Factors associated with pelvic floor muscle strength in women with pelvic floor dysfunction assessed by the Brink scale
IUGA Academy. Manonai J. Jun 30, 2018; 212796; 332 Topic: Pelvic Organ Prolapse
Jittima Manonai
Jittima Manonai

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Factors associated with pelvic floor muscle strength in women with pelvic floor dysfunction assessed by the Brink scale

Sarit-apirak, S1;Manonai, J2

1: Department of Nursing; 2: Department of OB-GYN

Introduction: The pelvic floor muscles (PFM) play a significant role in the continence mechanism and pelvic organ support. They may be exposed to alterations during different phases of a woman’s life, such as pregnancy, childbirth, aging and menopause. These factors may impair the strength of the PFM and lead to pelvic floor dysfunction. Pelvic floor muscle training (PFMT) is recommended as a first-line physical therapy treatment for women with urinary incontinence and pelvic organ prolapse. Measurement of PFM strength is an important parameter for PFMT. Investigating associated factors with PFM strength may lead to the specific training protocol or technique in women with different types of pelvic floor symptoms or different associated factors.

Objectives: To investigate the associated factors of pelvic floor muscle strength and the correlation between women’s characteristics, pelvic floor symptoms, stage of pelvic organ prolapse and PFM strength in women attending a urogynecology clinic using the Brink scale.

Methods: In this retrospective study, the medical records of consecutive women who had attended a tertiary urogynaecology clinic, from January 2011 and December 2014 were reviewed. Pelvic floor symptoms were evaluated using the Pelvic Floor Bother Questionnaire (PFBQ). All new patients were examined in the lithotomy position by urogynecologists according to the POP-Q system. Then, pelvic floor muscle strength assessments were performed using the Brink scoring system. The Brink scale evaluates 3 PFM contraction variables: vaginal pressure, duration of contraction and elevation or vertical displacement of the examiner’s fingers. Each muscle contraction variable is rated on a 4-point ordinal scale. Afterwards, ratings are summed to obtain total scores, with a possible range of scores of 3 to 12. Univariate associations between demographic data, pelvic floor symptoms, stage of pelvic organ prolapse, and Brink scale will be quantified using t test and Pearson correlation coefficients. A p value <0.05 will be considered statistically significant.

Results: A total of 579 women with complete Brink scale scores were included in the analysis. Of these

women, the mean age was 64.40 +/- 10.11 years, the mean body mass index (BMI) was 25.60 +/- 3.89 kg/m2, 544 (93.9%) were parous and 479 (82.7%) were postmenopausal. Two hundred and fifty-three women (43.7%) reported that they had had urgency urinary incontinence in the past month, 275 women (47.5%) reported of having stress urinary incontinence symptoms and 50 women (10.2%) undergone hysterectomy. The mean total Brink scale score was 7.82 +/- 2.56 with median of 8 (6,10) (Table 1).

Table 1 Brink scale scores in women with pelvic floor dysfunction (N=579)




Pressure; mean 2.74 +/- 0.88

1-no response

2-weak squeeze

3-moderate squeeze

4-strong squeeze









Duration; mean 2.72 +/- 0.93


2-<1 sec

3-1-3 sec

4->3 sec









Displacement of vertical plane; mean 2.37 +/- 0.94


2-finger base moves anteriorly

3-whole length of fingers

4-whole fingers are pulled in









Regarding associated factors, the present study found that parity was the only factor that significantly affected the PFM strength (p < 0.05) whereas BMI, vaginal delivery, menopausal status and pelvic floor symptoms did not. Correlations between demographic data, POP-Q findings and the total Brink scale scores are shown in Table 2. Correlation analysis determined a significant negative relationship between the higher total Brink scale scores and advancing age, higher number of parity and advanced anterior (point Ba) and apical compartment (point C) prolapse (p < 0.05).

Table 2 Correlations between factors and the total Brink scale scores


Correlation (r)


Age (years)



Body mass index (kg/m2)






Anterior compartment (Ba)



Apical compartment (C)



Posterior compartment (Bp)



Genital hiatus (cm)



Conclusions: Among women attending a urogynecology clinic, 11%-20% could not perform pelvic floor muscle exercises at all whereas 9.5% did correctly (total score of 12). Age and parity are significant factors affecting PFM strength evaluated with the Brink scale. Increasing severity of anterior and apical compartment prolapse were negatively correlated with PFM strength. These findings should be implemented in PFMT to improve specific PFM components, protocol and technique for individual woman presented with pelvic floor dysfunction.


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