Pelvic-Floor Muscle Function in Women With Pelvic

Organ Prolapse
Diane F Borello-France, Victoria L Handa, Morton B
Brown, Patricia Goode, Karl Kreder, Laura L Scheufele
and Anne M Weber
PHYS THER. 2007; 87:399-407.
Originally published online March 6, 2007
doi: 10.2522/ptj.20060160

The online version of this article, along with updated information and services, can be
found online at: http://ptjournal.apta.org/content/87/4/399

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 Research Report

DF Borello-France, PT, PhD, is As-

Pelvic-Floor Muscle Function in sistant Professor, Department of
Physical Therapy, 111 Health Sci-
Women With Pelvic Organ Prolapse ences Bldg, Duquesne University,
Pittsburgh, PA 15282 (USA). Ad-
dress all correspondence to Dr
Diane F Borello-France, Victoria L Handa, Morton B Brown, Patricia Goode, Borello-France at: borellofrance
Karl Kreder, Laura L Scheufele, Anne M Weber; for the Pelvic Floor Disorders @duq.edu.
Network
VL Handa, MD, is Associate Profes-
sor, Gynecology and Obstetrics,
Johns Hopkins University, Balti-
Background and Purpose more, Md.
The purpose of this study was to determine whether pelvic organ prolapse severity,
MB Brown, PhD, is Professor, De-
pelvic symptoms, quality of life, and sexual function differ based on pelvic-floor partment of Biostatistics, Univer-
muscle function in women planning to have prolapse surgery. sity of Michigan, Ann Arbor, Mich.

P Goode, MD, MSN, is Associate

Subjects and Methods Director for Clinical Programs, Ge-
Three hundred seventeen women without urinary stress incontinence who were riatric Research, Education, and
enrolled in a multicenter surgical trial were examined to determine pelvic-floor Clinical Center, Birmingham Vet-
muscle function (by Brink scale score). The subjects were 61.6⫾10.2 (X⫾SD) years erans Affairs Medical Center, and
Professor of Medicine, University
of age. Thirteen percent of the subjects had stage II (to the hymen) pelvic organ of Alabama at Birmingham, Bir-
prolapse, 68% had stage III (beyond the hymen) prolapse, and 19% had stage IV mingham, Ala.
(complete vaginal eversion) prolapse. Subjects with lowest (3– 6) and highest (10 –
K Kreder, MD, is Professor and
12) Brink scale scores were compared on prolapse severity, pelvic symptoms and Vice Chair, Department of Urol-
bother, quality of life, and sexual function. ogy, University of Iowa, Iowa City,
Iowa.
Results LL Scheufele, PT, BScPT, BCIA-
Subjects with the highest Brink scores (n⫽75) had less advanced prolapse, smaller PMDB, GCFP, is Pelvic Floor Phys-
genital hiatus measurements, and less urinary symptom burden compared with those ical Therapist, Johns Hopkins Bay-
with the lowest Brink scores (n⫽56). The results indicated that pelvic-floor muscle view Medical Center, Baltimore,
Md.
function was not associated with condition-specific quality of life or sexual function.
AM Weber, MD, MS, is Project Sci-
Discussion and Conclusion entist, Pelvic Floor Disorders Net-
work, National Institute of Child
Although modestly clinically significant, better pelvic-floor muscle function was Health and Human Development,
associated with less severe prolapse and urinary symptoms. National Institutes of Health, Be-
thesda, Md.

Pelvic Floor Disorders Network (see

listing of member sites and investi-
gators on page 406)

[Borello-France DF, Handa VL,

Brown MB, et al; for the Pelvic Floor
Disorders Network. Pelvic-floor
muscle function in women with pel-
vic organ prolapse. Phys Ther.
2007;87:399 – 407.]

© 2007 American Physical Therapy

Association.

For The Bottom Line:

www.ptjournal.org

April 2007 Volume 87 Number 4 Physical Therapy f 399

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Pelvic-Floor Muscle Function and Pelvic Organ Prolapse
P
elvic organ prolapse is the de-
scent of the apex of the vagina
or cervix (or vaginal vault after
hysterectomy), anterior vaginal wall
(previously referred to as “cystocele”),
or posterior vaginal wall (previously
called “rectocele”).1 As prolapse pro-
gresses, organs can protrude outside
the vaginal canal. This condition is com-
mon, with some degree of prolapse
seen in 94% of women.2 The lifetime
risk of undergoing surgery for pro-
lapse or urinary incontinence is ap-
proximately 11.1% by age 80 years.3
Women with advanced pelvic organ
prolapse are more likely to feel self-
conscious and less physically and sex-
ually attractive than women without
this condition. In addition, they score
poorer on both generic and condition-
specific quality-of-life (QOL) scales.4
About one third of sexually active
women with pelvic organ prolapse re-
port that their condition interferes
with sexual function.5,6
Normal support of the pelvic organs
depends on the integrity of the
pelvic-floor muscles, the supportive
connective tissue of the vagina (the
endopelvic fascia and the uterosacral
and cardinal ligaments), and normal
innervation.7 The pelvic-floor mus-
cles include the pubococcygeus,
puborectalis, and iliococcygeus (col-
lectively known as the levator ani
muscles).8 When functioning prop-
erly, tonic and voluntary activity of
the levator ani muscles narrows the
urogenital hiatus and draws the ure-
thra, vagina, and rectum toward the
pubic bone. In this situation, the sup-
porting connective tissues experi-
ence minimal tension. Loss of levator
ani muscle function has been pro-
posed as a mechanism for prolapse.7
As muscular support is lost, the uro-
genital hiatus widens and connective
tissue support, under tension, be-
come stretched or torn, thus leading
to prolapse.7
Loss of pelvic-floor muscle support is
only one of the many risk factors for
400 f Physical Therapy Volume 87 Number 4
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developing prolapse.9,10 Samuelsson
et al11 investigated factors related to
prolapse in 487 Swedish women
who were receiving gynecologic care.
Among multiple variables, age, parity,
and pelvic-floor muscle strength
(force-generating capacity, as esti-
mated by vaginal palpation) were as-
sociated with prolapse. However, only
2% of the women in the study by
Samuelsson et al had pelvic organ pro-
lapse severe enough to reach the vag-
inal introitus.
In a study of 358 women after pro-
lapse surgery, Vakili et al12 found
that women with greater preopera-
tive pelvic-floor muscle strength (as
assessed by vaginal palpation) had
less recurrent prolapse and were less
likely to have repeat surgery. Be-
cause of the retrospective nature of
this study, missing data led to the
elimination of some cases, poten-
tially introducing a selection bias.
Given the limitations of both stud-
ies,11,12 further investigation toward
understanding the relationship be-
tween pelvic-floor muscle function
and pelvic organ prolapse and its ef-
fect on QOL and sexual function is
needed.
Understanding the degree of risk that
a given factor contributes to the eti-
ology of prolapse is important in
both prevention and intervention. A
recent randomized controlled study
including pelvic floor muscle exer-
cise as an adjunct to surgery for pel-
vic organ prolapse or urinary incon-
tinence demonstrated improvements
in continence status, diurnal urinary
frequency, pelvic floor muscle
strength, and QOL.13 However, the
effectiveness of pelvic floor muscle
exercise alone as an intervention for
pelvic organ prolapse had not been
determined.14 Exploring the relation-
ship of pelvic-floor muscle function
and prolapse is a preliminary step
toward answering this question. The
aim of this prospective study was to
determine whether prolapse sever-
ity; pelvic symptoms; condition-
specific, health-related QOL; and
sexual function differ based on
pelvic-floor muscle strength in
women who are planning to have
surgery for prolapse. We hypothe-
sized that women with better pelvic-
floor muscles function would have
less severe prolapse, fewer pelvic
symptoms, and better QOL and sex-
ual function.
Method
Subjects
This study was conducted by the Pel-
vic Floor Disorders Network (PFDN),
sponsored by the National Institute
for Child Health and Human Develop-
ment. Data for this study came from
preoperative assessments that were
conducted in 317 of the 322 women
enrolled in a multicenter randomized
surgical trial, Colpopexy and Urinary
Reduction Efforts (CARE); data were
not available for 5 subjects.15 The
CARE trial sought to determine
whether adding Burch colposuspen-
sion to abdominal sacrocolpopexy for
prolapse is associated with decreased
postoperative urinary stress inconti-
nence in women without preopera-
tive stress incontinence.
To be defined as stress continent
for study eligibility, women were
screened at the clinical sites by com-
pleting the Medical, Epidemiologic,
and Social Aspects of Aging (MESA)
questionnaire16 and answering “never”
or “rarely” to the stress incontinence
questions. However, at subsequent
telephone interviewing, about 20% of
the eligible subjects did experience
some level of stress incontinence. In
addition, women could experience
urge incontinence and still be eligible
for the study. The institutional review
board at each PFDN clinical site and
the data coordinating center at the
University of Michigan approved the
protocol, and all participants provided
written informed consent.
April 2007

Procedure
Prolapse stage and pelvic-floor mus-
cle function data were obtained by
the site research nurse or surgeon
investigator according to standard-
ized criteria documented in the
study procedural manual. Staff from
the central telephone interviewing
facility at the University of Michigan
administered baseline symptom,
QOL, and sexual function question-
naires to participants.
Pelvic organ prolapse stage.
The International Continence Soci-
ety, the American Urogynecologic
Society, and the Society of Gyneco-
logic Surgeons have agreed on a stan-
dardized system to describe pelvic
support in women known as the Pel-
vic Organ Prolapse Quantification
(POP-Q).17 For the POP-Q examina-
tion, women were in dorsal lithot-
omy position. Maximal extent of pro-
lapse was measured (in centimeters)
using defined vaginal points relative
to the hymen. Points above (or in-
side) the hymen were negative num-
bers (eg, ⫺3 cm), and points below
(or outside) the hymen were positive
numbers (eg, ⫹3 cm); points at the
hymen were 0 cm. All vaginal points
were measured with maximal val-
salva effort except for total vaginal
length, which was measured at rest.
Genital hiatus was measured at rest
and with maximal valsalva effort.
The POP-Q measures (Fig. 1) in-
cluded in the analyses, in addition
to ordinal prolapse stage, were:
(1) greatest descent of the anterior
vagina (point “Ba”) and posterior
vagina (point “Bp”); (2) the cervix or
the vaginal cuff in women without a
uterus (point “C”); (3) for women
with a uterus, the posterior fornix
(point “D”); (4) total vaginal length
(ie, the greatest depth of the vagina
when point “C” or “D” was reduced
to normal position); and (5) genital
hiatus (ie, the distance from the mid-
dle of the external urethral meatus to
the inferior hymenal ring).17 Intra-
April 2007
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Pelvic-Floor Muscle Function and Pelvic Organ Prolapse
Figure 1.
Pelvic Organ Prolapse Quantification
(POP-Q) system for describing and stag-
ing pelvic support. Six sites (points “Aa,”
“Ba,” “C,” “D,” “Bp,” and “Ap”), genital
hiatus (gh), perineal body (pb), and total
vaginal length (tvl) used for pelvic organ
support quantification. Reprinted with
permission of Elsevier from: Bump RC,
Mattiasoon A, Bo K, et al. The standard-
ization of terminology of female pelvic or-
gan prolapse and pelvic floor dysfunction.
Am J Obstet Gynecol. 1996;175:10 –17.
observer reliability coefficients (r) for
the POP-Q measures have been re-
ported to range from .522 (point “C”)
to .912 (genital hiatus). Interobserver
reliability coefficients (r) ranged from
.765 (point “C”) to .934 (point “Ba”).18
According to POP-Q definitions, pro-
lapse is stage II when the vagina is
prolapsed between 1 cm above the
hymen (⫺1 cm) but not more than 1
cm below (outside) the hymen (⫹1
cm). Prolapse more than 1 cm be-
yond the hymen but no farther than
2 cm less than total vaginal length is
stage III prolapse. Stage IV prolapse
is complete vaginal eversion extend-
ing beyond the hymen to a distance
equal to the total vaginal length (⫾2
cm). Intraobserver and interobserver
reliability coefficients (r) reported
for staging of prolapse were .712 and
.70, respectively.18
Pelvic-floor muscle function.
Pelvic-floor muscle function is de-
fined as the ability to perform a cor-
rect contraction, meaning a squeeze
Volume 87 Number 4
around pelvic openings and an in-
ward, upward movement (lift) of the
pelvic floor.19 Pelvic-floor muscle
function was examined by vaginal
palpation and quantified using the
standardized Brink scale.20 The
Brink scale considers 3 dimensions to
evaluate the pelvic-floor muscle con-
traction: (1) squeeze pressure felt
around the examiner’s fingers,
(2) duration, and (3) vertical displace-
ment of the examiner’s fingers. Each
dimension or subscale is rated sepa-
rately on a 4-point categorical scale,
and the ratings then are summed for a
composite score ranging from 3 to 12,
with a higher score indicating better
muscle function (Tab. 1.)
Brink et al20 reported test-retest
(with an intertest interval of 2–7
weeks) reliability coefficients (r) of
.54, .51, and .53 for the squeeze pres-
sure, vertical displacement, and con-
traction duration subscale scores, re-
spectively, and .65 for the total
score. Interrater reliability coeffi-
cients (r) were .74, .67,and .52 for
the squeeze pressure, vertical dis-
placement, and contraction duration
subscale scores, respectively. Hund-
ley et al21 reported good interrater
reliability for the squeeze pressure
subscale and total Brink scale score
(r ⫽.68), with lower coefficients for
vertical displacement (r ⫽.58) and
contraction duration (r ⫽.44). Good
correlations (r ⫽.68 and .71 for 2 ex-
aminers) were found between the
Brink scale squeeze pressure subscale
score and maximal squeeze pressure
scores obtained using a perineometer.
Examiners followed standardized cri-
teria for pelvic-floor muscle examina-
tion and Brink scale scoring specified
in the study policy and procedure
manual. The pelvic-floor muscle ex-
aminations were performed with
women positioned supine with their
hips flexed and slightly abducted and
knees flexed. An examiner’s gloved
and lubricated index and middle fin-
gers, oriented vertically, were in-
Physical Therapy f 401
Pelvic-Floor Muscle Function and Pelvic Organ Prolapse

Table 1. Higher scores indicate more symp-

Brink Scoring System20
Muscle Function
Dimension
Squeeze pressure
Muscle contraction duration
Vertical displacement
Total
toms and worse symptom bother.
Score
The effect of pelvic symptoms on
QOL was assessed using the Pelvic
1⫽none
Floor Impact Questionnaire (PFIQ).22
2⫽weak squeeze, felt as a flick at various points along The PFIQ also contains 3 subscales:
finger surface; not all the way around
the Urinary Impact Questionnaire
3⫽moderate squeeze; felt all the way around finger (UIQ), the Pelvic Organ Prolapse Im-
surface pact Questionnaire (POPIQ), and the
4⫽strong squeeze; full circumference of fingers Colo-Rectal-Anal Impact Question-
compressed naire (CRAIQ). The degree to which
1⫽none pelvic symptoms affect QOL, in par-
2⫽less than 1 second ticular physical activity, social rela-
tionships, travel, and emotional
3⫽greater than 1 second; less than 3 seconds
health, is rated on a categorical scale,
4⫽greater than 3 seconds with scores ranging from 1 (activity/
1⫽none feeling affected “not at all”) to 4
2⫽finger bases move anteriorly (pushed up by muscle (activity/feeling affected “quite a
bulk) bit”). Each subscale of the PFIQ is
3⫽whole length of fingers moves anteriorly rated from 0 to 300, with higher
scores indicating a worse effect on
4⫽whole fingers move anteriorly, are gripped and
QOL. Both the PFDI and the PFIQ
pulled in
have been tested for internal consis-
Range⫽3–12 tency, reproducibility, and validity.22

serted along the posterior vagina to
the level of the examiner’s proximal
interphalangeal joints. Women were
asked to contract their pelvic-floor
muscles following the instruction:
“Squeeze around my fingers as hard
and as long as you can, as if you are
trying to hold back the passage of gas
or a bowel movement.”
If a subject performed the contrac-
tion incorrectly (by straining or con-
tracting her hip muscles instead of
her pelvic-floor muscles), the exam-
iner did not rate or record a Brink
scale score for this contraction but
provided feedback to the subject on
how to contract her muscles cor-
rectly and then asked her to perform
another pelvic-floor muscle contrac-
tion. If the contraction was per-
formed correctly, the examiner rated
the squeeze pressure and vertical dis-
placement dimensions according to
Brink scale criteria.20 Muscle con-
traction duration was determined
and rated during a separate pelvic-
floor muscle contraction. Examiners
timed the contraction using a stop-
watch. The stopwatch was stopped
when the contraction weakened, or
if the subject maintained the contrac-
tion beyond 8 seconds. Subjects were
cautioned not to “bear down” or per-
form a Valsalva maneuver during all
pelvic-floor muscle contractions. A
brief rest period (20 –30 seconds) was
given between contractions.
Symptom burden, quality of life,
and sexual function. The Pelvic
Floor Distress Inventory (PFDI)22 as-
sesses pelvic-floor symptoms across
3 subscales: the Urinary Distress In-
ventory (UDI), the Pelvic Organ Pro-
lapse Distress Inventory (POPDI),
and the Colorectal-anal Distress In-
ventory (CRADI). In completing the
PFDI, subjects are asked to indicate
whether they have a particular symp-
tom and, if so, to assess how much
it bothers them on a 4-point scale rang-
ing from 1 (“not at all”) to 4 (“quite a
bit”). Scores for the UDI and the
POPDI range from 0 to 300, and scores
for the CRADI range from 0 to 400.
To assess sexual function, subjects
were asked to respond to the Pelvic
Organ Prolapse/Urinary Incontinence
Sexual Function Questionnaire (PISQ-
12),23 which measures sexual func-
tion across 3 factors: behavioral/
emotive, physical, and partner-related.
The PISQ-12 scores can be reported as
scores for individual items or as a total
score, ranging from 0 to 48, with
higher scores indicating better sexual
function. Test-retest reliability and va-
lidity of the PISQ-12 have been re-
ported for sexually active women.23 A
PISQ-12 score can be computed only
for women who complete at least 11
of the 12 items.23
Data Analysis
We aimed, a priori, to compare
women with the best and worst
pelvic-floor muscle function with re-
spect to prolapse severity and QOL.
All hypotheses assumed that the
greatest difference would be found
between subjects with the highest
and lowest Brink scale quartiles. Be-
cause we aimed to assess whether

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 Pelvic-Floor Muscle Function and Pelvic Organ Prolapse

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

Variable Brink Scale Quartilea

Lower Middle Upper P
(Scoreⴝ3–6) (Scoreⴝ7–9) (Scoreⴝ10–12) (Lower Quartile vs
(nⴝ56) (nⴝ186) (nⴝ75) Higher Quartile)
Age (y), X⫾SD 63.2⫾10.5 61.7⫾10.4 59.8⫾9.3 .05
b
Menopausal status, n (%) .15
Postmenopausal (n⫽274) 52 (19.0) 158 (57.7) 64 (23.3)
Premenopausal (n⫽36) 3 (8.3) 23 (63.9) 10 (27.8)
c
Prolapse stage, n (%) .11
II (n⫽42) 4 (9.5) 24 (57.1) 14 (33.3)
III (n⫽214) 38 (17.8) 127 (59.3) 49 (22.9)
IV (n⫽61) 14 (22.9) 35 (57.4) 12 (19.7)
d
Genital hiatus, no strain (cm), X⫾SD 4.6⫾1.9 4.4⫾1.4 4.0⫾1.5 .09
Genital hiatus, with strain (cm), X⫾SD 5.8⫾1.8 5.6⫾1.5 5.0⫾1.5 .01
Maximal prolapsee (cm), X⫾SD 4.4⫾2.5 3.9⫾2.4 3.8⫾2.5 .43
a
The Brink scale quartiles were based on the approximate distribution of the subjects across Brink scale scores.
b
Menopausal status data were available only for 310 women.
c
Stage II prolapse⫽the vagina has prolapsed to the level between 1 cm above the hymen (⫺1 cm) but not more than 1 cm below (outside) the hymen (⫹1
cm), stage III prolapse⫽prolapse more than 1 cm beyond the hymen but no farther than 2 cm less than total vaginal length, and stage IV
prolapse⫽complete vaginal eversion extending to total vaginal length (⫾2 cm).
d
Genital hiatus⫽the distance from the middle of the external urethral meatus to the inferior hymenal ring.
e
Maximal prolapse⫽the leading edge of prolapse (ie, at maximal descent relative to the hymen), regardless of which vaginal point or points involved; can
be point “Ba,” “Bp,” “C,” or “D.”

prolapse severity, POP-Q, and QOL
outcomes differed as a function of
Brink scale score, we chose to
present the outcome scores accord-
ing to Brink scale scoring categories.
Therefore, Brink scale scores were
categorized into low, medium, and
high quartiles for analysis.
Treating Brink scale scores as cate-
gorical, we first grouped subjects
based on approximate Brink scale
quartiles, representing 25% of the
study population with the lowest
scores (3– 6), 50% of subjects in the
middle range (7–9), and the remain-
ing 25% with the highest scores (10 –
12). If the distribution by scores had
been perfectly even, the number of
subjects in each quartile would be 80
(25% of 320); however, because the
distribution was not perfect, the re-
sultant groups contained 56, 186,
and 75 subjects, respectively. The
Fisher exact test was used to com-
pare women in the highest and low-
est Brink scale quartiles on meno-
pausal status and POP-Q stage, and
an age-adjusted analysis of variance
(ANOVA) was used to compare
POP-Q points. The 2-tailed Wilcoxon
rank sum test was used for compar-
isons of PFDI, PFIQ, and PISQ scores
due to their skewed distributions.
We also aimed to determine whether
Brink scale scores differed by pro-
lapse stage. For these analyses, Brink
scale scores were treated as contin-
uous. A 2-sample t test was used for
comparisons of Brink subscale scores
between women with stage IV versus
stage II prolapse. The total Brink scale
scores of women with stage IV versus
stage II prolapse were compared by
age-adjusted ANOVA.
With 56 and 75 subjects in the 2
Brink scale quartiles being com-
pared, there was 80% power to iden-
tify an effect size of 0.5 (ie, a differ-
ence of 0.5 standard deviations). In
addition, there was 80% power to
identify a difference between pro-
portions of 50% and 75%, or of sim-
ilar magnitude.
Results
Among the 317 participants, mean
age (⫾SD) was 61.6⫾10.2 years. Me-
dian parity was 3 (range⫽0 –11).
Most women (88.4%) were post-
menopausal. Forty-two women
(13%) had stage II prolapse, 214
(68%) had stage III, and 61 (19%) had
stage IV prolapse.
Age, self-reported menopausal sta-
tus, POP-Q stage, and selected
POP-Q points are presented in Table
2. Menopausal status and POP-Q
stage did not differ between Brink
scale quartiles. Age decreased from
the lowest to the highest Brink scale
quartile, but the difference was only
marginally statistically significant
(P⫽.05). Mean genital hiatus with
maximal strain was 0.8 cm smaller in

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Pelvic-Floor Muscle Function and Pelvic Organ Prolapse

elevate their pelvic floor during pel-

vic muscle contraction than women
with more advanced prolapse. Sec-
ond, women in the lower Brink scale
quartile had larger genital hiatus
measurements when straining. Both
observations are consistent with an
etiologic theory of prolapse that in-
criminates poor pelvic-floor muscle
function as one of the inciting or con-
tributory factors in the development
of prolapse, although the magnitude
of the differences was relatively small.

Another plausible explanation is that

prolapse contributes to pelvic-floor
muscle weakness. Advancing prolapse
could cause passive stretch and im-
paired contractility of the pelvic-floor
muscles.24 It is possible that pelvic-
floor muscle dysfunction could both
contribute to the development of pro-
Figure 2.
lapse and represent a consequence of
Comparison of Brink scale scores between women with stage II and stage IV prolapse.
Women with stage II prolapse had greater vertical displacement (P⫽.03) and total Brink prolapse. By the time women reach
scale scores (P⫽.04) than women with stage IV prolapse. However, note the modest clinical care for prolapse, it is not pos-
magnitude of the differences, in relation to the standard deviation of the scores and in sible to determine which came first.
relation to the potential range of the scores. Asterisk indicates differences between Longitudinal studies would help to de-
women with stage II and stage IV prolapse that were statistically significant. termine the temporal relationship be-
tween pelvic-floor muscle weakness
and prolapse.
the women in the highest Brink scale PISQ-12 (sexual function) are pre-
quartile compared with those in the sented by Brink scale quartile in Ta- It is noteworthy that, despite the dif-
lowest Brink scale quartile (P⫽.01). ble 3. The PFIQ and PISQ-12 scores ferences observed, Brink scale quar-
Other POP-Q measures did not differ did not differ significantly between tiles did not distinguish between
between Brink scale quartiles. women in the upper versus lower stages of prolapse. It may be that,
Brink scale quartiles. The PFDI sub- once prolapse of a certain degree
Considering Brink scale scores as a scale scores differed only with re- (eg, stage II) develops, pelvic-floor
continuous variable, we observed gard to urinary symptoms. Women muscle function is not further im-
small differences in mean Brink in the lowest Brink scale quartile had paired. That is, the reason that the
scores between women with stage II higher UDI scores (ie, more urinary Brink scale quartiles were similar
versus stage IV prolapse. Figure 2 symptoms and bother) than women across stages of prolapse may be that
shows that women with stage II pro- in the upper Brink scale quartile a certain level of pelvic-floor muscle
lapse had higher Brink scores (P⫽.016). dysfunction had been reached and,
(P⫽.04). However, the difference in regardless of further advancement
scores occurred only in the vertical Discussion and Conclusions of the prolapse itself, the level of
displacement subscale (P⫽.03). That We observed 2 potentially important pelvic-floor muscle function (or dys-
is, women with a lower stage of pro- relationships between pelvic-floor function) remained stable.
lapse were able to elevate the pelvic muscle function and prolapse in this
floor somewhat better during pelvic- study. First, women with less ad- We selected vaginal palpation to as-
floor muscle contraction. vanced prolapse had higher Brink sess pelvic-floor muscle function be-
scale scores, primarily due to the ver- cause of its practicality in both re-
Scores for PFDI (pelvic-floor symp- tical displacement component. That search and clinical settings. The
toms and bother), PFIQ (pelvic-floor is, women with less advanced pro- standardized Brink scale was desirable
symptom impact on QOL), and lapse were somewhat better able to as an evaluation scale because of its

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 Pelvic-Floor Muscle Function and Pelvic Organ Prolapse

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

Variable Brink Scale Quartile

Lower Middle Upper P
(Scoreⴝ3–6) (Scoreⴝ7–9) (Scoreⴝ10–12) (Lower Quartile vs
(nⴝ56) (nⴝ182) (nⴝ71) Higher Quartile)
Symptoms and bother: PFDI subscales, X⫾SD
UDI (range⫽0–300) 70.2⫾42.7 61.1⫾41.9 53.4⫾34.7 .016
POPDI (range⫽0–300) 108.2⫾61.2 110.0⫾70.7 95.9⫾60.9 .20
CRADI (range⫽0–400) 74.3⫾72.6 73.5⫾66.8 63.1⫾62.1 .53
Quality-of-life impact: PFIQ subscales, X⫾SD
UIQ (range⫽0–300) 47.0⫾44.3 51.6⫾53.7 39.0⫾47.2 .12
POPIQ (range⫽0–300) 41.7⫾47.2 48.1⫾62.7 43.0⫾55.1 .61
CRAIQ (range⫽0–300) 23.8⫾34.2 34.8⫾56.0 25.6⫾53.9 .27
Sexual function: PISQ-12,b (range⫽0–48), X⫾SD n⫽23 n⫽96 n⫽39
33.7⫾6.3 33.8⫾7.1 33.8⫾7.4 .96
a
PFDI⫽Pelvic Floor Distress Inventory, UDI⫽Urinary Distress Inventory, POPDI⫽Pelvic Organ Prolapse Distress Inventory, CRADI⫽Colorectal-anal Distress
Inventory, PFIQ⫽Pelvic Floor Impact Questionnaire, UIQ⫽Urinary Impact Questionnaire, POPIQ⫽Pelvic Organ Prolapse Impact Questionnaire, CRAIQ⫽Colo-
Rectal-Anal Impact Questionnaire, PISQ-12⫽Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire–12. Quality-of-life data were
obtained on only 309 of the 317 subjects.
b
Completed by women who were sexually active with a partner.

demonstrated interrater reproducibil-
ity, test-retest reliability, and validity20
and because of its prior use in re-
search related to pelvic-floor disor-
ders.21 It is possible, however, that the
Brink method of assessing pelvic-floor
muscle function is not sufficiently pre-
cise to demonstrate a clear association
with prolapse severity.
Physical therapists may be more fa-
miliar with other pelvic-floor muscle
grading scales, such as the Oxford or
Laycock scale,25 which evaluates
strength of contraction on a 6-point
scale ranging from 0 (no contrac-
tion) to 5 (strong contraction). In
contrast, the Brink scale measures 3
different aspects of pelvic-floor mus-
cle function: squeeze pressure, du-
ration of contraction, and vertical
displacement. In this study, we as-
signed categorization to the total
Brink scale score, with the connota-
tion of poor pelvic-floor muscle func-
tion for the low scores and good, or
at least better, pelvic-floor muscle
function to the high scores. This cat-
egorization is relatively arbitrary and
has not been separately validated.
Studies are needed to compare vari-
ous scales for evaluating pelvic-floor
muscle function based on digital ex-
amination with each other and with
other means of assessing pelvic-floor
muscle function, such as pressure
perineometry or force measurements.
In addition, pelvic-floor muscle func-
tion tests and measures have not been
adequately evaluated for construct
validity, particularly with regard to
identifying aspects of muscle physiol-
ogy that are most critical to providing
pelvic support. Thus, there is no con-
sensus as to how to “best” assess
pelvic-floor muscle function, and over-
coming this current limitation should
be a high priority for future research.
Although we found a statistically sig-
nificant association between prolapse
severity and Brink scale scores, we ob-
served considerable overlap in Brink
scale scores across prolapse stages
(Fig. 2), and comparisons by Brink
scale quartiles and prolapse stage were
not statistically significant (Tab. 2).
These findings are not surprising,
given the multifactorial etiology of
prolapse. However, they do limit the
clinical interpretation of our findings,
especially in the absence of compari-
son data from women without pro-
lapse. Regardless, we suggest that it is
prudent to consider all known risk fac-
tors when determining a physical ther-
apist prognosis and plan of care for a
woman with pelvic organ prolapse.
We also observed a statistically signif-
icant association between Brink scale
quartile and UDI score, which re-
flects the number of urinary symp-
toms and their associated bother.
Again, the magnitude of the difference
between the lower and upper Brink
scale quartiles was modest: a 17-point
difference between the means, in a
subscale with an upper limit of 300
points. Poor pelvic-floor muscle func-
tion has been correlated with urinary
incontinence. Women with stress in-
continence have weaker pelvic-floor

April 2007 Volume 87 Number 4 Physical Therapy f 405

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Pelvic-Floor Muscle Function and Pelvic Organ Prolapse
muscles,26 –28 and pelvic-floor muscle
exercise is an effective intervention
for stress and urge incontinence.29
In our study, women who reported
stress incontinence on the MESA ques-
tionnaire were excluded by study de-
sign; yet, we still observed a small in-
crease in UDI scores among women
with poor pelvic-floor muscle func-
tion. This finding suggests that pelvic-
floor muscle weakness may predis-
pose women to other urinary
symptoms besides stress inconti-
nence; whether prolapse is a key
feature of this association or not is
unknown.
Other than urinary incontinence,
Brink scale quartiles were not associ-
ated with other pelvic-floor symp-
toms. For example, we did not see
an association between pelvic-floor
muscle function and severity of pro-
lapse symptoms (ie, POPDI and
POPIQ scores), colorectal symptoms
(ie, CRADI and CRAIQ scores), or sex-
ual function (PISQ-12 scores). Pelvic
symptoms have correlated poorly, if at
all, with clinical measurements of pro-
lapse severity.30 –32 The findings of our
study support the perception of pro-
lapse symptoms and their associated
bother as complex and incompletely
understood at the current time. Other
demographic, etiologic, and psycho-
social variables may play a greater role
in symptom bother and effect on QOL
than pelvic-floor muscle function in
women with prolapse.
A limitation of this study was that we
included only women who had pro-
lapse bothersome enough to seek
treatment. In addition, only women
who were eligible and who agreed to
enroll in a randomized surgical trial
for prolapse contributed data to this
study, potentially limiting the gener-
alizability of our findings. The cross-
sectional nature of this study also
precludes us from determining a
causal or temporal relationship be-
tween pelvic-floor muscle function
and prolapse.
406 f Physical Therapy Volume 87 Number 4
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This study’s results cannot be used
directly to support the potential pre-
ventative role of pelvic-floor muscle
exercise for women with prolapse.
Recent research has begun to examine
whether pelvic-floor muscle exercise
is effective as a primary or secondary
prevention for pelvic organ pro-
lapse.13 Certainly, pelvic-floor muscle
exercise has a well-established role in
the prevention and management of
other pelvic-floor disorders, including
urinary and fecal incontinence.29 Fur-
ther research is needed to investigate
the potential for physical therapy in-
terventions in the prevention and re-
habilitation of pelvic organ prolapse.
Dr Borello-France, Dr Goode, and Dr Kreder
provided concept/idea/research design. Dr
Borello-France, Dr Handa, Dr Goode, Dr Kre-
der, and Dr Weber provided writing. Dr
Handa provided data collection. Dr Brown,
Dr Goode, and Dr Kreder provided data
analysis. Dr Weber provided project man-
agement. Dr Goode provided fund procure-
ment and institutional liaisons. Dr Handa
and Dr Kreder provided subjects. Dr Kreder
provided facilities/equipment. Dr Brown, Dr
Kreder, Ms Scheufele, Dr Weber provided
consultation (including review of manuscript
before submission). The authors thank Dr
Robert Park, Chair of the Pelvic Floor Disor-
ders Network Steering Committee, for his
contributions to the network (2001–2006).
Pelvic Floor Disorders Network Members:
University of Alabama at Birmingham—Holly E
Richter, PhD, MD (Principal Investigator),
Kathryn L Burgio, PhD (Co-Principal Investiga-
tor), Patricia S Goode, MD (Co-Investigator),
R Edward Varner, MD (Co-Investigator), Vel-
ria Willis, RN, BSN (Research Coordinator);
Baylor College of Medicine—Paul M Fine, MD
(Principal Investigator), Rodney A Appell, MD
(Co-Principal Investigator), Peter K Thompson,
MD (Co-Investigator), Peter M Lotze, MD
(Co-Investigator), Naomi Frierson (Research
Coordinator); University of Iowa—Ingrid Ny-
gaard, MD (Principal Investigator), Debra
Brandt, RN (Research Coordinator), Denise
Haury, RN (Research Coordinator), Karl Kre-
der, MD (Co-Investigator), Catherine Bradley,
MD (Co-Investigator), Satish Rao, MD (Co-
Investigator); Johns Hopkins Medical Institutes
—Geoffrey Cundiff, MD (Principal Investiga-
tor), Victoria Handa, MD (Co-Investigator),
Robert Gutman, MD (Co-Investigator), Mary
Elizabeth Sauter, NP (Research Coordinator),
Jamie Wright, MD (Co-Investigator); Loyola
University, Chicago—Linda Brubaker, MD
(Principal Investigator), Mary Pat Fitzgerald,
MD (Co-Principal Investigator), Kimberly
Kenton, MD (Co-Investigator), Dorothea
Koch, RN (Research Coordinator), Charity
Ball, RN (Research Coordinator); University of
North Carolina at Chapel Hill—Anthony G
Visco, MD (Principal Investigator), AnnaMa-
rie Connolly, MD (Co-Investigator), John
Lavelle, MD (Co-Investigator), Mary J Loo-
mis, RN (Research Coordinator), Anita K
Murphy, NP (Research Coordinator), Ellen C
Wells, MD (Co-Investigator), William E
Whitehead, PhD (Co-Investigator); Univer-
sity of Pittsburgh/Magee–Womens Hospitals
—Halina Zyczynski, MD (Principal Inves-
tigator), Diane Borello-France, PhD (Co-
Investigator), Judy A Gruss, BS, MS (Re-
search Coordinator), Wendy Leng, MD
(Co-Investigator), Pamela A Moalli, MD, PhD
(Co-Investigator), Elizabeth Sagan, MD
(Co-Investigator), Arnold Wald, MD (Co-
Investigator); Data Coordinating Center, Uni-
versity of Michigan—Morton B Brown, PhD
(Principal Investigator), John T Wei, MD, MS
(Co-Principal Investigator), Beverley March-
ant, RN (Project Manager), John OL De-
Lancey, MD (Co-Investigator), Nancy K Janz,
PhD (Co-Investigator), Dean G Smith, PhD
(Co-Investigator), Patricia A Wren, PhD
(Co-Investigator), Li Peng, MS (Statistician),
James Imus, MS (Statistician), Yang Wang
Casher, MS (Database Programmer); Steering
Committee Chairman—Robert Park, MD; NIH
Project Scientist—Anne M Weber, MD, MS.
A poster presentation of this research was
given at the 2005 American Urogynecologic
Society Meeting; September 15–17, 2005;
Atlanta, Ga.
This article reflects work performed by the
Pelvic Floor Disorders Network, supported
by the National Institute of Child Health
and Human Development (grants U01
HD41249, U10 HD41268, U10 HD41248,
U10 HD41250, U10 HD41261, U10
HD41263, U10 HD41269, and U10
HD41267).
This article was received June 12, 2006, and
was accepted December 21, 2006.
DOI: 10.2522/ptj.20060160
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Physical Therapy f 407
 Pelvic-Floor Muscle Function in Women With Pelvic
Organ Prolapse
Diane F Borello-France, Victoria L Handa, Morton B
Brown, Patricia Goode, Karl Kreder, Laura L Scheufele
and Anne M Weber
PHYS THER. 2007; 87:399-407.
Originally published online March 6, 2007
doi: 10.2522/ptj.20060160

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