Changes In Pelvic Floor Research Articles

Pelvic floor status during pregnancy as a predictor of pelvic dysfunction and birth outcome

This literature review presents an analysis of a number of studies that examined the association between pelvic floor health during pregnancy and the development of pelvic dysfunction and birth outcomes. These studies consistently demonstrated that changes in pelvic floor structure and function during pregnancy are associated with an increased risk of developing pelvic disorders such as urinary incontinence and pelvic organ prolapse. Besides, certain pelvic floor characteristics, such as muscle strength, tone, and stretching ability, have been identified as potential predictors of pelvic floor dysfunction during pregnancy and prolonged second-stage labor. The data collected suggest that pelvic floor assessment during pregnancy may provide valuable prognostic information about birth outcomes. Understanding these relationships may lead to improved prenatal care strategies and interventions to optimize pelvic floor function and reduce the incidence of adverse birth outcomes. Further research is required to clarify the specific parameters for evaluating pelvic floor changes that are most indicative of pelvic organ dysfunction and adverse birth outcomes, as well as to assess the efficacy of preventive interventions.

Association of the second birth mode of delivery and interval with maternal pelvic floor changes: a prospective cohort study

BackgroundThis study aimed to explore the association of the second birth delivery mode and interval with maternal pelvic floor changes.MethodsThis prospective cohort study included women who had a first delivery and were in weeks 36–41 of a subsequent pregnancy at Panzhihua Central Hospital between July 2017 and June 2018. The primary outcomes of the study were the hiatus area at 6 months postpartum and bladder neck (mm) at rest and during a maximum Valsalva maneuver.ResultsThere were 112 women with vaginal delivery and 182 with Cesarean section. The hiatus area and hiatus circumference decreased at all time points (all P < 0.001). The women with Cesarean section had a smaller hiatus area and circumference (P < 0.001 and P < 0.001). The hiatus diameters decreased with time in both groups (all P < 0.001) and were smaller after Cesarean section (both P < 0.001). The bladder neck at maximum Valsalva increased with time (all P < 0.001) without significant differences between the two groups. Finally, the proportion of patients with POP-Q stage 0/I increased with time in both groups (all P < 0.001), with the proportions being higher in the Cesarean group (P = 0.002). The birth interval was negatively correlated with the hiatus area (B=-0.17, 95%CI: -0.25, -0.08, P < 0.001) and positively correlated with the bladder neck at rest (B = 0.22, 95%CI: 0.08, 0.35, P = 0.001) and at maximum Valsalva (B = 0.85, 95%CI: 0.65, 1.05, P < 0.001).ConclusionsIn conclusion, the mode of delivery at the second birth could influence the hiatus area and circumference and bladder neck size. The birth interval was negatively correlated with the hiatus area and positively correlated with the bladder neck at rest and at maximum Valsalva.

Total Pelvic Floor Lifting: A New Approach for the Anatomic Repair of Pelvic Floor Hypermobility and Vaginal Laxity in Parous Women.

Recent years have seen a steady increase in the information available regarding pelvic floor changes after childbirth. Obstetric trauma, to which all structures of the urogenital sphere are subjected, can affect different anatomical areas, including the vagina, perineum, deep pelvic floor muscles, and sphincter. Main complaints of parous women with regard to their pelvic floor are vaginal laxity, a wide introitus, and increased mobility of the uterus. Unilateral pectineal suspension is a novel method for surgical correction of the sequelae of vaginal birth-giving such as uterine hypermobility and perception of loose tissue, restoring a natural anatomy when conservative therapy has failed. Since the method is not ablative and does not interfere with anatomical structures, subsequent pregnancies and deliveries remain possible. Furthermore, there is no mesh application, adding to the safety aspects of this unique approach. The surgical technique is straightforward and can be adopted by laparoscopically trained surgeons without problems. The procedure consists of five clearly defined steps, which makes it easily reproducible. Unilateral pectineal suspension restores the pelvic floor and the vagina, with a single suture lifting the sagging structures back to their original position. If needed and according to the patient's choice, a short perineum associated with a wide introitus can be corrected in the same session by perineoplasty, resulting in a total aesthetic reconstruction of the female genital anatomy.

Pelvic floor parameters predict postpartum stress urinary incontinence: a prospective MRI study

ObjectiveTo investigate the pelvic floor changes in primiparas with postpartum stress urinary incontinence (SUI) after vaginal delivery using pelvic floor MRI.Materials and methodsFifty-two women were enrolled in the primiparous stress urinary incontinent (PSUI) group and 51 in the primiparous continent (PC) group. Thirty nulliparas were also recruited as the nulliparous control (NC) group. Levator ani muscle (LAM) injury, levator hiatus area (LHA), H-line, M-line, the distance from the bladder neck and cervix to the pubococcygeal line (B-PCL and U-PCL), levator plate angle, the anterior angle of the urethra, bladder neck descent, retrovesicourethral angle, functional urethral length, and a bladder neck funnel were evaluated on MRI images. Univariate and multivariate logistic regression analyses were used to explore anatomical predictors for SUI.ResultsThe primiparas in the PSUI group showed more obvious LAM injuries than in the PC groups (p = 0.001). LAM function assessment: the PSUI group had larger LHA and shorter B-PCL and U-PCL than the other groups during straining. Assessment of urethral mobility and function: the PSUI group had larger anterior angle of the urethra, bladder neck descent, retrovesicourethral angle, and shorter functional urethral length than the other two groups (all p < 0.05). Up to 88.5% of primiparas in the PSUI group showed bladder funnel (p < 0.001). The logistic regression analysis showed that retrovesicourethral angle, functional urethral length, and the presence of bladder funnel were significantly associated with postpartum SUI (p < 0.05).ConclusionsIncreased retrovesicourethral angle, shortened functional urethral length, and the presence of bladder funnel may be anatomical predictors for SUI in the early postpartum period. Urethral sphincter dysfunction plays an essential role in developing postpartum SUI.Critical relevance statementThis study used several measurements to reflect the anatomical structure and functional changes of the pelvic floor to identify the best anatomical predictors associated with postpartum stress urinary incontinence (SUI), aiming to provide new insights into treatment strategies for postpartum SUI.Key points• Increased retrovesicourethral angle, shortened functional urethral length, and the presence of bladder funnel are more commonly seen in primiparas with SUI.• The combination of retrovesicourethral angle, functional urethral length, and bladder funnel had the highest diagnostic performance in predicting postpartum SUI (AUC=0.947).• Urethral sphincter dysfunction may be the main pathophysiological foundation in SUI development.Graphical

Longitudinal changes in pelvic organ support among primiparas with postpartum pelvic organ prolapse: A follow-up magnetic resonance imaging study.

To quantify morphological changes of pelvic floor in primiparas with postpartum pelvic organ prolapse (POP) during the early postpartum period. A total of 309 primiparas underwent pelvic floor magnetic resonance imaging (MRI) at 6 weeks postpartum. Those primiparas diagnosed with postpartum POP by MRI criterion were followed up at 3 and 6months postpartum. Normal primiparas were enrolled in the control group. The puborectal hiatus line, muscular pelvic floor relaxation line, levator hiatus area, iliococcygeus angle, levator plate angle, uterus-pubococcygeal line, and bladder-pubococcygeal line were assessed on MRI. Longitudinal changes in pelvic floor measurements between the two groups were compared by repeated-measures analysis of variance. Compared with the control group, enlarged puborectal hiatus line, levator hiatus area, and RICA and decreased uterus-pubococcygeal line were observed at rest in the POP group (all P< 0.05). All of the pelvic floor measurements were significantly different in the POP group compared with the control group at the maximum Valsalva maneuver (all P< 0.05). All of the pelvic floor measurements showed no significant change over time in both the POP and control groups (all P> 0.05). Postpartum POP accompanied by poor pelvic floor support will persist in the early postpartum period.

Pelvic floor healing milestones after obstetric anal sphincter injury: a prospective case control feasibility study.

Introduction and hypothesisSevere perineal tears can predict bothersome pelvic floor disorders later in life. We have a poor understanding of pelvic floor changes during the third trimester and the first few postpartum months. We aimed to compare women with severe perineal trauma during childbirth with women who experienced minimal trauma, for condition-specific quality of life, sexual function, mental health and overall quality of life in the first 6 months postpartum.MethodsWe recruited primiparous women with third- or fourth-degree tears (obstetric anal sphincter injuries, OASIS) and age-matched controls with no tears or first-degree tears in the immediate postpartum period. Participants completed validated questionnaires at baseline, 2, 4 and 6 months postpartum. Mixed effects linear regression or quantile regression adjusted for baseline score were used to compare the groups as appropriate.ResultsA total of 74 women completed at least one questionnaire (35 OASIS, 39 controls). Both groups had similar demographics. Women with OASIS tended to have worse Pelvic Floor Distress Index-40 scores at month 2; median scores were similar in the two groups by month 6. They also had significantly lower Female Sexual Function Index scores (mean difference: −6.1; 95% CI: −11.9, −0.2, p=0.043) at month 2. There were no mental health group differences and quality of life improved over time, mainly in the OASIS group. Six-month participant attrition rate was 52%.ConclusionsWomen with OASIS encounter specific pelvic floor challenges during the first 6 months postpartum. Although our recruitment rate was high, the attrition rate was also high, demonstrating challenges with retention of postpartum women into longitudinal research.

Evaluation of the Pelvic Floor of Women with Breast Cancer Using Tamoxifen by Transperineal 3D Ultrasonography.

This study aimed to investigate the anatomical changes in the pelvic floor of women with breast cancer using tamoxifen by transperineal 3D ultrasonography and their effect on the urinary incontinence and sexual dysfunction. Ninety-four patients with breast cancer using TAM in the study group and ninety-five healthy women of the same age in the control group were included in this prospective cohort study. Female Sexual Function Index and Incontinence Questionnaire-Short Form scales were applied to both groups. Ultrasonographic evaluation was performed at resting and Valsalva Maneuver with a convex (3-8MHz) probe transperineally and the levator urethra gap and levator hiatus diameter were measured after 3-dimensional imaging. Independent t-tests were performed for statistical analysis. The mean age and body mass index of the experimental group versus control groups were 46.3 ± 6.12years versus 46.4 ± 5.23years and 27.6 ± 4.34kg/m2 versus 29.2 ± 6.45kg/m2, respectively. LUG and LH values were found significantly higher for the experimental groups compared to control groups at 17.23 ± 2.53mm versus 14.1 ± 2.23mm and 21 ± 2.45cm2 versus 18 ± 4.56cm2, respectively. (p < 0.05). The FSFI score significantly decreased (12.49 ± 3.58 versus 20.89 ± 3.69) and the ICIQ-SF score increased (4.02 ± 0.34 versus 2.34 ± 0.45) in the experimental group in comparison to control group (p < 0.05). This study demonstrated that the effects of TAM usage on pelvic floor can be detected by measuring the changes in the levator ani muscle using the transperineal 3D USG. With transperineal USG screening, pelvic floor changes can be early diagnosed and clinical measures can be taken before they become symptomatic.

Quantification of 3/4D ultrasound pelvic floor changes induced by postpartum muscle training in patients with levator ani muscle avulsion: a parallel randomized controlled trial.

We believe that physiotherapy with muscle training (MT) of the postpartum pelvic floor may lead to a change in the clinical management of patients with avulsion of the puborectal portion of the levator ani muscle (LAM). Our objective is to assess whether physiotherapy with MT of the postpartum pelvic floor in patients with LAM avulsion produces changes in pelvic floor morphology evaluated by 3/4D transperineal ultrasound. This parallel randomized controlled trial (RCT) included 97 primiparous patients. A study was conducted in three parts. In the first part (3 months postpartum), primiparous patients with LAM avulsion were recruited, and the levator hiatus and the LAM areas were measured using 3/4D transperineal ultrasound. In the second part (3 to 6 months postpartum), patients were randomized into two groups, with one undergoing rehabilitation (experimental group) and another without rehabilitation (control group). At the end of 6 months, a new transperineal ultrasound was performed. In the third part (9 months postpartum), the levator hiatus and LAM dimensions were analyzed again. The RCT was registered at ClinicalTrials.gov (NCT03686956). Project PI16/01387 funded by Instituto de Salud Carlos III (Spain) integrated in the national I+D+i 2013-2016 and cofounded by the European Union (ERDF/ESF, "Investing in your future"). A total of 92 completed the study, including 46 patients in the experimental group and 46 in the control group. The experimental group had a greater LAM area at 6 months (9.2±1.9 vs. 7.6±2.1 cm2, P=0.008; 95% CI: 0.6-3.0) and 9 months after labor (9.4±2.7 vs. 7.6±2.0 cm2, P=0.012; 95% CI: 0.4-3.2), which was not observed at 3 months postpartum (8.3±1.6 vs. 7.5±2.3 cm2; P=0.183; 95% CI: 0.39-1.99). The levator hiatus area decreased more in the experimental group in almost all comparisons. The most significant change occurred from 3 to 6 months during the Valsalva maneuver (-3.92±5.12 vs. 0.45±3.06 cm2; P<0.005; 95% CI: 2.64-5.00). Women with a rehabilitated LAM through physiotherapy showed a significant reduction in the levator hiatus area during Valsalva while receiving in-person physical therapy (3 to 6 months after delivery). These differences did not persist once physical therapy was completed (6 to 9 months after delivery). ClinicalTrials.gov identifier NCT03686956.

Influencing Pelvic Floor Changes on the Quality of Women’s Life During and Post Pregnancy

Introduction: Pelvic floor dysfunctions are widely acknowledged as one of the most serious public health issues, in terms of frequency, cost, and influence on quality of life of women. Over a third of females are believed to have pelvic floor diseases of varying severity at some point in their lives. Objective: To evaluate the influencing pelvic floor changes on the quality of women’s life during and post pregnancy. Methodology: This Multi-Centre cohort study was carried at the department of Urology &amp; Transplantation, Institute of Kidney Diseases Peshawar, and Department of Gynaecology Jamrud Hospital Peshawar .The study duration was one year from June 2020 to June 2021 after approval of synopsis. A total of 45 women fulfilling the inclusion criteria were enrolled in our study. All the collection of data was carried out through predesigned questionnaire. Vaginal examination, translabial 2D/3D ultrasonography and a POP-Q test was done in the 3rd trimester of gestation and Three months after birth. The statistical analyses were performed using SAS software version 9.4. Results: In the current study, weakness of connective tissues was observed in 23 (51.1%) and Gestational diabetes was observed in 6 (13%). Amongst 45 women, vaginal deliveries were observed in 17 (37.78%), caesarean section in 17 (37.78%) while vacuum extraction deliveries were observed in 11 (24.44%) females. Two subjects were found to have LAM avulsion three months after their VE deliveries. Conclusion: Pelvic floor dysfunction is associated with connective tissue weakening and a larger fetus weight at delivery. To minimize future Pelvic floor problems, more women should seek postpartum care services. Keywords: Pelvic floor changes; Quality of life; Post pregnancy

Longitudinal Study of Pelvic Floor Characteristics Before, During, and After Pregnancy in Nulliparous Women.

ObjectivesTo investigate the changes in the pelvic floor before, during, and after pregnancy in the same collective of nulliparous women.MethodsIn a prospective observational pilot study between April 2015 and June 2019 in nulliparous women with planned pregnancy, we used the pelvic organ prolapse quantification (POP‐Q) system; a 2‐dimensional (2D) sonography to investigate the bladder neck, cervix, and anorectal junction positions; and a 3D/4D sonography to measure the hiatus of the levator ani muscle (LH area) during Valsalva maneuver. Five visits were planned: 1 before, 3 during, and 1 visit after pregnancy.ResultsTwenty‐four women participated in the study. We achieved a minimum of 2 visit measurements from 10 women who became pregnant. The LH area decreased during the first trimester and then increased until the third trimester. Postpartum, the LH area reached the prepregnancy state. We observed changes in the bladder neck mobility, bladder neck position, cervix, and anorectal junction from the first trimester. Postpartum, the bladder neck mobility was higher, and the position of the bladder neck and anorectal junction was lower than before pregnancy. We observed no remarkable changes in the POP‐Q state during pregnancy.ConclusionThis was the first study to investigate pelvic floor characteristics in the same collective before, during, and after pregnancy. We observed pelvic floor changes from the prepregnancy state to the first trimester to postpartum. The study results need to be confirmed in a larger study.

Pelvic floor assessment using magnetic resonance imaging after vaginal delivery and elective caesarean delivery.

We aimed to compare quantitative static and dynamic magnetic resonance imaging (MRI) measurements of pelvic floor changes during postpartum recovery from 1 week to 6 months after different modes of delivery. In this prospective study, 51 primiparous women (vaginal delivery group: 30 women; elective caesarean delivery group: 21 women) underwent static and dynamic MRI at 1 week, 6 weeks, 3 months, and 6 months postpartum to measure pelvic floor MRI values. Between-group differences in pelvic floor values at these time points were determined; subsequently, within-group comparisons according to time were performed. Analysis included independent samples t-tests and paired t-tests. The puborectal hiatus line (H line), muscular pelvic floor relaxation line (M line), bladder-pubococcygeal line (B-PCL), and uterus-pubococcygeal line (U-PCL) differed significantly between groups during the Valsalva manoeuvre at 1 week postpartum (p < 0.05). The H line, M line, and B-PCL values differed significantly between groups during the Valsalva manoeuvre at 6 weeks postpartum (p < 0.05). There were few significant between-group differences in pelvic floor values at 3 months and 6 months postpartum. In the vaginal delivery group, the differences in the H line and M line at 1 week, 6 weeks, and 3 months postpartum were significant (p < 0.001). In the elective caesarean delivery group, U-PCL differed significantly at 6 weeks compared to 1 week postpartum during the Valsalva manoeuvre (p < 0.05). Pelvic floor recovery primarily occurred during the early phase after delivery in both groups. Elective caesarean delivery had a non-significant protective effect on postpartum pelvic floor structure and function compared to vaginal delivery.

MAIN MANOMETRIC FINDINGS AND POTENTIAL FOR ANORECTAL PHYSICAL THERAPY IN THE TREATMENT OF PATIENTS WITH EVACUATION DISORDERS.

Evacuation disorders are prevalent in the adult population, and a significant portion of cases may originate from pelvic floor muscle dysfunctions. Anorectal manometry (ARM) is an important diagnostic tool and can guide conservative treatment. To evaluate the prevalence of pelvic dysfunction in patients with evacuation disorders through clinical and manometric findings and to evaluate, using the same findings, whether there are published protocols that could be guided by anorectal manometry. A retrospective analysis of a prospective database of 278 anorectal manometries performed for the investigation of evacuation disorders in patients seen at the anorectal physiology outpatient clinic of Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto between January 2015 to June 2019 was conducted. The following parameters were calculated: resting pressure (RP), squeeze pressure (SP), high-pressure zone (HPZ), rectal sensitivity (RS) and rectal capacity (RC). The pressure measurements and manometric plots were reviewed to determine the diagnosis and to propose potential pelvic physical therapy procedures. Analysis of variance (ANOVA) and Fisher's exact test were used to compare the continuous variables and to evaluate the equality of variances between groups of patients with fecal incontinence (FI) and chronic constipation (CC). Results with a significance level lower than 0.05 (P-value <0.05) were considered statistically significant. Statistical analysis was performed using IBM® SPSS® Statistics version 20. The mean age of the sample was 45±22 years, with a predominance of females (64.4%) and economically inactive (72.7%) patients. The indications for exam performance were FI (65.8%) and CC (34.2%). Patients with FI had lower RP (41.9 mmHg x 67.6 mmHg; P<0.001), SP (85.4 mmHg x 116.0 mmHg; P<0.001), HPZ (1.49 cm x 2.42 cm; P<0.001), RS (57.9 mL x 71.5 mL; P=0.044) and RC (146.2 mL x 195.5 mL; P<0.001) compared to those of patients with CC. For patients with FI, the main diagnosis was the absence of a functional anal canal (49.7%). For patients with CC, the main diagnosis was outflow tract obstruction (54.7%). For patients with FI, the main protocol involved a combination of anorectal biofeedback (aBF) with tibial nerve stimulation (TNS) (57.9%). For patients with CC, the most indicated protocol was aBF combined with TNS and rectal balloon training (RBT) (54.7%). There was a high prevalence of pelvic floor changes in patients with evacuation disorders. There was a high potential for performing pelvic floor physical therapy based on the clinical and manometric findings.

Early postpartum physical activity and pelvic floor support and symptoms 1 year postpartum

Risks of pelvic organ prolapse and urinary incontinence increase after the first vaginal delivery. During the early postpartum period, a time of active regeneration and healing of the pelvic floor, women may be particularly vulnerable to greater pelvic floor loading. This prospective cohort study aimed to determine whether objectively measured moderate to vigorous physical activity in the early postpartum period predicts pelvic floor support and symptoms 1 year after the first vaginal birth. We enrolled nulliparous women in the third trimester, later excluding those who had a cesarean or preterm delivery. Participants wore triaxial wrist accelerometers at 2 to 3 weeks and 5 to 6 weeks postpartum for ≥4 days. Primary outcomes, assessed 1 year postpartum, included (1) pelvic floor support on Pelvic Organ Prolapse Quantification examination, dichotomized as maximal vaginal descent of <0 cm (better support) vs ≥0 cm (worse support); and (2) pelvic floor symptom burden, considered positive with report of ≥1 bothersome symptom in ≥2 of 6 domains, assessed using the Epidemiology of Prolapse and Incontinence Questionnaire. The primary predictor was average daily moderate to vigorous physical activity. Because we could not eliminate women with pelvic floor changes before pregnancy, we modeled prevalence, rather than risk, ratios for each outcome using modified Poisson regression. Of 825 participants eligible after delivery, 611 completed accelerometry and 1-year follow-up; 562 completed in-person visits, and 609 completed questionnaires. The mean age was 28.9 years (standard deviation, 5.01). The mean for moderate to vigorous physical activity measured in minutes per day was 57.3 (standard deviation, 25.4) and 68.1 (standard deviation, 28.9) at 2 to 3 weeks and 5 to 6 weeks, respectively. One year postpartum, 53 of 562 participants (9.4%) demonstrated worse vaginal support and 330 of 609 participants (54.2%) met criteria for pelvic floor symptom burden. In addition, 324 (53.1%), 284 (46.6%), 144 (23.6%), and 25 (4.1%) reported secondary outcomes of stress urinary incontinence, overactive bladder, anal incontinence, and constipation, respectively, and 264 (43.4%), 250 (41.0%), and 89 (14.6%) reported no, mild, or moderate to severe urinary incontinence, respectively. The relationship between moderate to vigorous physical activity and outcomes was not linear. On the basis of plots, we grouped quintiles of moderate to vigorous physical activity into 3 categories: first and second quintiles combined, third and fourth quintiles combined, and fifth quintile. In final multivariable models, compared with women in moderate to vigorous physical activity quintiles 3 and 4, those in the lower 2 (prevalence ratio, 0.55; 95% confidence interval, 0.31-1.00) and upper quintile (prevalence ratio, 0.70; 95% confidence interval, 0.35-1.38)) trended toward lower prevalence of worse support. However, we observed the reverse for symptom burden: compared with women in quintiles 3 and 4, those in the lower 2 (prevalence ratio, 1.20; 95% confidence interval, 1.02-1.41) and upper quintile prevalence ratio 1.34 (95% confidence interval, 1.11-1.61) demonstrated higher prevalence of symptom burden. Moderate to vigorous physical activity did not predict any of the secondary outcomes. The presence of a delivery factor with potential to increase risk for levator ani muscle injury did not modify the effect of moderate to vigorous physical activity on outcomes. Except for support, which was worse in women with moderately high levels of activity, early postpartum moderate to vigorous physical activity was either protective or had no effect on other parameters of pelvic floor health. Few women performed substantial vigorous activity, and thus, these results do not apply to women performing strenuous exercise shortly after delivery.

Pelvic floor changes in the first term pregnancy and postpartum period.

To follow a prospective cohort of women during their first term pregnancy to elucidate the nature and timing of changes to the pelvic floor during pregnancy and after vaginal delivery. Enrolled subjects were evaluated at four time points with dynamic MRI, POP-Q examinations, and validated symptom questionnaires. The four assessments occurred during the first trimester (ePG), late third trimester (lPG), within a week after vaginal delivery (ePP), and three months postpartum (lPP). Two-dimensional T1-weighted MRI measurements included bladder descent and area of the levator hiatus at rest and during Valsalva maneuvers. Sample size of ten subjects was calculated for a power of 0.8 to detect a 20% change in bladder position with p < 0.05. Comparative statistical tests were used for parametric and non-parametric data, respectively. Twelve subjects completed the study. At lPP, the bladder descent was increased (p = 0.03) at rest and with Valsalva compared to ePG. Levator hiatus area did not differ (p = 0.63) between time points at rest or with Valsalva. Median POP stage increased (p = 0.001) to 1.5 at lPP. Mean genital hiatus increased (p = 0.0003) at each time point. Higher scores were recorded on the UDI-6 (p < 0.001) and the PFDI-20 (p = 0.003) questionnaires at lPG and ePP, but returned to ePG levels by lPP. Anatomic changes measured by dynamic MRI and POP-Q examinations demonstrate significant descent at 3 months postpartum. However, these anatomic changes did not significantly correlate with changes in symptoms.

Pelvic floor shape variations during pregnancy and after vaginal delivery

Background and objectiveStrong evidence suggests that pelvic soft tissues soften during pregnancy to facilitate vaginal delivery while protecting against maternal birth injury. We hypothesized that these adaptations likely result in changes to the shape of the pelvic floor. Thus, this study aimed to compare midsagittal pelvic floor shapes from MRIs of nulliparous, gravid, and vaginally parous women using statistical shape modeling. MethodsA retrospective study of 22 nulliparous, 29 gravid (vaginally nulliparous), and 18 vaginally parous women who underwent pelvic MRI was performed. The pelvic floor was segmented from pubic symphysis to coccyx as a 2D polyline in the midsagittal plane. Once corresponding landmarks were computed and the variances between them determined by principal component analysis, the principal component scores were calculated for modes that explained variance greater than noise. These became the dependent variables in a MANOVA with univariate ANOVAs, linear regressions, and Benjamini-Hochberg corrections post hoc. Two initial statistical shape analyses were conducted to analyze differences based on gestational age (1st/2nd vs 3rd trimester) and vaginal parity (VP1 vs VP2-4). There were significant differences based on gestational age, but not vaginal parity. Thus, the final statistical shape analysis evaluated pelvic floor shapes of nulliparous, 3rd trimester gravid, and all vaginally parous subjects. ResultsIn the final analysis, six modes described variance—a measure of shape variability—greater than noise. Groups differed significantly for modes 1, 2, and 4 (p < 0.001, p = 0.021, and p = 0.015, respectively) and only differed between the nulliparous and gravid groups (p < 0.001, p = 0.018, and p = 0.012, respectively). Anatomically, these modes described levator plate relaxation and level III support protrusion in gravid compared to nulliparous subjects while the parous group straddled the other two. ConclusionsThe shape of the pelvic floor changes significantly during pregnancy and some of those changes are present after vaginal delivery. The fact that the nulliparous and gravid groups differ while the parous is similar to both suggests that some parous women regain their nulliparous shape after pregnancy and delivery while others do not. This indicates that remodeling during pregnancy and/or injury during vaginal delivery can have lasting effects on the pelvic floor.

Predictive Value of Biomechanical Mapping for Pelvic Organ Prolapse Surgery.

This study examined biomechanical changes in pelvic floor after urogynecological surgery. This multisite clinical study was designed to explore changes in tissue elasticity, pelvic support, and certain functions (contractive strength, muscle relaxation speed, muscle motility) after pelvic organ prolapse (POP) surgery. A biomechanical mapping of the pelvic floor was performed before and 4 to 6 months after the surgery. The biomechanical data for 52 parameters were acquired by vaginal tactile imaging for manually applied deflection pressures to vaginal walls and pelvic muscle contractions. The two-sample t-test (P < 0.05) was used to test the null hypothesis that presurgery data in group 1 (positive parameter change after surgery) and presurgery data in group 2 (negative parameter change after surgery) belonged to the same distribution. A total of 78 subjects with 255 surgical procedures were analyzed across 5 participating clinical sites. All 52 t-tests for group 1 versus group 2 had P value in the range from 4.0 × 10-10 to 4.3 × 10-2 associating all of the 52 parameter changes after surgery with the presurgical conditions. The P value of before and after surgery correlation ranged from 3.7 × 10-18 to 1.6 × 10-2 for 50 of 52 tests, with Pearson correlation coefficient ranging from -0.79 to -0.27. Thus, vaginal tactile imaging parameters strongly correlated weak pelvic floor presurgery with the positive POP surgery outcome of improved biomechanical properties. Pelvic organ prolapse surgery, in general, improves the biomechanical conditions and integrity of the weak pelvic floor. The proposed biomechanical parameters can predict changes resulting from POP surgery.

OP17.11: The changes of pelvic floor during labour

OP17.11: The changes of pelvic floor during labour

Five-year outcome after pelvic floor reconstructive surgery: evaluation using dynamic magnetic resonance imaging compared to clinical examination and quality-of-life questionnaire.

Background Dynamic magnetic resonance imaging (dMRI) captures the entire pelvis during Valsalva maneuver and helps diagnosing pelvic floor changes after reconstructive surgery. Purpose To evaluate therapeutic outcome five years after reconstructive surgery using clinical examination, dMRI, and quality-of-life (QOL) questionnaire. Material and Methods Clinical examination, dMRI, and QOL questionnaire were conducted before surgery and in the follow-ups at 12 weeks, one year, and five years in women with pelvic organ prolapse (POP) stage ≥2. dMRI was performed at 1.5-T using a predefined protocol including sagittal T2-weighted (T2W) sequence at rest and sagittal T2W true-FISP sequence at maximum strain for metric POP measurements (reference points = bladder, cervix, pouch, rectum). Pelvic organ mobility (POM) was defined as the difference of the metric measurement at maximum strain and at rest. Results Twenty-six women with 104 MRI examinations were available for analysis. dMRI results mostly differ to clinical examination regarding the overall five-year outcome and the posterior compartment in particular. dMRI diagnosed substantially more patients with recurrent or de novo POP in the posterior compartment (n = 17) compared to clinical examination (n = 4). POM after five years aligns to preoperative status except for the bladder. POM reflects best the QOL results regarding defecation disorders. Conclusion A tendency for recurrent and de novo POP was seen in all diagnostic modalities applied. dMRI objectively visualizes the interaction of the pelvic organs and the pelvic floor after reconstructive surgery and POM correlated best with the women's personal impression on pelvic floor complaints.

Female pelvic floor biomechanics

The pelvic floor is a complex assembly of connective tissues and striated muscles that simultaneously counteracts gravitational forces, inertial forces, and intra-abdominal pressures while maintaining the position of the pelvic organs. In 30% of women, injury or failure of the pelvic floor results in pelvic organ prolapse. Surgical treatments have high recurrence rates, due, in part, to a limited understanding of physiologic loading conditions. It is critical to apply biomechanics to help elucidate how altered loading conditions of the pelvis contribute to the development of pelvic organ prolapse and to define surgeries to restore normal support. Evidence suggests the ewe is a potential animal model for studying vaginal properties and that uterosacral and cardinal ligaments experience significant creep, which may be affecting surgical outcomes. A new method of measuring ligament displacements in vivo was developed, and finite element models that simulate urethral support, pelvic floor dynamics, and the impact of episiotomies on the pelvic floor were studied. The current review highlights some contributions over the past year, including mechanical testing and the creation of models, which are used to understand pelvic floor changes with loading and the impact of surgical procedures, to illustrate how biomechanics is being utilized.

Early postpartum pelvic floor changes in primiparous women after vaginal delivery using 3T MRI

AIMSDetection of early morphological pelvic floor changes after vaginal delivery in primiparous women using 3 Tesla magnetic resonance imaging.METHODSA 3 Tesla magnetic resonance imaging was performed using static T2‐weighted turbo spin echo (tse) in three planes, T2‐weighted tse fat saturated and T1‐weighted sequence in transverse plane. All visible changes of pelvic structures (edema, hematoma, tear, or avulsion) were documented. Measurements for the integrity of the pelvic floor were performed and compared to a nulliparous control‐group. Differences in pelvic floor parameters were analyzed using an unpaired t‐test. P&lt;0.05 was considered statistically significant.RESULTSTwenty‐five primiparous women delivered vaginally at term and underwent postpartum magnetic resonance imaging. Several morphological changes in the pelvis, superficial as well as deep, were detected in all participants. Anteroposterior hiatus, hiatal circumference, hiatal area, laterolateral hiatus, maximum muscle thickness, and levator urethra gap were significantly different to the nulliparous control‐group.CONCLUSIONSTwo‐dimensional 3 Tesla magnetic resonance imaging is feasible in a clinical and early postpartum setting establishing a reliable diagnostic tool to evaluate numerous morphological pelvic floor changes and the integrity of the pelvic floor.