Pelvic floor function in women with stress urinary incontinence

Objective To evaluate the changes of pelvic floor structure and function quantitatively in different periods after taking total hysterectomy by transperineal pelvic ultrasound. Methods A total of 105 female patients who underwent ultrasound examination after hysterectomy at the Second Hospital of Lanzhou University from March 2016 to July 2017 were enrolled. Among them, 37 cases were 40-49 years old, 49 cases were 50-59 years old, 19 cases were over 60 years old; 29 cases were less than 1 years after hysterectomy, 33 cases were>1,≤5 years after hysterectomy, 28 cases were>5,≤10 years after hysterectomy, and 15 cases were over 10 years after hysterectomy. A total of 120 female volunteers from the Second Hospital of Lanzhou University who had not been diagnosed with pelvic floor dysfunction (PFD) were selected as the healthy control group without total hysterectomy or other pelvic floor surgery. All subjects were examined by pelvic floor ultrasound. The distance from the bladder neck to the lower edge of pubic symphysis (X), urethral angle (α), retrovesical angle (β), the distance from the lowest point from the rectal ampulla to the lower edge of pubic symphysis (D) and detrusor thickness under resting state and maximal Valsalva state were measured. And the urethral rotation angle (Rα) and bladder neck descent value (BND) were calculated. T test was used to compare the ultrasonic quantitative parameters between the total hysterectomy group and the healthy control group, and the detection rate of PFD was compared by Chi-square test between the patients of different age groups at different time after hysterectomy. Results The thickness of bladder detrusor in total hysterectomy group was significantly higher than that in healthy control group. The age of patients in the total hysterectomy group was older than that in the healthy control group, and the difference was statistically significant. At rest, compared with the subjects in the healthy control group, the βincreased, the X and D decreased in patients with total hysterectomy. The differences were significant. The α increased after hysterectomy, but the difference was not statistically significant. At maximum Valsalva state, compared with the subjects in the healthy control group, the α, β, Rα and BND all increased in the group of total hysterectomy, and the X and D decreased. The difference was statistically significant. The detection rate of PFD in 105 cases of total hysterectomy group was 60% (63/105), the detection rate of stress incontinence (SUI) was 33.3% (35/105), and the detection rate of pelvic organ prolapse (POP) was 36.2% (38/105). In POP, the detection rate of bladder prolapse, rectal prolapse and intestinal hernia was 18.1% (19/105), 10.5% (11/105) and 6.7% (7/105). SUI was the main occurrence of PFD within 1 year after total hysterectomy, and the detection rate was 48.3% (14/29). 10 years after operation, POP was the predominant occurrence of PFD, and the detection rate was 80.0% (12/15). There was no significant difference in the detection rate of PFD between different age groups after hysterectomy, indicating that the detection rate of PFD at different times after hysterectomy may not be closely related to the age of patients. Conclusion Transperineal pelvic floor ultrasonography can dynamically observe the changes of pelvic floor structure after total hysterectomy, and can evaluate PFD quantitatively after operation. Key words: Ultrasonography; Pelvic floor; Stress incontinence; Pelvic organ prolapse; Hysterectomy

Objective To evaluate the pelvic floor function in post-hysterectomy patients. Methods Transperineal pelvic ultrasound was used to observe the pelvic organs in post- hysterectomy patients, and parameters of pelvic floor were measured. Taking the inferior margin of public symphysis as the reference plane, the shape and motion of the proximal urethra and bladder neck were observed at rest and on maximum Valsalva maneuver. Bladder neck-symphyseal distance(BSD) and retrovesical angle were measured. And the bladder neck descent(BND), urethral rotation angle and the rotation angle of the bladder neck were also calculated. Interclass correlation coefficients were calculated to evaluate the consistency of data. Results At rest, the BSD and retrovesical angle were (-2.73±0.37)cm and (119.00±22.40)°, while on maximum Valsalva maneuver was (-0.25±0.67)cm and (114.74±21.50)°, respectively. BND was (2.46±0.59)cm, the urethral rotation angle and the rotation angle of the bladder neck was (70.68±19.91)° and (60.81±17.34)°, respectively. Combined with pelvic ultrasound and clinical manifestations, 29 cases of pelvic floor dysfunction after hysterectomy were diagnosed (58.00%, 5 cases of stress urinary incontinence, 8 cases of proctoptoma and 16 cases of bladder prolapse). The consistency was very high in measuring BNS, retrovesical angle at rest and on maximum Valsalva maneuver and BND by different observers. The interclass coefficient was 0.90, 0.89, 0.91, 0.88, 0.92, respectively. And the interclass coefficient of urethral rotation angle and the rotation angle of the bladder neck was 0.79, 0.88, respectively. These results showed a good interobserver agreement. Conclusion Transperineal pelvic ultrasound is a simple, reproducible and noninvasive imaging method, which can reveal the position and function of female pelvic organ dynamically and evaluate postoperative pelvic floor function. Key words: Ultrasonography; Pelvi floor function; Hysterectomy

Pelvic organ prolapse (POP) and stress urinary incontinence (SUI) share common pathological mechanisms,[1] and both manifest as a tape of pelvic floor dysfunction, often co-occurring and developing concomitantly. Although POP develops concomitantly with evident SUI in some cases, there have been instances wherein POP occurs without prior urine leakage before repositioning the prolapsed organs, but urinary incontinence develops after the prolapsed organs are repositioned. The condition in such cases is termed as occult SUI (OSUI), with an incidence of approximately 23.5% among patients with POP.[2] 1. Epidemiology and pathological mechanisms Despite sharing several epidemiological risk factors such as pregnancy, increased gravidity and parity, obesity, advanced age, persistently elevated intra-abdominal pressures (IAP) (eg, persistent cough or constipation), menopause, and family history, POP and SUI have complex and multifactorial etiologies. Furthermore, advanced age and Green type III cystocele (bladder prolapses to the level of the urinary meatus, the posterior urethrovesical angle <140°, urethral rotation angle ≥45°) are risk factors for concomitant OSUI in patients with POP.[3] Although POP and SUI represent distinct clinical manifestations with a shared cause, which is currently believed to be a class of disorders linked to an imbalance of pelvic floor dynamics, the majority of POP cases involve the anterior vaginal wall or the bladder. This type of prolapse is highly likely to result in laxity and protrusion of the bladder's neck and posterior wall, causing impaired support from the middle posterior urethra. This, in turn, leads to a reduced functional length of the urethra and the development of SUI symptoms.[4] Although current surgical procedures for POP repositioning can correct the anatomical positions of the involved organs, they cannot address problems involving the mechanisms of urinary control, such as sphincter dysfunction, thinning of the urethral mucosa, and autonomic dysfunction of the involved organs. Consequently, SUI becomes particularly prominent in the postoperative period.[5,6] Biomechanical finite element analyses of the pathological mechanisms of pelvic floor stress dysfunction reveal that SUI and POP are disorders of mechanical imbalance inexorably linked to each other. Moreover, they serve as pelvic manifestations of the overall systemic deterioration of the body's mechanical properties. Achieving optimal therapeutic efficacy requires more than just correcting SUI or POP in isolation. It necessitates restoring the overall health of the body and its mechanics through a comprehensive understanding of the body's overall condition and mechanical imbalance post–pelvic floor stress dysfunction.[7,8] 2. Diagnosis and evaluation The diagnosis of POP accompanied by SUI primarily relies on a thorough medical history and specialized examination. Questionnaires and laboratory examinations are not suitable for clear differential diagnosis from POP or SUI alone. 2.1. Medical history The typical symptom of POP accompanied by SUI involves protrusion of a mass from the vagina that can be seen, palpated, or otherwise sensed, which may also be accompanied by urine leakage during activities that increase IAP, such as exercise, laughing, coughing, or sneezing. Some patients may also present with frequent urination, urinary urgency, urge incontinence, or difficult urination. 2.2. Specialist examination Patients should be positioned in lithotomy or, if necessary, a standing position for examination. Observation includes checking for urinary leakage from the external urethral meatus, prolapse of pelvic organs, and maximum extent of organ prolapse at rest, during coughing or breath holding. Results should be recorded using the POP-Q system. Vaginal repositioning testing should be performed to avoid missing a diagnosis of OSUI. Specifically, stress induction testing should be performed after repositioning of the prolapsed organs, preferably in the standing position if possible. In addition, pad weight testing should be performed as a preliminary evaluation of urine leakage. Many methods of repositioning are available, with reliable results achieved by restoring the normal position of the vagina using an appropriately sized pessary or sterile cotton gauze.[9,10] 2.3. Urodynamic testing The 2019 National Institute for Health and Care Excellence guidelines serve as the international consensus to determine whether urodynamic testing is required in cases of POP accompanied by SUI. Urodynamic testing is currently recommended in the following situations: (1) mixed urinary incontinence or urinary incontinence of unknown cause; (2) voiding dysfunction as the primary symptom; (3) SUI with concomitant anterior or apical prolapse; (4) previous history of surgical treatment for urinary incontinence. Notably, this testing should be conducted only after repositioning of the prolapsed pelvic organs, distinguishing it from other urodynamic testing methods. 2.4. Differential diagnosis It is necessary to differentiate among the types of urinary incontinence associated with pelvic organ prolapse, primarily including the following: Urge incontinence: Involuntary urine leakage associated with a strong and sudden need to urinate, rather than leakage triggered by activities such as coughing or sneezing that elevate intra-abdominal pressure. Overflow incontinence: Involuntary leakage of urine due to an overdistended bladder. This is commonly encountered in cases of chronic urinary retention caused by various factors, resulting in continuous or intermittent urine leakage when bladder pressure exceeds urethral resistance. Genuine stress incontinence: A loss of urine due to a rise in intra-abdominal pressure, even when the bladder is not full. Common causes include urethral sphincter damage and congenital or acquired neurogenic diseases. 3. Conservative treatment Conservative treatment is recommended for patients with POP of grade ≤2, as assessed by the POP-Q, accompanied by mild or moderate SUI. The selection of treatment depends on the patient's preferences, disease severity, the benefits and risks of the chosen treatment, and other relevant factors. Various treatment methods are available, including follow-up observation, lifestyle interventions, pelvic floor muscle training (PFMT), pelvic floor physical therapy, pessaries, medication, and traditional Chinese medicine and acupuncture. 3.1. Follow-up observation Follow-up observation is a suitable option for asymptomatic patients, but it should be accompanied by lifestyle intervention guidance and health education. 3.2. Lifestyle interventions All patients diagnosed with POP accompanied by SUI should actively receive behavioral guidance to mitigate factors that exacerbate pelvic floor injury. This may involve weight loss, smoking cessation, avoidance of activities that increase pelvic floor stress, and the treatment of constipation and cough. 3.3. Pelvic floor muscle training Numerous PFMT methods are available, with Kegel exercises being simple yet effective in increasing the strength and coordination of weak pelvic floor muscles. Currently, a recommended duration of 3 continuous months of muscle training is advised for improving pelvic floor dysfunction, especially in cases of mild or moderate SUI.[11,12] 3.4. Physical therapy Biofeedback, adjuvant electrical stimulation, and electromagnetic therapy can enhance the effectiveness of PFMT and shorten the duration of therapy. 3.5. Pessaries Pessaries are devices inserted into the vagina to enhance pelvic floor function by restoring the normal anatomical positions of the uterus, vaginal wall, urethra, and bladder. They represent a first-line conservative treatment option for POP. Specifically, pessaries designed to address urinary incontinence can alleviate the majority of symptoms in patients with mild to moderate POP accompanied by SUI[13] and are particularly suitable for patients with fertility requirements or those for whom surgery is contraindicated. However, proper guidance on usage and regular follow-up visits are essential. 3.6. Medication Generally, medication is not considered a first-line treatment for POP accompanied by SUI. However, local estrogen treatment may be considered if the patient presents with genitourinary syndrome of menopause, which can help alleviate vaginal dryness, reduce urinary tract symptoms, and increase the thickness of the urethral mucosa, indirectly improving symptoms of urinary incontinence.[14] 3.7. Traditional Chinese medicine Electroacupuncture, traditional Chinese medicine, and other procedures can improve pelvic floor support and alleviate symptoms of prolapse and urinary incontinence to some extent, serving as adjuvant treatments. 4. Surgical treatment of POP with SUI Nearly 70% of patients with severe POP exhibit symptoms of SUI.[15] For POP patients with evident SUI, surgical treatments solely addressing POP have limited efficacy for SUI. Hence, we recommend simultaneous surgical treatment of SUI (evidence grade C). Surgical interventions for SUI encompass midurethral slings (MUS) and Burch colposuspension (Burch procedure). 4.1. Midurethral sling Midurethral sling corrects urinary incontinence by strengthening the overactive middle segment of the urethra. With a subjective cure rate of 75%–94% and an objective cure rate of 57%–92% for SUI, MUS stands as a superior treatment for urinary incontinence compared with the Burch procedure, establishing itself as the criterion standard for surgical treatment of female SUI. Medical evidence indicates that, in POP patients with evident SUI preoperatively, simultaneous MUS during pelvic floor reconstruction can reduce the subjective incidence of postoperative SUI and further decrease the need for surgical management of SUI.[16] For SUI patients with characteristics such as small bladder volume, urinary retention, or detrusor muscle dysfunction, preoperative urodynamic testing should be conducted to assess bladder function, and the option of surgical SUI management should be carefully considered. In cases where MUS is performed simultaneously with surgical POP management, it is recommended to tighten the sling and adjust tension after completing pelvic floor reconstruction. Complications of MUS may include bladder and urethral injury, difficult urination, pain in the medial thigh and pelvic cavity, and mesh exposure or erosion. 4.2. Burch procedure The Burch procedure addresses urinary incontinence by elevating the neck of the bladder and restoring the posterior urethrovesical angle. It is currently employed in laparoscopic POP reconstruction when surgical SUI management is necessary. Studies have demonstrated that patients undergoing the Burch procedure exhibit significantly lower overall cure rate and objective cure rate than those undergoing MUS. Thus, the Burch procedure is not considered the first choice for surgical SUI management in patients with POP accompanied by SUI. 5. Surgical treatment of POP with OSUI The choice between a "one-step" and a "two-step" treatment for POP accompanied by OSUI remains a matter of debate. Conducting MUS simultaneously with the surgical management of POP has shown advantages, such as reducing the risk of new-onset SUI postoperation, diminishing the need for postoperative SUI treatment, decreasing the requirements of anesthesia, and lowering medical costs. In addition, it does not affect the patient's ability to void and retain urine, nor does it compromise bladder compliance. However, this approach is associated with an increased incidence of overactive bladder, difficult urination, urine retention, urinary tract infections, and elevated risks of sling erosion and bladder perforation.[17,18] Pelvic organ prolapse patients lacking symptoms of SUI are particularly susceptible to developing OSUI, especially in cases of anterior and central POP. Preoperatively, prolapsed tissues should be repositioned through the vagina before detailed examination to confirm the presence or absence of OSUI to prevent postoperative SUI. We recommend the following methods in the formulation of the surgical plan (Fig. 1): For patients with POP in which SUI was not preoperatively confirmed, vaginal repositioning testing should be performed first. If the result is negative, SUI surgery is not necessary. If the result is positive, the strategy should be formulated considering whether the patient has a previous history of SUI. For patients with a confirmed history of SUI that resolved with increasing prolapse and for those without a history of SUI who do not wish to undergo a second operation, simultaneous SUI surgery can be performed. In summary, patients with POP accompanied by OSUI should be examined on an individual basis to weigh the risks and benefits, the surgical procedure should be carefully selected, and communications with the patient and family members should be timely and thorough.Figure 1: Diagnostic flowchart for POP accompanied by OSUI. POP = pelvic organ prolapse; SUI = stress urinary incontinence. POP = pelvic organ prolapse; SUI = stress urinary incontinence.If simultaneous SUI surgery is deemed necessary, the primary options include both the Burch procedure and MUS, with the choice dependent on the surgical approach for POP (transabdominal or transvaginal). Notably, the efficacy of MUS is better than that of the Burch procedure, and the effectiveness of MUS via the retropubic approach or the transobturator approach is comparable. 6. Prevention and surveillance 6.1. Prevention Pelvic organ prolapse and SUI have the same epidemiological risk factors and therefore similar preventive measures. Improving health during pregnancy and the postpartum period through interventions such as weight control and PFMT exercises combined with breathing exercises.[19] Avoiding activities that increase IAP, such as managing constipation and minimizing intense physical activity. Controlling body weight, avoiding/quitting smoking, and maintaining nutritional balance. Postmenopausal patients can undergo appropriate hormone replacement therapy after evaluation by a physician, thus improving overall health and managing symptoms of genitourinary syndrome of menopause. 6.2. Surveillance Surveillance of patients with POP accompanied by SUI should include the following: Follow-up for conservative treatment: At 3–6 months of treatment, follow-up should include a 72-hour voiding diary, a 1-hour urine pad test, pelvic floor muscle myoelectric testing, the International Consultation on Incontinence Questionnaire—Urinary Incontinence Short Form (ICI-Q-SF), and urodynamic testing if necessary.[20] Follow-up for surgical treatment: At 6 months postoperatively, the patient should be examined for short-term complications such as infection, bleeding, and tissue injury. After 6 months, the patient should be examined for long-term complications and efficacy of surgical treatment. Follow-up examination should include a 72-hour voiding diary, a 1-hour urine pad test, the ICI-Q-SF, Pelvic Floor Distress Inventory-20, Pelvic Organ Prolapse Distress Inventory-6, Urinary Distress Inventory-6 Colorectal-Anal Distress Inventory-8, Pelvic Floor Impact Questionnaire-7, the American Urological Association Symptom Score, and other questionnaires, as well as urodynamic testing, B-scan ultrasound of the pelvic floor, cystography, and other examinations as necessary to evaluate bladder function and mechanical recovery of the pelvic floor. Patients with mesh exposure should be referred to a trained and experienced pelvic floor specialist for further diagnosis and treatment.[21] The use of standardized CTS terminology and standardized documentation for complications is recommended to facilitate future management and referral. This article is a second publication and English translation of Chinese expert consensus on the diagnosis and treatment of pelvic organ prolapse and stress urinary incontinence, which was first published in Zhonghua Miniao Waike Zazhi, 2023, 44(6):401–404. doi: 10.3760/cma.j.cn12330-20230516-00172

Deep learning–assisted two-dimensional transperineal ultrasound for analyzing bladder neck motion in women with stress urinary incontinence

Objective To investigate the application value of MRI in evaluating the disorders of pelvic floor in female stress urinary incontinence (SUI). Methods From January 2017 to January 2019, the patients in the SUI group and the control group of Beijing Chaoyang Hospital, Capital Medical University were prospectively collected. Some patients in the SUI group were treated with tension-free vaginal tape (TVT). The dynamic MR was performed in both SUI patients and volunteers, and the following functional MR parameters were assessed between two groups: the urethral length and urethral hypermobility; the opening of urethral and bladder neck; and the pelvic organ prolapse. For SUI patients, the functional changes of the pelvic floor on MRI after TVT was also analyzed. Chi-square test, rank-sum test and t test were used. Results Comparing with the control groups (n=25), the urethral hypermobility, shortening functional urethral length, bladder neck funneling and urethra opening were significantly associated with SUI group (n=33). Thirty one patients were treated with TVT, 12 of them were reexamined with MRI at 3 to 6 months after operation. Postoperative MR showed that SUI patients had lower risk of the urethral opening and bladder neck funneling (P 0.05). Conclusion MRI can accurately evaluate pelvic floor function of SUI patients. However, TVT did not significantly improve weak pelvic supporting structures and pelvic organ prolapse. Key words: Urinary incontinence, stress; Magnetic resonance imaging; Tension-free vaginal tape; Pelvic floor disfunction; Pelvic floor

Objective To investigate effects of macrosomia on the incidence of early pelvic floor dysfunction (PFD) in puerperae. Methods A total of 301 primiparae who had full-term pregnancy and vaginal delivery, and evaluated the pelvic floor function after 6-8 weeks postpartum from March to December 2014 in Affliated Hospital of Hubei University of Medicine, Xiangyang No.1 People′s Hospital, were chosen as research subjects. According to birth weight of newborns, they were divided into study group (n=145, macrosomia delivery, birth weight ≥4 000 g) and control group (n=156, normal weight fetus delivery, 3 000 g≤ birth weight<4 000 g). The general clinical data, the proportion of normal pelvic floor muscle strength, fatigue degree and vaginal dynamic pressure, incidence rates of postpartum stress urinary incontinence (SUI) and pelvic organ prolapse (POP), and the results of maternal perineal ultrasonography were all statistically compared between two groups of puerperae by independent-samples t test or chi-square test. The study protocol was approved by the Ethics Committee of Affliated Hospital of Hubei University of Medicine, Xiangyang No.1 People′s Hospital, and informed consents were obtained and signed by participants. Results ① There were no significant differences between two groups of puerperae in general clinical data such as maternal age, body mass index before pregnancy, incidence rates of prolonged labor and perineal episiotomy, family monthly income, etc. (P>0.05). ②The proportions of normal pelvic floor typeⅠ and Ⅱ muscle fibers strength of puerperae were 9.7% and 11.0% in study group, and 19.2% and 21.2% in control group, respectively; The proportions of normal pelvic floor type Ⅰ and Ⅱ muscle fibers fatigue degrees of puerperae were 15.9% and 11.7% in study group, and 30.8% and 26.3% in control group, respectively; The proportions of normal vaginal dynamic pressure of puerperae were 31.0% in study group and 81.4% in control group, respectively. The above mentioned proportions of indexes of puerperae in study group were all lower than those in control group, and all the differences were statistically significant (χ2=5.521, P=0.019; χ2=5.646, P=0.017; χ2=9.265, P=0.002; χ2=10.238, P=0.001; χ2=77.873, P<0.001). ③The incidence rates of SUI, anterior and posterior vaginal walls prolapse of puerperae in study group (9.0%, 27.6%, 25.5%) were all higher than those in control group (2.6%, 11.5%, 10.3%), and the differences were statistically significant (χ2=5.779, P=0.016; χ2=12.441, P<0.001; χ2=12.064, P=0.001). ④The results of perineal ultrasonography in 38 cases of puerperae in study group and 40 cases of puerperae in control group showed that incidence rates of POP, the distance of downward dislocation of bladder neck and urethral metastatic angle during Valsalva movement, and the levator ani muscle hole area during calm state, anal contraction and Valsalva movements in study group [68.4%, (28.4±5.8) mm, (46.2±16.3)°, (15.1±3.5) mm2, (13.6±1.6) mm2, (22.9±5.2) mm2] were all higher, wider or larger than those in control group [40.0%, (6.4±4.4) mm, (19.3±13.2)°, (12.9±3.4) mm2, (11.1±2.3) mm2, (14.3±2.8) mm2], and the differences were statistically significant (χ2=6.334, P=0.012; t=18.930, P<0.001; t=8.029, P<0.001; t=2.816, P=0.006; t=5.545, P<0.001; t=9.157, P<0.001). Conclusions Macrosomia can reduce pelvic floor muscle strength and vaginal dynamic pressure of puerperae, increase muscle fatigue degree, which resulting in SUI and POP in postpartum. Mild PFD and injuries of levator ani muscle should be detected by postpartum three dimensional ultrasonography. Key words: Fetal macrosomia; Pregnancy; Parturition; Urinary incontinence, stress; Pelvic organ prolapse; Muscle fatigue; Puerpera

Objective To investigate the influence of different modes of delivery on primiparae's pelvic floor structure and function change.Methods 250 cases delivering through caesarean section (C-section group) and 250 cases delivering vaginally (natural labor group) were chosen,then their pelvic floors were checked by three-dimensional uhrasonography 6-8 weeks after the delivery.The signs of anterior,middle,and posterior pelvic prolapse were observed and the bladder neck down distance and the urethral transfer angle were measured during Valsalva maneuver.The changes were observed and the areas of levator hiatal were measured when the patients was in rest,Shrinkage anal maneuver,and Valsalva maneuver.Results More cases occurred more severe pelvic organ prolapse in the natural labor group than in the C-section group (P ＜ 0.05).During Valsalva maneuver,the bladder neck down distance was longer and the urethral teansfer angle was larger in the natural labor group than in the C-section group (P ＜ 0.05).When the patients were in rest,Shrinkage anal maneuver,and Valsalva maneuver,the areas of levator hiatal were larger in the natural labor group than in the C-section group (P ＜ 0.05).Conclusions Natural labor is more harmful to primiparae's pelvic floor structure and function than C-section.Three-dimensional ultrasonography is a simple and objective method for postpartum pelvic floor dysfunction screening and worth being generalized. Key words: Three-dimensional ultrasonography; Delivery mode; Primipara; Pelvic organ prolapse; Levator hiatal

Objective To dynamically observe and evaluate the position and movement of anterior pelvic floor organs in vaginal delivery and selective caesarean section primipara with translabial two-dimensional(2D) ultrasound, and discuss the short-term effect of delivery mode on the anterior compartment of pelvic floor. Methods Translabial 2D ultrasound was performed on selective caesarean section and vaginal delivery primipara in 6-8 weeks. The position of bladder, the existence of bladder neck funneling were observed, and the mobility of bladder neck and the urethral rotation angle were measured during maximum Valsalva maneuver. Results The mobility of bladder neck was larger in vaginal delivery group than selective caesarean section group during maximum Valsalva maneuver. The rates of bladder neck funneling, cystocele and stress urinary incontinence were higher in vaginal delivery group. Conclusions Translabial 2D ultrasound could dynamically observe and evaluate the position and movement of anterior pelvic floor organ, which could be used to assess the effect of delivery mode on anterior compartment of pelvic floor. The short-term effect of vaginal delivery on anterior compartment of pelvic floor is greater than that of selective cesarean delivery. Key words: Translabial ultrasonography; Pelvic floor; Delivery mode; Anterior compartment of pelvic floor

Objective To explore quantity of typeⅠ and Ⅲcollagen and decorin(DCN) mRNA expression in the upper portion of the anterior vaginal wall in patients with pelvic organ prolapse (POP) and stress urinary incontinence(SUI). Methods Transvaginal biopsies were obtained from the anterior vaginal wall in 21 cases of POP(POP group), 20 cases of POP+ SUI(POP+ SUI group) and 17 cases of normal women (control group). The concentration of typeⅠand Ⅲ collagen were determined by ELISA method. RTQ-PCR was used to verify the level of DCN mRNA. Results The mean concentration extracellular matrix metabolism was significantly reduced in patients of POP group and POP+ SUI group, compared to control group(P 0.05). Conclusion A decrease in quantity of collagen type Ⅰ and Ⅲ in the connective tissue of anterior vaginal wall may compromise the tensile strength and flexibility, and result in an increase susceptibility to prolapse and stress urinary incontinence. To some extent, decorin might be involved in the pathogenesis of pelvic organ prolapse and stress urinary incontinence by influencing collagen metabolism in connective tissue of pelvic floor, and weaken their support strength and elastic properties.The pathogenesis of pelvic organ prolapse in post-menopausal women is complicated. Key words: pelvic organ prolapse(POP); stress urinary incontinence (SUI); collagen type Ⅰand Ⅲ; decorin(DCN)

Objective To investigate the MRI features of urethral sphincter in female with stress urinary incontinence(SUI) by the study of the indexes of the thickness of middle urethral sphincter, the function urethral length and bladder neck funnel. Methods Forty patients of female patients diagnosed as SUI by clinical were retrospectively as SUI group, and 40 asymptomatic female volunteers were recruited as reference group. All of the subjects were tested by pelvic MRI scanning both in static status and in the condition of Valsalva. The thickness of middle urinary sphincter was measured in the horizontal axis plane. In the midsagittal plane, the function urethral length was measured from the internal orifice to perineal fascia. The bladder neck funnel whether exist was observed from the midsagittal plane. For the comparison of the urinary sphincter thickness and urethral length of the two groups, independent sample t test was adopted. For urethral length in static status and under the condition of Valsalva, paired t test was done. For comparison of positive rate of the bladder neck funnel, Chi-squared test has been done. Results The value of the middle urinary sphincter thickness in the groups of SUI and reference were (2.23±0.68) mm and (2.69±0.75) mm, respectively. Thus the differences of the two groups had statistical significance (t=-2.839, P< 0.01). In the static status, the urethral length in SUI and reference group were (2.72±0.51) cm and (2.94±0.34) cm respectively, wheras in Valsalva condition, the value were (2.33±0.49) cm and (2.43±0.43) cm respectively. The differences of the two groups had statistical significance in static status (t=-2.322, P=0.023), wheras there had no statistical significance in the two groups in Valsalva condition (t=-1.049,P=0.297). For SUI and reference group, both in static status and Valsalva condition, the difference of function urethral length had statistical significance (P< 0.01). The positive rate of bladder neck funnel for SUI was 72.5% (29/40), and for reference was 22.5% (9/40), the difference of the two groups had statistical significance(χ2=20.050, P< 0.01). Conclusion For female SUI patients, urinary sphincter muscle is much thinner, function urethral length is much shorter and has higher positive rate of bladder neck funnel. Key words: Urinary incontinence,stress; Magnetic resonance imaging; Urinary sphincter muscle

Vasoactive intestinal peptide expression in the vaginal anterior wall of patients with pelvic organ prolapse

The aim of present study was to compare pelvic floor morphology and function in women with and without major defects of the pubovisceral muscle. One hundred fifty-seven women with pelvic organ prolapse participated in this cross-sectional study. Participants answered a symptom questionnaire and underwent clinical and three- and four-dimensional transperineal ultrasound examination. Pelvic floor muscle maximum voluntary contraction (MVC), endurance, and resting vaginal pressure were registered with a vaginal balloon catheter. Offline analyses were performed for the presence of major pubovisceral muscle defects (PVMD) and hiatal dimensions. The levator hiatus dimensions at rest and contraction were significantly larger in women with than without major PVMD. Mean differences in levator hiatus area between women with and without major PVMD were: rest 1.9 cm(2) 95% confidence intervals (CI) 0.21-3.7, P = 0.028 and contraction 2.75 cm(2) 95% CI 1.0-4.5, P =0.002; and Valsalva maneuver mean difference was 0.82 cm(2) 95% CI 2.18-3.83, P = 0.543. Women with major PVMD had lower MVC and endurance measurements as compared with women without major PVMD, but the differences were not statistically significant. Women with major pubovisceral muscle defects have larger hiatal dimensions at rest and at contraction than women without PVMD. We were unable to prove the corresponding relationship for hiatal dimensions on Valsalva.

To evaluate the safety and efficacy of modified Prolift pelvic floor reconstruction with improving the placement of Prolift-A in treatment of severe pelvic floor dysfunction and stress urinary incontinence (SUI). From July 2008 to September 2010, 170 cases with severe pelvic organ prolapse (POP) treated by modified Prolift pelvic floor reconstruction surgery in Fuzhou General Hospital were enrolled in this study. The Prolift-A was laid tension-free under the mid-urethra with the position of Prolift-A displaced from the neck of bladder to the mid-urethra. No concomitant tension-free urethra suspender via vagina was performed. Primary outcomes were assessed with POP quantitation (POP-Q) system to evaluate the postoperative anatomical replacement stage. Secondary outcome measure were: urogenital distress inventory 6 (UDI-6), the incontinence impact questionnaire 7 (IIQ-7) and the pelvic floor incontinence questionnaire 7 (PFIQ-7) to evaluate the impact on life quality at the follow-up of 1, 6, 12 months. At 6 and 12 months after surgery, 168 cases and 163 cases were followed up. The anatomical cure rates were 98.8% (166/168) at 6 months and 97.5% (159/163) at 12 months, respectively. One case with bladder injury and 1 case with rectum injury were observed. Five cases with recurrence were observed, including 2 cases with anterior vagina prolapse, 2 cases with uterine prolapse and 1 case with posterior vagina prolapse. Meanwhile, 3 cases with hematoma and 7 cases with mesh erosion were observed. Quality of life of all patients were improved significantly by UDI-6, IIQ-7 and PFIQ-7 scoring system evaluation. Among 79 POP patients with SUI, the cure rate of SUI was 93.7% (74/79). Of 5 cases with symptomatic SUI, 2 cases were needed surgical intervention. Twenty-three cases were found with minimal SUI symptoms and subjective satisfaction without objective influence on quality of life. Seven patients presented dysuria after surgery, 5 cases recovered urination with 10 days, 1 case recovered with 1 months, and 1 case with 6 months by bladder drainage. Eleven cases with discomfort urination and 3 cases with slow urination were found. The modified Prolift pelvic reconstructive surgery was safe and efficacy intervention in treatment of POP and prevention of SUI.

Pelvic Floor Structure and Function in Women with Vesicovaginal Fistula

To evaluate the effects of different delivery methods on the pelvic floor structure and function among primiparas by transperineal ultrasound, with a view to providing guidance for early postpartum intervention. Primiparas who underwent postpartum examination with transperineal ultrasound were recruited. Subjects were divided according to mode of delivery (vaginal and cesarean delivery). General information (including age, pre-pregnancy BMI and neonatal weight) were collected, and transperineal ultrasound was performed to measure such indicators as the levator hiatus areas in resting, constrictive anal and maximum Valsalva states, the posterior vesicourethral angles and distances between vesical neck and posterior inferior margin of pubic symphysis in resting and maximum Valsalva states, as well as the vesical neck mobility and urethral rotation angle in maximum Valsalva state. The inter-group differences in ultrasound indicators between the resting and Valsalva states were compared to analyze the postpartum incidences of pelvic floor dysfunctions like stress urinary incontinence, urethral funnel formation, bladder prolapse and uterine prolapse in primiparas. The levator hiatus areas in resting, constrictive anal and maximum Valsalva states were all larger in the vaginal delivery group than in the cesarean delivery group (P < 0.05). Compared to the cesarean delivery group, the vaginal delivery group exhibited larger posterior vesicourethral angles in resting and maximum Valsalva states (P < 0.05). The distances between vesical neck and posterior inferior margin of pubic symphysis were greater in the cesarean delivery group than in the vaginal delivery group at both resting and maximum Valsalva, with that at maximum Valsalva showing significant inter-group difference (P < 0.05). The vaginal delivery group exhibited greater vesical neck mobility and urethral rotation angle at maximum Valsalva compared to the cesarean delivery group (P < 0.05). The incidences of stress urinary incontinence, urethral funnel formation, bladder prolapse and uterine prolapse were all higher in the vaginal delivery group than in the cesarean delivery group, with the stress urinary incontinence and bladder prolapse incidences showing significant inter-group differences (P < 0.05). With transperineal ultrasound, various pelvic floor indicators of primiparas can be clearly measured and, through these ultrasound indicators, the effects of different delivery methods on the pelvic floor function can be evaluated, which is conducive to early clinical detection and intervention of postpartum pelvic floor dysfunctions, thus facilitating the early postpartum treatment.