Biomechanical Analysis of female pelvic floor anatomy: A novel integrative framework

IntroductionMedical school training is often thought of in two segments: preclinical and clinical years. The preclinical years provide knowledge of normal anatomy and physiology while clinical rotations allow students to see pathology in action. Anatomy is universal to preclinical education for future doctors, and it has traditionally been taught through in‐person labs working with deceased donations. As students advance through their training, they face the challenge of making connections between the knowledge from their early clinical years and clinical applications they see in the patients they treat while in training. The COVID‐19 pandemic made this even more challenging as institutions had to maintain safety with social distancing and limit in‐person anatomy laboratory experiences while increasing the use of virtual resources such as virtual 3D anatomy platforms.HypothesisIn first year medical students, the utilization of 3D Anatomy platforms with prosected deceased donations enhances comprehension of female pelvic floor anatomy and pathology compared to using prosected deceased donations alone.Materials and MethodsFirst‐year medical students in the HWCOM Class of 2025 participated. Groups of 6‐10 students rotated through four 25‐minute stations. One station was led by fourth‐year medical student teaching assistants using prosected deceased donations and virtual 3D anatomy platform. The teaching assistants used the first ten minutes of the station to teach specific topics in female pelvic floor anatomy using a prosected deceased donation. In the next ten minutes they used virtual 3D anatomy models to further demonstrate the anatomy and pathology taught using the deceased donation. In the last five minutes of the station, students completed a five question end‐of‐course survey (Appendix 1) including pre‐test and post‐test questions on female pelvic anatomy and how likely students were to recommend virtual anatomy platforms to other students using a 5‐point Likert Scale.Results137 students answered the first three of five questions on the survey. There was improvement on the majority of post‐tests responses relative to the pre‐test. 62.6% of 125 student respondents agreed (34.96%) and strongly agreed (27.64%) that the virtual 3D Complete Anatomy platform was helpful to their understanding of female pelvic anatomy and pathology. 87.2% of 125 student respondents were said they were likely (25.60%) and very likely (61.60%) to recommend virtual 3D Complete Anatomy platform to other medical students.ConclusionsThe data show that the use of virtual 3D anatomy platforms to supplement prosected deceased donations might enhance students’ knowledge of female pelvic floor anatomy and pathology The majority of students were in favor of using the virtual platform and recommending its use to others medical students for their anatomy learning experience.Significance/ ImplicationThe utilization of virtual 3D anatomy platforms in preclinical courses for medical students will strengthen the quality of anatomy medical education. These strategies will become part of our institution’s curriculum for first‐year students and also for students to utilize throughout the remainder of their clinical training.

Female Pelvic Floor Immersive Simulation: A Randomized Trial to Test the Effectiveness of a Virtual Reality Anatomic Model on Resident Knowledge of Female Pelvic Anatomy

The objectives of the study are to review the female pelvic floor anatomy relevant to childbirth simulations, to discuss available methods for clinical evaluation of female pelvic floor function, and to review the variation in pelvic floor changes after vaginal childbirth. A high-resolution magnetic resonance (MR) data set from an asymptomatic nullipara was used to illustrate the MR anatomy of the female pelvic floor. Manual segmentation was performed and three-dimensional reconstructions of the pelvic floor structures were generated, which were used to illustrate the 3D anatomy of the pelvic floor. Variation in the post partum appearance of the levator ani muscles is illustrated using other 2D MR data sets, which depict unilateral and bilateral disruptions in the puborectalis portion of levator ani, as well as shape variations, which may be seen in the post partum levator. The clinical evaluation of the pelvic floor is then reviewed. The female pelvis is composed of a bony scaffold, from which the pelvic floor muscles (obturator internus, levator ani) are suspended. The rectum fits in a midline groove in the levator ani. The vagina is suspended across the midline, attaching bilaterally to the obturator and levator ani. The vagina supports the bladder and urethra. MR studies have demonstrated disruptions in levator ani attachments after vaginal childbirth. Such disruptions are rare in women who have not given birth vaginally. Changes to the neuromuscular apparatus of the pelvic floor can also be demonstrated after vaginal delivery. The combination of childbirth-related anatomic and neurological injury to the pelvic floor may be associated with pelvic floor dysfunction (PFD). These changes are difficult to study in vivo but may be studied through simulations. Appropriate consideration of clinical anatomy is important in these simulations.

IntroductionFemale pelvic anatomy poses challenges for learners due to complexity of the spatial relationships between pelvic floor structures. As anatomy education continue to implement novel approaches such as use of 3D and interactive models to enhance student learning,1 strategies to improve the medical school curriculum remain vast. Problem‐based learning (PBL) is often recognized as a successful teaching method in which learners are encouraged to apply their own knowledge and investigative skills in solving defined problems.2 This study will analyze the effects of using clinical scenarios and PBL in combination with prosected cadavers on student recall ability and knowledge base improvement.ObjectivesIncorporation of clinical vignettes and PBL with prosected cadavers will facilitate improved understanding of female pelvic anatomy compared with using only prosected cadavers.MethodsFirst‐year medical students at Florida International University HWCOM class of 2025 were put into 16 groups of approximately 7 to 10 students (n=137) and rotated through four 25‐minutes stations. One station was facilitated by a 4th year medical student teaching assistant (TA), who used clinical vignettes and PBL combined with a prosected female cadaver that exposed pelvic floor structures. Students also rotated at three other 25‐minute stations (before or after) containing radiologic imaging of relevant anatomy, self‐study, and a procedural station (ureteral catheterization). Prior to the TA station, the students were provided a pre‐session examination containing 2 questions to assess their knowledge of common female pelvic anatomy concepts. Students were then provided the same questions after completing the station to assess for enhanced recall. Both the pre‐ and post‐session examinations used clinical vignettes with multiple choice answers (A through D). Students received 1 point if they answered correctly and 0 points if they answered incorrectly.ResultsFor the first question assessing proximity of the uterine artery to the ureter, 91% of students answered correctly in the post‐test, compared with 67% in the pre‐test. For the second question assessing ovarian torsion, 72% answered correctly in both the pre‐ and post‐tests.Conclusion/ Significance and ImplicationThe results of the first question supports that the use of clinical vignettes and PBL in addition to cadaver prosection can improve the student knowledge base. However, the results of the second question did not support the hypothesis. Possible contributors could be due to lack of standardization in teaching styles among different instructors on the female cadaver or that addition of PBL may be insufficient to generate better outcomes in learning for questions that are of higher complexity. Potential follow up to this study could include assessing for alternative confounders to explore discrepancies in the results.1. Hampton BS, Sung VW. Improving medical student knowledge of female pelvic floor dysfunction and anatomy: a randomized trial. Am J Obstet Gynecol. 2010 Jun;202(6):601.e1‐8. doi: 10.1016/j.ajog.2009.08.038. Epub 2010 Apr 28.2. Savery JR. Overview of problem‐based learning: definitions and distinctions. Interdiscip J Probl Based Learn. 2006;1(1):9–20.

: To estimate the effect of a computer trainer on improving knowledge and attitudes of Obstetrics and Gynecology residents regarding female pelvic anatomy (PA) and pelvic floor dysfunction (PFD) compared to usual teaching. : A randomized trial was conducted between April and June 2008. Obstetrics and Gynecology residents randomized by year of training participated in a 1-hour session with a computer trainer for individual-based learning of female PA and PFD or usual teaching. Questionnaires assessing (1) knowledge of and (2) attitude regarding, or comfort with, female PA and PFD were completed at baseline and 1 month following recruitment. Residents randomized to the trainer answered trainer-specific questions on the post-intervention questionnaire. Higher scores indicated higher knowledge and comfort level. Between-group differences in pre-intervention and post-intervention questionnaire knowledge and attitude scores were analyzed. Eleven residents randomized to each group would provide a power of 0.8 at α = 0.05. : Twenty-two residents completed the study. There were no significant differences between residents randomized to trainer versus usual teaching in knowledge or attitude scores on the pre-intervention questionnaire (p > 0.50). There was no significant difference in median post-intervention knowledge (14 [range 13-17] vs 13 [range 10-18], P = 0.10) or attitude scores (30 [range 14-41] vs 22 [range 11-42], P = 0.49) for the residents randomized to the trainer compared to the controls. : In this single-center study, the trainer was not associated with significant improvements in resident knowledge or attitude scores regarding female PA and PFD.

Improving medical student knowledge of female pelvic floor dysfunction and anatomy: a randomized trial

INTRODUCTION: Whereas cadaveric dissection is essential to learning anatomy and its structural relationships, it is expensive and donors are limited. Lectures alone lack the kinesthetic learning that gross dissection offers. The objective was to determine whether clay modeling with concurrent lecture is an effective way of reviewing female pelvic anatomy for third-year and physician assistant students. METHODS: A pretest preceded each 2-hour lecture presentation and clay modeling session on female internal and external pelvic anatomy for 23 third-year medical and four physician assistant students at SUNY Downstate Medical Center. Each student was paired with another to form a working dyad. Peer learning and teaching were facilitated and encouraged throughout each of the two 2-hour lecture and clay modeling sessions. A posttest was administered at the end of each session. RESULTS: Using one-tailed dependent variable t test for comparison of means, there was a significant difference (P<.05) between pretest and posttest scores for all students. There was no significant difference between the mean pretest and posttest scores of the third-year medical compared with the physician assistant students. The group as a whole showed significant improvement in knowledge (P<.05). The dyads showed marked improvement in scores when compared with individual results. CONCLUSION: Clay modeling with concurrent lecture is an effective method to help third-year medical and physician assistant students review internal and external female pelvic anatomy. Interestingly, despite previous shorter anatomy training, the physician assistant students knew as much pelvic anatomy as the medical students.

BACKGROUND: Knowledge of female pelvic anatomy is essential to training in obstetrics and gynecology; however, much of this teaching is done informally throughout residency. Our goal was to evaluate if using existing resources (lectures and cadavers) from our associated medical school could improve resident knowledge and confidence in female pelvic anatomy. METHODS: Residents attended two consecutive 1 hour lectures traditionally given to first-year medical students, (female pelvis and perineum), conducted by two faculty in the department of Cellular Biology and Anatomy. Residents completed pretesting and posttesting on a 50-item test composed of 25 cadaver tags, using existing dissected cadavers, and 25 multiple choice questions related to female pelvic anatomy, derived from an existing medical student secure test bank; results were reported as total percent correct. Three weeks elapsed between pretesting and posttesting. Residents were also asked to assess their confidence in knowledge of pelvic anatomy and in identifying female pelvic structures, using a five-point Likert scale. RESULTS: All residents (n=16) participated. Mean pretest scores of 54.6%±11.6 increased 24% at posttest to 72%±9.1 (P<.05). Mean resident confidence in knowledge of pelvic anatomy increased 44% from 1.64 to 2.92 (P<.05), and mean confidence in identification of pelvic structures increased 33% from 2.21 to 3.28 (P<.05). CONCLUSION: Our pilot study shows promise for using existing medical school resources to provide structured teaching of female pelvic anatomy to obstetrics and gynecology residents while increasing resident knowledge and confidence.

Detailed knowledge of female pelvic floor anatomy is essential for midwifery and other professionals in obstetrics. Physical models have shown great potential for teaching anatomy and enhancing surgical skills. In this article, we introduce an innovative physical anatomy model called "Pelvic+" to teach anatomical relationships in the female pelvis. The Pelvic+ model's value was compared to a traditional lecture in 61 first-year midwifery students randomly allocated to either the Pelvic+ (n = 30) or a control group (n = 32). The primary outcome measure was a quiz comprised of 15 multiple choice questions on pelvic anatomy. Participants were assessed at baseline (Pre-Test), upon completion of the intervention (Post-Test1) and 4 months afterward (Post-Test2). Satisfaction with the approach was assessed at Post-Test1. Increase in knowledge was greater and the approach more accepted among resident midwives when Pelvic+ was used instead of standard lectures. Four months after the intervention, the improvement in knowledge was preserved in the Pelvic+ group. This randomized study demonstrates that the Pelvic+ simulator is more effective than classical learning for pelvic anatomy education, and offers a higher level of satisfaction among students during the educational process. Medical students training in obstetrics and gynecology, or any professional who specializes in the female pelvic floor might also benefit from incorporation of the Pelvic+ model into their training program.

Objective To evaluate the influence of different modes of delivery on the incidence rate of stress urinary incontinence (SUI) and female pelvic floor anatomy. Methods From May to December 2008, a total of 49 cases from age of 18 to 35 with 28~36 gestational weeks were included into this study (study group). They were further divided into vaginal delivery group(n=24) and elective cesarean section(ECS) group(ECS group, n=22)according to the different modes of delivery. Meanwhile, another 20 healthy childless women of childbearing age were included into control group. The study protocol was approved by the Ethical Review Board of Investigation in Human Being of First Affiliated Hospital of Ji'nan University. Informed consent was obtained from all participants. Each subject received examination during rest and during Valsalva's maneuver for the following parameters: anteroposterior diameter (AP) and lateral diameter (LD) of levator hiatus (LH), posterior urethra-vesical angle (α), flexibility of bladder neck (θ), and distance between the pubic symphysis midpoint and bladder neck (D). The content of serum C-terminal propeptide of type Ⅰ procollagen (PICP) was detected by enzyme linked immunosorbent assay (ELISA) method. The above indicators were compared at 28 to 36 gestational weeks , 6 to 8 and 12 to 14 weeks after delivery between study group and control group. Results The incidence of stress urinary incontinence reduced after delivery. For vaginal delivery group, the flexibility of bladder neck and distance between the pubic symphysis midpoint and bladder neck at 6 to 8 weeks after delivery had larger changes compared to ECS group (P 0.05). Conclusion Pelvic tissue damages under elective cesarean section is less than that of vaginal delivery. Elective cesarean section has protective effects on pelvic structure. Pelvic damages under all methods of delivery are temporary, and it could be recovered by natural course. Serum procollagen peptide structural damage as the pelvic fibrosis serum markers, can indirectly from post-natal pelvic floor injury response to self-repair process of development. However, elective cesarean section has a limited protective effect on pelvic floor function. Key words: vaginal delivery; elective cesarean section(ECS); stress urinary incontinence(SUI); C-terminal propeptide of type Ⅰ procollagen (PICP)

Our knowledge of the immediate effects of parturition on pelvic floor anatomy and physiology has been sparse. However, with the introduction of computed tomography, ultrasonography, and magnetic resonance imaging, new tools have become available for visualizing dynamic antenatal and postpartum changes in the pelvic musculature. Although few studies have been performed, there is evidence of a pregnancy-related increase in the frequency of urinary stress incontinence, and of an increased frequency of persistent anal incontinence in cases of sphincter tears.

PELVIC FLOOR ANATOMY IN CLASSIC BLADDER EXSTROPHY USING 3-DIMENSIONAL COMPUTERIZED TOMOGRAPHY: INITIAL INSIGHTS

Evaluation of the aged female baboon as a model of pelvic organ prolapse and pelvic reconstructive surgery

The pelvic floor is characterized by a complex morphology because different functional systems join here. Since a clear understanding of the pelvic floor region is crucial for female pelvic surgery and fundamental mechanisms of urogenital dysfunction and treatment, we here describe the accurate and functional anatomy of important pelvic structures and landmarks, clarify their terminology and point out possible errors or misunderstandings as to their existence.

Obstetric trauma to the puborectal muscle seems to be an important cause of pelvic floor dysfunction in women. Due to the complicated three-dimensional (3D) arrangement of the pelvic structures, two-dimensional images are not sufficient to demonstrate its relationships in a complex fashion. Thus, we aimed to create a 3D computer model to visualize the normal female pelvic floor anatomy and to compare this with the anatomy after bilateral avulsion of the puborectal muscle following delivery. We created two 3D computer models of the female pelvic floor, one of a healthy nulliparous woman and the other of a woman with bilateral puborectal muscle avulsion after vaginal delivery. The data for the models were obtained from magnetic resonance imaging examinations and the following structures were depicted: pelvic bones, puborectal muscle, internal obturator muscle, urethra, urinary bladder, vagina and rectum. The models were compared. The models allowed us to demonstrate in three dimensions changes in the puborectal muscle after avulsion. Its relations to the bone, internal obturator muscle, perineal membrane and the deep part of the external anal sphincter were modeled and differences from the normal non-injured anatomy were demonstrated. Avulsion altered the support to the whole endopelvic fascia and destabilized both the anterior and the posterior vaginal walls. The use of 3D technology including modeling allows for the acquisition of new knowledge and aids in the understanding of both normal and pathological pelvic anatomy.