič K, Martsidis K, Merletti R (2014) Characterization of the motor units of the external anal sphincter in pregnant women with multichannel surface EMG. Int Urogynecol J 25:1097–1103

    Article  PubMed  Google Scholar 

  5. Cescon C, Riva D, Začesta V, Drusany-Starič K, Martsidis K, Protsepko O, Baessler K, Merletti R (2014) Effect of vaginal delivery on external anal sphincter muscle innervation pattern evaluated with multichannel surface EMG (results of the multicenter study TASI-2). Int Urogynecol J 25:1491–1499

    Google Scholar 

  6. López A, Nilsson BY, Mellgren A, Zetterström J, Holmström B (1999) Electromyography of the external anal sphincter: comparison between needle and surface electrodes. Dis Colon Rectum 42:482–485

    Article  PubMed  Google Scholar 

  7. Podnar S, Lukanovič A, Vodusek DB (2000) Anal sphincter electromyography after vaginal delivery: neuropathic insufficiency or normal wear and tear? Neurourol Urodyn 19:249–257

    Article  CAS  PubMed  Google Scholar 

  8. Enck P, Hinninghofen H, Merletti R, Azpiroz F (2005) The external anal sphincter and the role of surface electromyography. Neurogastroenterol Motil 17(Suppl 1):60–67

    Article  PubMed  Google Scholar 

  9. Merletti R, Bottin A, Cescon C, Farina D, Mesin L, Gazzoni M, Martina S, Pozzo M, Rainoldi A, Enck P (2004) Multichannel surface EMG for the non-invasive assessment of the anal sphincter muscle. Digestion 69:112–122

    Article  CAS  PubMed  Google Scholar 

  10. Barbero M, Merletti R, Rainoldi A (2012) Atlas of muscle innervation zones: understanding surface electromyography and its applications. Springer Verlag Italia. ISBN 978-88-470-2462-5

    Google Scholar 

  11. Merletti R, Farina D (eds.) (2015) Surface electromyography: physiology, engineering and applications. J Wiley and IEEE Press, NJ, USA

    Google Scholar 

  12. Cescon C, Mesin L, Nowakowski M, Merletti R (2011) Geometry assessment of anal sphincter muscle based on monopolar multichannel surface EMG signals. J Electromyogr Kinesiol 21(2):394–401

    Article  PubMed  Google Scholar 

  13. Enck P, Franz H, Davico E, Mastrangelo F, Mesin L, Merletti R (2010) Repeatability of innervation zone identification in the external anal sphincter muscle. Neurourol Urodyn 29(3):449–457

    PubMed  Google Scholar 

  14. Ullah K, Cescon C, Afsharipour B, Merletti R (2014) Automatic detection of motor unit innervation zones of the external anal sphincter by multichannel surface EMG. J Electromyogr Kinesiol 24(6):860–867

    Google Scholar 

  15. Nygaard I (2005) Should women be offered elective cesarean section in the hope of preserving pelvic floor function? Int Urogynecol J 16:253–254

    Google Scholar 

  16. Tincello D, Williams A, Fowler G, Adams E, Richmond D, Alfirevic Z (2003) Differences in episiotomy technique between midwives and doctors. BJOG 110(12):1041–1044

    Article  PubMed  Google Scholar 

  17. Kalis V, Karbanova J, Horak M, Lobovsky L, Kralickova M, Rokyta Z (2008) The incision angle of mediolateral episiotomy before delivery and after repair. Int J Gynaecol Obstet 103:5–8

    Article  PubMed  Google Scholar 

  18. Freeman RM, Hollands HJ, Barron L, Kapoor DS (2014) Cutting a mediolateral episiotomy at the correct angle: evaluation of a new device, the Episcissors-60. Med Devices (Auckl) 7:23–28

    CAS  Google Scholar 

  19. Signorello LB, Harlow BL, Chekos AK, Repke JT (2000) Midline episiotomy and anal incontinence: retrospective cohort study. BMJ 320(7227):86–90

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  20. Borello-France D, Burgio KL, Richter HE, Zyczynski H, Fitzgerald MP, Whitehead W, Fine P, Nygaard I, Handa VL, Visco AG, Weber AM, Brown MB (2006) Fecal and urinary incontinence in primiparous women. Obstet Gynecol 108(4):863–872

    Article  PubMed  Google Scholar 

  21. Fenner D (2006) Anal incontinence: relationship to pregnancy, vaginal delivery, and cesarean section. Semin Perinatol 30(5):261–266

    Article  PubMed  Google Scholar 

  22. Andrews V, Sultan AH, Thakar R, Jones PW (2006) Risk factors for obstetric anal sphincter injury: a prospective study. Birth 33(2):117–1122

    Article  PubMed  Google Scholar 

  23. Sartore A, De Seta F, Maso G, Pregazzi R, Grimaldi E, Guaschino S (2004) The effects of mediolateral episiotomy on pelvic floor function after vaginal delivery. Obstet Gynecol 103:669–673

    Article  PubMed  Google Scholar 

  24. Wheeler TL, Richter HE (2007) Delivery method, anal sphincter tears and fecal incontinence: new information on a persistent problem. Curr Opin Obstet Gynecol 19(5):474–479

    Article  PubMed  Google Scholar 

  25. De Leeuw JW, Vierhout ME, Struijk PC, Hop WC, Wallenburg HC (2001) Anal sphincter damage after vaginal delivery: functional outcome and risk factors for fecal incontinence. Acta Obstet Gynecol Scand 80(9):830–834

    Article  PubMed  Google Scholar 

  26. Andrews V, Thakar R, Sultan A, Jones P (2005) Are mediolateral episiotomies actually mediolateral? BJOG 112:1156–1158

    Article  PubMed  Google Scholar 

  27. Franz H, Hinninghofen H, Kowalski A, Merletti R, Enck P (2006) Mode of delivery affects anal sphincter innervation. Gastroenterology 130(Suppl 2):S724

    Google Scholar 

  28. Wietek BM, Hinninghofen H, Jehle EC, Enck P, Franz HB (2007) Asymmetric sphincter innervation is associated with fecal incontinence after anal sphincter trauma during childbirth. Neurourol Urodyn 26(1):134–139

    Article  PubMed  Google Scholar 

  29. Carroli G, Belizan J (2000) Episiotomy for vaginal birth. Cochrane Database Syst Rev (1):CD000081

    Google Scholar 

  30. Christianson LM, Bovbjerg VE, McDavitt EC, Hullfish KL (2003) Risk factors for perineal injury during delivery. Am J Obstet Gynecol 189(1):255–260

    Article  CAS  PubMed  Google Scholar 

  31. Dudding TC, Vaizey CJ, Kamm MA (2008) Obstetric anal sphincter injury: incidence, risk factors, and management. Ann Surg 247(2):224–237

    Article  PubMed  Google Scholar 

  32. Fritel X, Schaal J, Fauconnier A, Bertrand V, Levet C, Pigne A (2008) Pelvic floor disorders four years after first delivery: a comparative study of restrictive versus systematic episiotomy. BJOG 115:247–252

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  33. Gee AS, Jones RS, Durdey P (2000) On line quantitative analysis of surface electromyography of the pelvic floor in patients with faecal incontinence. Br J Surg 87(6):814–818

    Article  CAS  PubMed  Google Scholar 

  34. Gregory WT, Lou JS, Simmons K, Clark AL (2008) Quantitative anal sphincter electromyography in primiparous women with anal incontinence. Am J Obstet Gynecol 198(5):550.e1–550.e6

    Article  Google Scholar 

  35. Guise JM, Morris C, Osterwell P, Li H, Rosenberg D, Greenlick M (2007) Incidence of fecal incontinence after childbirth. Obstet Gynecol 109:281–288

    Article  PubMed  Google Scholar 

  36. McKinnie V, Swift SE, Wang W, Woodman P, O’Boyle A, Kahn M, Valley M, Bland D, Schaffer J (2005) The effect of pregnancy and mode of delivery on the prevalence of urinary and fecal incontinence. Am J Obstet Gynecol 193:512–517

    Article  PubMed  Google Scholar 

  37. Murphy D, Macleod M, Bahl R, Goyder K, Howarth L, Strachan B (2008) A randomized controlled trial of routine versus restrictive use of episiotomy at operative vaginal delivery: a multicenter Pilot study. BJOG 115(13):1695–1702; discussion 1702–3 (2008)

    Article  CAS  PubMed  Google Scholar 

  38. Nelson RL (2004) Epidemiology of faecal incontinence. Gastroenterology 126:3–7

    Article  Google Scholar 

  39. Fitzgerald MP, Weber AM, Howden N, Cundiff GW, Brown MB (2007) Risk factors for anal sphincter tear during vaginal delivery. Obstet Gynecol 109(1):29–34

    Article  PubMed  Google Scholar 

  40. Handa VL, Blomquist JL, McDermott KC, Friedman S, Muñoz A (2012) Pelvic floor disorders after vaginal birth: effect of episiotomy, perineal laceration, and operative birth. Obstet Gynecol 119(2 Pt 1):233–239

    Article  PubMed Central  PubMed  Google Scholar 

  41. Kudish B, Blackwell S, Mcneeley SG, Bujold E, Kruger M, Hendrix SL, Sokol R (2006) Operative vaginal delivery and midline episiotomy: a bad combination for the perineum. Am J Obstet Gynecol 195:749–754

    Article  PubMed  Google Scholar 

  42. Lewicky-Gaupp C, Hamilton Q, Ashton-Miller J, Huebner M, DeLancey JQ, Fenner DE (2009) Anal sphincter structure and function relationships in aging and fecal incontinence. Am J Obstet Gynecol 200(5):559

    PubMed Central  PubMed  Google Scholar 

  43. Oberwalder M, Dinnewitzer A, Baig MK, Thaler K, Cotman K, Nogueras JJ, Weiss EG, Efron J, Vernava AM, Wexner SD (2004) The association between late-onset fecal incontinence and obstetric anal sphincter defects. Arch Surg 139(4):429–432

    Article  PubMed  Google Scholar 

  44. Macmillan AK, Merrie AE, Marshall RJ, Parry BR (2004) The prevalence of fecal incontinence in community-dwelling adults: a systematic review of the literature. Dis Colon Rectum 47:1341–1349

    Article  PubMed  Google Scholar 

  45. Mellgren A, Jensen LL, Zetterstrom JP et al (1999) Long-term cost of fecal incontinence secondary to obstetric injuries. Dis Colon Rectum 42:857–867

    Article  CAS  PubMed  Google Scholar 

  46. Hartmann K, Meera Viswanathan M, Palmieri R, Gartlehner G, Thorp J, Lohr K (2005) Outcomes of routine episiotomy a systematic review. JAMA 293(17):2141–2148

    Article  CAS  PubMed  Google Scholar 

  47. Eason E, Labrecque M, Marcoux S, Mondor M (2002) Anal incontinence after childbirth. CMAJ 166(3):326–330

    PubMed Central  PubMed  Google Scholar 

  48. van Brummen HJ, Bruinse HW, van de Pol G, Heintz AP, van der Vaart CH (2006) Defecatory symptoms during and after the first pregnancy: prevalences and associated factors. Int Urogynecol J Pelvic Floor Dysfunct 17(3):224–230, Epub 2005 Aug 3

    Article  PubMed  Google Scholar 

  49. Tetzschner T, Sørensen M, Lose G, Christiansen J (1996) Anal and urinary incontinence in women with obstetric anal sphincter rupture. Br J Obstet Gynaecol 103(10):1034–1040

    Article  CAS  PubMed  Google Scholar 

  50. Kamm MA (2003) Faecal incontinence. BMJ 327:1299–1300

    Article  PubMed Central  PubMed  Google Scholar 

  51. Deutekom M, Terra MP, Dobben AC, Dijkgraaf MG, Felt-Bersma RJ, Stoker J, Bossuyt PM (2005) Selecting an outcome measure for evaluating treatment in fecal incontinence. Dis Colon Rectum 48(12):2294–2301

    Article  PubMed  Google Scholar 

  52. Sung VW, Rogers ML, Myers DL, Akbari HM, Clark MA (2007) National trends and costs of surgical treatment for female fecal incontinence. Am J Obstet Gynecol 197(6):652.e1–652.e5

    Article  Google Scholar 

  53. Amorim M, Franca-Neto A, Leal N, Melo F, Maia S, Alve J (2014) Is it possible to never perform episiotomy during vaginal delivery ? Obstet Gynecol 123(Suppl 1):38S. doi:10.1097/01.AOG.00004473114.51968.54

    Article  Google Scholar 

  54. Bharucha AE, Zinsmeister AR, Locke GR, Seide BM, McKeon K, Schleck CD, Melton LJ (2005) Prevalence and burden of fecal incontinence: a population-based study in women. Gastroenterology 129:42–49

    Article  PubMed  Google Scholar 

  55. Weber AM (2004) The perspective of a gynecologist on treatment-related research for fecal incontinence in women. Gastroenterology 126:S169–S171

    Article  PubMed  Google Scholar 

  56. Pirro N, Sastre B, Sielezneff IJ (2007) What are the risk factors of anal incontinence after vaginal delivery? J Chir (Paris) 144(3):197–202, Review. French

    Article  CAS  Google Scholar 

  57. South MM, Stinnet SS, Sanders DB, Weidner AC (2009) Levator ani denervation and reinnervation six months after childbirth. Am J Obstet Gynecol 200(5):519.e1–519.e7

    Article  Google Scholar 

  58. Woolley RJ (1995) Benefits and risks of episiotomy: a review of the English-language literature since 1980. Part I and Part II. Obstet Gynecol Surv 50:806–835

    Article  CAS  PubMed  Google Scholar 

  59. Wunderlich M, Swash M (1993) The overlapping innervation of the two sides of the external anal sphincter by the pudendal nerves. J Neurol Sci 59:97–109

    Article  Google Scholar 

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Acknowledgments

The author is grateful to Prof Taian Vieira, and to the partners of Project TASI [4, 5] for contributing material and data. The clinical advice and revision by Dr D. Riva are greatly appreciated. This chapter is extensively based on material published in Chap. 14 “Applications in proctology and obstetrics” of the book “Surface electromyography: physiology, engineering and applications” R. Merletti and D Farina editors, J Wiley and IEEE press 2015 and on material published in the book “Atlas of muscle innervation zones: understanding surface electromyography and its applications” by M. Barbero, R. Merletti and A. Rainoldi, published by Springer Verlag (2012). The author is grateful to Springer Verlag, John Wiley and IEEE Press for permission to reproduce material from these books. Project TASI as well as the preparation of this chapter were financially supported by Compagnia di San Paolo, Torino, Italy.

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Merletti, R. (2016). Pelvic Floor EMG: Principles, Techniques, and Applications. In: Riva, D., Minini, G. (eds) Childbirth-Related Pelvic Floor Dysfunction. Springer, Cham. https://doi.org/10.1007/978-3-319-18197-4_7

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  • DOI: https://doi.org/10.1007/978-3-319-18197-4_7

  • Publisher Name: Springer, Cham

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