Coughing, sneezing, or laughing provokes urine leakage for one in three women. These are events that induce high, quick intra-abdominal pressure. Speaking and shouting also produce a range of intra-abdominal pressures, though these events have not been investigated for how they affect the pelvic floor muscles or could be contributing to urine leakage or even treatment. This study aims to identify how pelvic floor muscles respond to speaking and shouting events in healthy women and those with stress urinary incontinence (SUI). The hypothesis is that women will strain/lengthen their pelvic floor muscles during voicing, with greater strain seen during louder voicing (shouting). Those with pelvic floor symptoms will either have minimal pelvic floor strain or excessive movement/strain during voicing tasks.

58 women, ages 20-68 (mean 40.3 years). Symptom severity was based on the answer to question 6 of the Australian Pelvic Floor Questionnaire (“Do you leak urine with coughing, sneezing, laughing, exercising?”): Included were 20 women without leakage, 29 with occasional leakage, 6 with frequent leakage, and 3 with daily leakage. To measure pelvic floor response to voicing, this study used b-mode, 2-dimensional transperineal and transabdominal ultrasound (TPUS and TAUS) to measure bladder neck displacement. For TPUS the measurement of interest is bladder neck height, which is measured as the base of the bladder neck to the intersection point with the line from pubic bone to anorectal angle, which accounts for angular motion of bladder neck on contraction. For TAUS the distance between the most superior/anterior and the most inferior/posterior portion of the bladder is measured before and after each task. The tasks include: pelvic floor contraction, pelvic floor strain, counting to 4 on one exhale with: deep pitch voice/speaking volume, deep pitch voice/shouting volume, high pitch voice/speaking volume and high pitch voice/shouting volume. Each task was performed three times. Length change was measured from the start to maximal displacement for each task and averaged over three trials. Analysis included repeated measures analysis of variance (ANOVA) and one-way ANOVA.

Repeated measures ANOVA with a Greenhouse-Geisser correction determined that mean bladder neck displacement differed statistically between tasks. For TPUS: (F (1.9, 108.04) = 54.97, P<0.001).  For TAUS: (F (2.84, 162.01) = 77.87, P<0.001).  Pairwise comparison showed there was no significant different between bladder diagonal length change for low versus high pitch speaking or low versus high pitch shouting though both speaking tasks differed significantly from shouting tasks for low and high voicing (P<0.001, P= 0.05 respectively). There were no differences in length change for participants with varying degrees of symptom severity though the sample size was small and under-powered.

Because of small an uneven distribution on women with varying symptom severity, a power analysis was not able to determine effect size. This likely contributed to no differences seen in group response as categorized by symptom severity. Differences were seen across all participants for response to the 6 tasks where all responses to voicing were in the same direction as straining and the opposite direction as contracting. This finding can be interpreted as pelvic floor muscles strain to varying degrees during voicing, regardless of symptoms. Pelvic floor lengthening was seen to increase with louder voicing and did not change in response to different pitch.

Those at risk of urine leakage should be mindful of shouting as a potentially provocative activity, and those with difficulty lengthening pelvic floor muscles may incorporate voicing to help perform this task.

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