Development Of Pelvic Floor Disorders Research Articles

A finite strain integral model for the creep behavior of vaginal tissue

Vaginal delivery causes significant stretching of the vagina and surrounding muscles, potentially leading to the development of pelvic floor disorders and other maternal morbidities. Despite the extended duration of labor, little experimental and theoretical work has been done to characterize the long-term viscoelastic behavior of vaginal tissue. To mathematically capture the creep response of rat vaginal tissue measured, this study presents a new anisotropic finite-strain constitutive model within the single integral Pipkin-Rogers viscoelastic framework. The constitutive parameters are computed by curve-fitting the model to strain versus time data collected from ex vivo inflation testing along the two primary anatomical directions of the vagina, the longitudinal and circumferential directions. The results showed good agreement between theory and experiments, suggesting that the proposed model could be used to advance our understanding of the time-dependent deformations that are experienced by the vagina during delivery. This modeling framework represents a first step toward the development of accurate computational tools that can predict the safety of vaginal deliveries, reducing unnecessary Cesarean sections and their related complications.

Remodeling of murine vaginal smooth muscle function with reproductive age and elastic fiber disruption

Advanced maternal age during pregnancy is associated with increased risk of vaginal tearing during delivery and maladaptive postpartum healing. Although the underlying mechanisms of age-related vaginal injuries are not fully elucidated, changes in vaginal microstructure may contribute. Smooth muscle cells promote the contractile nature of the vagina and contribute to pelvic floor stability. While menopause is associated with decreased vaginal smooth muscle content, whether contractile changes occur before the onset of menopause remains unknown. Therefore, the first objective of this study was to quantify the active mechanical behavior of the murine vagina with age. Further, aging is associated with decreased vaginal elastin content. As such, the second objective was to determine if elastic fiber disruption alters vaginal contractility. Vaginal samples from mice aged 2–14 months were used in maximum contractility experiments and biaxial extension-inflation protocols. To evaluate the role of elastic fibers with age, half of the vaginal samples were randomly allocated to enzymatic elastic fiber disruption. Contractile potential decreased and vaginal material stiffness increased with age. These age-related changes in smooth muscle function may be due, in part, to changes in microstructural composition or contractile gene expression. Furthermore, elastic fiber disruption had a diminished effect on smooth muscle contractility in older mice. This suggests a decreased functional role of elastic fibers with age. Quantifying the age-dependent mechanical contribution of smooth muscle cells and elastic fibers to vaginal properties provides a first step towards better understanding how age-related changes in vaginal structure may contribute to tissue integrity and healing. Statement of significanceAdvanced maternal age at the time of pregnancy is linked to increased risks of vaginal tearing during delivery, postpartum hemorrhaging, and the development of pelvic floor disorders. While the underlying causes of increased vaginal injuries with age and associated pathologies remain unclear, changes in vaginal microstructure, such as elastic fibers and smooth muscle cells, may contribute. Menopause is associated with fragmented elastic fibers and decreased smooth muscle content; however, how reproductive aging affects changes in the vaginal composition and the mechanical properties remains unknown. Quantifying the mechanical contribution of smooth muscle cells and elastic fibers to vaginal properties with age will advance understanding of the potential structural causes of age-related changes to tissue integrity and healing.

Effects of preoperative intravaginal estrogen on pelvic floor disorder symptoms in postmenopausal women with pelvic organ prolapse

Menopause and the decline in systemic estrogen are associated with the development of pelvic floor disorders, such as prolapse, urinary incontinence, overactive bladder, and vulvovaginal atrophy symptoms. Past evidence suggests that postmenopausal women with symptomatic prolapse gain benefit from the preoperative application of intravaginal estrogen, but it is unknown whether they would experience improvement in other pelvic floor symptoms when treated with intravaginal estrogen. This study aimed to determine the effects of intravaginal estrogen (compared with placebo) on stress and urgency urinary incontinence, urinary frequency, sexual function and dyspareunia, and vaginal atrophy symptoms and signs in postmenopausal women with symptomatic prolapse. This was a planned ancillary analysis of a randomized, double-blind trial, "Investigation to Minimize Prolapse Recurrence Of the Vagina using Estrogen," which included participants with ≥stage 2 apical and/or anterior prolapse scheduled for transvaginal native tissue apical repair at 3 US sites. The intervention was 1 g conjugated estrogen intravaginal cream (0.625 mg/g) or identical placebo (1:1), inserted nightly for 2 weeks and then twice weekly for ≥5 weeks total before surgery and continued twice weekly for 1 year postoperatively. For this analysis, question responses were compared from participants' baseline and preoperative visits: lower urinary tract symptoms (Urogenital Distress Inventory-6 Questionnaire); sexual health questions, including dyspareunia (Pelvic Organ Prolapse/Incontinence Sexual Function Questionnaire-IUGA-Revised); and atrophy-related symptoms (dryness, soreness, dyspareunia, discharge, and itching; each scored 1-4, 4 being quite a bit bothersome). Masked examiners assessed vaginal color, dryness, and petechiae (each scored 1-3, total range 3-9, with 9 being the most estrogenized appearing). Data were analyzed by intent to treat and "per protocol" (ie, those adherent with ≥50% of expected intravaginal cream use, per objective tube before and after weights). Of 199 participants randomized (mean age of 65 years) and contributing baseline data, 191 had preoperative data. The characteristics were similar between groups. Total Urogenital Distress Inventory-6 Questionnaire scores showed minimal change during this median time of 7 weeks between baseline and preoperative visits, but for those with at least moderately bothersome baseline stress urinary incontinence (32 in the estrogen group and 21 in the placebo group), 16 (50%) in the estrogen group and 9 (43%) in the placebo group showed improvement (P=.78). In addition, 43% of participants in the estrogen group and 31% of participants in the placebo group showed improvement in urgency urinary incontinence (P=.41), and 41% of participants in the estrogen group and 26% of participants in the placebo group showed improvement in urinary frequency (P=.18). There was minimal change in the Pelvic Organ Prolapse/Incontinence Sexual Function Questionnaire-IUGA-Revised scores among sexually active women; dyspareunia rates did not differ between intravaginal estrogen and placebo at the preoperative assessment: 42% and 48%, respectively (P=.49). The maximum score for most bothersome atrophy symptom (among those with baseline symptoms and adherent to study cream) improved slightly more with intravaginal estrogen (adjusted mean difference,-0.33 points; 95% confidence interval,-0.98 to 0.31), but this was not statistically significant (P=.19). However, on examination, among adherent participants, objective signs of atrophy were more improved with intravaginal estrogen treatment (+1.54 vs+0.69; mean difference, 0.85; 95% confidence interval, 0.05-1.65; P=.01). Despite objective changes in the vaginal epithelium consistent with increased estrogenization among drug-adherent participants, the results were inconclusive regarding whether 7 weeks of preoperative intravaginal estrogen cream in postmenopausal women with symptomatic pelvic organ prolapse was associated with improved urinary function, sexual function, dyspareunia symptoms, and other symptoms commonly attributed to atrophy. Additional study is needed.

Validation of online delivery of the Australian Pelvic Floor Questionnaire in an Irish obstetric population.

Childbirth remains an important risk factor for the development of pelvic floor disorders, regardless of the mode of delivery. To accurately assess these symptoms, accurate, woman-centric assessments are needed. Online versions of these assessments may be especially useful in the COVID-19 era. Women may potentially answer questions differently in an online format, and this study aimed to validate an online version of the paper-based self-administered Australian Pelvic Floor Questionnaire (APFQ). The questionnaire was completed antenatally and at 3months postpartum by 647 and 481 women respectively. Test- validity was assessed in subgroups of 61 and 57 women in each period, using intraclass correlation coefficients and Cohen's kappa. Sensitivity to change was assessed by comparing responses during pregnancy to those at 3 months postpartum. Internal consistency was assessed using Cronbach's alpha. Construct validity was assessed by comparing women with and without subjective bothersomeness. Intraclass correlation coefficients were above 0.9 for all domains and the overall questionnaire. Cohen's kappa for individual questions ranged from 0.71-1.00 across the antenatal and postnatal questionnaires. Cronbach's alpha was acceptable for all domains except the prolapse domain. The APFQ was sensitive to changes occurring between antenatal recruitment and 3 months postpartum. Effect sizes ranged from 0.83-7.99. This online version of the APFQ is valid for assessing pelvic floor disorders in an Irish obstetric population. The APFQ is reproducible and responsive to change occurring with childbirth, and can be used to research longitudinal changes in pelvic floor disorders. As an online tool, this questionnaire may be useful in increasing response rates to clinical research.

Prevalence of pelvic floor disorders, associations of endocrine therapy, and surgical intervention among breast cancer survivors.

To evaluate prevalence of pelvic floor disorders, association of endocrine therapy with pelvic floor disorders, and rates of pelvic floor surgery among breast cancer survivors compared to matched controls without history of cancer. This is a retrospective, cohort study using electronic medical record data from a ten-hospital regional healthcare system. A total of 19,483 women diagnosed with breast cancer between January 2008 and April 2020 were propensity score matched to 19,483 women without a history of cancer. Medical charts were abstracted for ICD-9 and ICD-10 codes for pelvic floor disorders, use of endocrine therapy, and CPT codes for pelvic floor surgeries and procedures. Overall, the prevalence of pelvic floor disorders was lower among breast cancer survivors (8.8% vs. 22.6%, p < 0.001), and mean time to development of pelvic floor disorders among breast cancer survivors was 3 years. Selective estrogen receptor modulators and aromatase inhibitors were associated with pelvic organ prolapse and stress urinary incontinence, while estrogen antagonists were associated with urge urinary incontinence and lower urinary tract symptoms. Women with breast cancer had similar or higher rates of pelvic floor surgery compared to matched controls. Rates of pelvic floor disorders were lower among breast cancer survivors compared to controls but rates of surgical intervention did not differ and were higher for some conditions among breast cancer survivors. Screening for these disorders should be considered as part of routine survivorship care.

Seeking the Truth About Primary Elective Cesarean Delivery and Pelvic Floor Disorders: A Systematic Review and Meta-Analysis.

A better understanding of the effect of elective cesarean delivery (CD) on the development of pelvic floor disorders can help obstetricians counsel pregnant women. This study aimed to perform a systematic review and meta-analysis evaluating whether primary elective CD is protective against pelvic floor disorders. Using the MOOSE criteria, electronic databases were searched for studies that compared the prevalence of pelvic floor disorders among primiparous women. Outcomes of interest were urinary incontinence (UI), fecal incontinence (FI), anal incontinence (AI), and pelvic organ prolapse (POP). Comparisons were made between CD before the onset of labor ("Elective CD"), CD after trial of labor ("Labor CD"), and vaginal delivery (VD). Risk ratios (RRs) were computed using STATA. Between-study heterogeneity was assessed via Cochrane's homogeneity test and review of the I2 statistic. Nineteen studies were included. The overall prevalence of UI for Elective CD was estimated at 7% (95% confidence interval [CI], 3%-13%), Labor CD at 14% (95% CI, 8%-21%), and VD at 26% (95% CI, 20%-32%). Meta-analysis demonstrated a decreased risk of UI after Elective CD compared with Labor CD (RR, 0.75; P = 0.011) or VD (RR, 0.43; P < 0.001). There was a decreased risk of FI or AI after Elective CD compared with VD, but not when compared with Labor CD. Only 2 studies examined POP, precluding meta-analysis. Among primiparous women, Elective CD may be protective against UI when compared with Labor CD. There was not a protective effect of Elective CD against FI and AI when compared with Labor CD. More data on the effect of elective CD on POP are needed.

Association of lower degree perineal lacerations at delivery and occult injury of levator ani muscles

Significant perineal lacerations and levator ani injury are associated with development of pelvic floor disorders (PFDs). The objective was to assess occurrence of occult levator ani injury when no severe perineal laceration is diagnosed.

466 Knowledge of Pelvic Floor Disorders among nulliparous and multiparous women in Israel

An adequate knowledge of the possible long-term consequences of labor on the development of pelvic floor disorders (PFD) may better enable women to make informed decisions regarding their perinatal care, and to increase their awareness to seek help if PFD appear. In this study, we aimed to examine the knowledge of women during the third trimester of pregnancy regarding PFD. A cross-sectional study was performed at a large university medical center in Israel between June to September 2020. Women in their third trimester of pregnancy were asked to complete the validated Hebrew version of the Prolapse and Incontinence Knowledge Questionnaire (PIKQ). The PIKQ is a reliable and valid instrument that specifically examines the knowledge of two major PFD: Urinary Incontinence (UI) and Pelvic Organ Prolapse (POP). The study population included women over 18 years who speak and read Hebrew fluently and who have consented to participate in the study. Two separate scores were calculated, one for each section of the PIKQ. Scores were then compared across subgroups using the student's t-test or one-way ANOVA. Correlations were examined using Pearson's or Spearman's correlation coefficient. During the study period, 360 women in their third trimester of pregnancy were included and had completed the Hebrew version of the PIKQ. The means and standard deviations (SD) for the UI scores were 7.59±2.8 and the POP scores were 5.16±2. A significant difference in woman's knowledge was found between nulliparous (N=126) and multiparous (N=234) parturient in both the UI (7.1±2.9 vs 7.8±2.6 P = 0.023) and in the POP (4.6±2.8 vs. 5.4±2.7 p<0.01) domains of the questionnaire. Multiparous women scored higher in both (Table 1, 2). The knowledge of pelvic floor disorders among nulliparous women was found to be lower compared with multiparous women. Founding educational programs for nulliparous women may facilitate making informed decisions regarding perinatal care and seeking help if PFD appears.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Pelvic floor muscle strength and the incidence of pelvic floor disorders after vaginal and cesarean delivery

Pelvic floor disorders (including urinary and anal incontinence and pelvic organ prolapse) are associated with childbirth. Injury to the pelvic floor muscles during vaginal childbirth, such as avulsion of the levator ani muscle, is associated with weaker pelvic floor muscle strength. As weak pelvic floor muscle strength may be a modifiable risk factor for the later development of pelvic floor disorders, it is important to understand how pelvic floor muscle strength affects the course of pelvic floor disorders over time. To investigate the association between pelvic floor muscle strength and the incidence of pelvic floor disorders, and to identify maternal and obstetrical characteristics that modify the association. This is a longitudinal study investigating pelvic floor disorders after childbirth. Participants were recruited 5-10 years after their first delivery and were assessed for pelvic floor disorders annually for up to 9 years. Stress incontinence, overactive bladder, and anal incontinence were assessed at each annual visit using the Epidemiology of Prolapse and Incontinence Questionnaire. Pelvic organ prolapse was assessed on physical examination, and was defined as descent of the vaginal walls or cervix beyond the hymen during forceful Valsalva. The primary exposure of interest was pelvic floor muscle strength, defined as the peak pressure during a voluntary pelvic muscle contraction (measured with a perineometer). The relationship between pelvic floor muscle strength and the cumulative incidence (time to event) of each pelvic floor disorder was evaluated using lognormal models, stratified by vaginal vs cesarean delivery. The relative hazard for each pelvic floor disorder (among those women free of the disorder at enrollment and thus more than 5-10 years from first delivery), was estimated using semiparametric proportional hazard models as a function of delivery mode, pelvic floor muscle strength, and other covariates. Of 1143 participants, the median age was 40 (interquartile range, 36.6-43.7) years, and 73% were multiparous. On perineometry, women with at least 1 vaginal delivery were more likely to have a low peak pressure, defined as <20 cm H2O (243 of 588 women with at least 1 vaginal delivery vs 107 of 555 women who delivered all of their children by cesarean delivery, P < .001). Among women who had at least 1 vaginal delivery, a pelvic floor muscle strength of <20 cm H2O was associated with a shorter time to event for stress incontinence (time ratio, 0.67; 95% confidence interval, 0.50-0.90), overactive bladder (time ratio, 0.67; 95% confidence interval, 0.51-0.86), and pelvic organ prolapse (time ratio, 0.76; 95% confidence interval, 0.65-0.88). No such association was found among women who delivered all of their children by cesarean delivery. Among women with at least 1 vaginal delivery and considering only pelvic floor disorders that developed during study observation (5-10 years after the first delivery), and controlling for maternal characteristics (body mass index and genital hiatus), women who had a peak pressure of <20 cm H2O had hazard ratios (relative to ≥20 cm H2O) of 1.16 (95% confidence interval, 0.74-1.81) for stress incontinence, 1.27 (95% confidence interval, 0.78-2.05) for overactive bladder, and 1.43 (95% confidence interval, 0.99-2.07) for pelvic organ prolapse. Among women who delivered all of their children by cesarean delivery, there was no association between muscle strength and relative hazard of pelvic floor disorders when controlling for maternal characteristics. After vaginal delivery, but not cesarean delivery, the cumulative incidence of pelvic organ prolapse, stress incontinence, and overactive bladder is associated with pelvic muscle strength, but the associations attenuate when adjusting for genital hiatus and body mass index.

The Relationship Between Intra-Abdominal Pressure and Body Acceleration During Exercise.

High intra-abdominal pressure (IAP) may influence the development of pelvic floor disorders. We and others have used intravaginal pressure transducers to measure IAP in women during exercise and daily activities, but utilizing the transducer for long-term measurements creates compliance issues. Waist-worn accelerometers are prominent in research and may be a reliable alternative for approximating IAP. We hypothesized that there are pair-wise positive correlations between the mean maximal accelerometer vector magnitude and 2 IAP measurements: mean maximal IAP and area under the curve (AUC). Twenty-five women who regularly participated in exercise performed 13 activities. Intra-abdominal pressure was measured with an intravaginal transducer and acceleration with a waist-worn accelerometer. We determined the mean maximal IAP, AUC for IAP, and mean maximal accelerometer vector magnitude for each activity and participant. The relationship between IAP and acceleration was determined by computing the Pearson correlation coefficient (R) and the 95% confidence interval for mean maximal accelerometer vector magnitude versus mean maximal IAP and mean maximal accelerometer vector magnitude versus AUC for IAP. The R values were 0.7353 for mean maximal accelerometer vector magnitude versus mean maximal IAP (including walking) and 0.5059 for mean maximal accelerometer vector magnitude versus AUC for IAP (excluding walking). Walking at 3 speeds, analyzed separately, presented R values of 0.72208 for mean maximal IAP and 0.21678 for AUC. Waist-worn accelerometers may provide a viable method for approximating mean maximal IAP in a population of women during most activities.

Predicting risk of pelvic floor disorders 12 and 20 years after delivery

Little progress has been made in the prevention of pelvic floor disorders, despite their significant health and economic impact. The identification of women who are at risk remains a key element in targeting prevention and planning health resource allocation strategies. Although events around the time of childbirth are recognized clinically as important predictors, it is difficult to counsel women and to intervene around the time of childbirth because of an inability to convey a patient's risk accurately in the presence of multiple risk factors and the long time lapse, which is often decades, between obstetric events and the onset of pelvic floor disorders later in life. Prediction models and scoring systems have been used in other areas of medicine to identify patients who are at risk for chronic diseases. Models have been developed for use before delivery that predict short-term risk of pelvic floor disorders after childbirth, but no models that predict long-term risk exist. The purpose of this study was to use variables that are known before and during childbirth to develop and validate prognostic models that will estimate the risks of these disorders 12 and 20 years after delivery. Obstetric variables were collected from 2 cohorts: (1) women who gave birth in the United Kingdom and New Zealand (n=3763) and (2) women from the Swedish Medical Birth Register (n=4991). Pelvic floor disorders were self-reported 12 years after childbirth in the United Kingdom/New Zealand cohort and 20 years after childbirth in the Swedish Register. The cohorts were split so that data during the first half of the cohort's time period were used to fit prediction models, and validation was performed from the second half (temporal validation). Because there is currently no consensus on how to best define pelvic floor disorders from a patient's perspective, we chose to fit the data for each model using multiple outcome definitions for prolapse, urinary incontinence, fecal incontinence, ≥1 pelvic floor disorder, and ≥2 pelvic floor disorders. Model accuracy was measured in the following manner: (1) by ranking an individual's risk among all subjects in the cohort (discrimination) with the use of a concordance index and (2) by observing whether the predicted probability was too high or low (calibration) at a range of predicted probabilities with the use of visual plots. Models were able to discriminate between women who experienced bothersome symptoms or received treatment at 12 and 20 years, respectively, for pelvic organ prolapse (concordance indices, 0.570, 0.627), urinary incontinence (concordance indices, 0.653, 0.689), fecal incontinence (concordance indices, 0.618, 0.676), ≥1 pelvic floor disorders (concordance indices, 0.639, 0.675), and ≥2 pelvic floor disorders (concordance indices, 0.635, 0.619). Route of delivery and family history of each pelvic floor disorder were strong predictors in most models. Urinary incontinence before and during the index pregnancy was a strong predictor for the development of all pelvic floor disorders in most models 12 years after delivery. The 12- and 20-year bothersome symptoms or treatment for prolapse models were accurate when predictions were provided for risk from 0% to approximately 15%. The 12- and 20-year primiparous model began to over predict when risk rates reached 20%. When we predicted bothersome symptoms or treatment for urinary incontinence, the 12-year models were accurate when predictions ranged from approximately 5-60%; the 20-year primiparous models were accurate from 5% and 80%. For bothersome symptoms or treatment for fecal incontinence, the 12- and 20-year models were accurate from 1-15% risk and began to over predict at rates at >15% and 20%, respectively. Models may provide an opportunity before birth to identify women who are at low risk of the development of pelvic floor disorders and may provide institute prevention strategies such as pelvic floor muscle training, weight control, or elective cesarean section for women who are at higher risk. Models are provided at http://riskcalc.org/UR_CHOICE/.

Role of bariatric surgery in the pelvic floor disorders

Pelvic floor disorders are very frequent among women. Weight loss can help them to achieve urinary and faecal continence again. In this narrative review, the possible mechanisms of pelvic floor disorders in obese women, their symptoms and the role of bariatric sur- gery in changing their quality of life are presented. We retrieved the included results of our study after per- forming a systematic, electronic search in PubMed (De- cember 17, 2012) and Scopus (December 17, 2012). The main mechanism causing the development of pelvic floor disorders is chronically increased abdominal pressure as it overts structural damage or neurologic dysfunction predisposing to prolapse and incontinence. The symptoms include a sensation of vaginal fullness or pressure, uterine descent, sacral back pain with stand- ing, vaginal spotting from ulceration of the protruding cervix or vagina, coital difficulty, lower abdominal dis- comfort, and voiding and defecatory difficulties. Evi- dence indicates that massive weight loss (45 to 50 kg) improves incontinence in morbidly obese women after bariatic surgery. Faecal incontinence is also improved after bariatric surgery. This review highlights the role of bariatric surgery in weight reduction of obese women that could act as a treatment for the pelvic floor disor- ders faced by those women offering improvement in incontinence as well as quality of life.

Pelvic floor disorders following vaginal or cesarean delivery

Pelvic floor disorders affect women of all ages and are associated with significant economic burden and poor quality of life. Current literature suggests an association between childbirth and these disorders. In this review, we summarize recent advancements in our understanding of this association. Vaginal childbirth appears to be strongly associated with stress urinary incontinence and pelvic organ prolapse. There is less evidence to suggest an association between vaginal delivery and overactive bladder symptoms. History of more than one perineal laceration increases the likelihood of developing prolapse. Similar association has not been established for episiotomy. Disruption or denervation of structural components of pelvic floor support system, particularly levator ani muscle complex, is associated with later development of pelvic floor disorders. Imbalance in homeostasis of connective tissue remodeling of the vaginal wall from overstretching during childbirth is another possible mechanism. Pelvic floor disorders represent a significant health problem affecting women of all ages. Identification of potential modifiable risk factors and advancement in understanding of the underlying pathophysiology is crucial for primary and secondary prevention of these disorders and for improvement in treatment strategies.

Expression of apoptotic factors in vaginal tissues from women with urogenital prolapse

Increased apoptotic activity in pelvic tissues may contribute to development of pelvic floor disorders. We evaluated expression of apoptotic factors (Bcl-2 family) in vaginal tissues from women with pelvic organ prolapse (POP) and how these factors correlate with severity of prolapse. mRNA and protein expression of anti-apoptotic and pro-apoptotic factors in vaginal tissues from subjects and controls were determined by real-time PCR and Western blot. Severity of prolapse was staged using POP-Q criteria. Differential expression of Bcl-2 family factors was observed in protein rather than in gene expression. During the secretory phase, the anti-apoptotic (Bcl-2, Bcl-xl) and pro-apoptotic protein (Bax) were upregulated in controls compared to cases (P < 0.05). The ratios of Bcl-2/Bax and Bcl-2/Bad, which determine cellular sensitivity to induction of apoptosis, were higher in controls versus cases. Higher ratios indicate reduced cellular sensitivity to apoptosis. Protein expression of Bax and Bad was higher in women with severe compared to mild prolapse (P < 0.05). Increased expression of Bad, Bax, and decreased ratios of Bcl-2/Bax, Bcl-2/Bad suggest increased apoptotic activity or sensitivity to induction of apoptosis in vaginal tissues of women with POP.

Tissu conjonctif de soutien et genèse des prolapsus

The pathophysiology of pelvic floor disorders still remains not well understood. Increasing age as well as vaginal multiparity are the main commonly accepted factors. The hypothesis of a defect of connective tissues of the pelvic floor with aging due to collagen deficiency and/or elastic fiber degradation is often highlighted. The issue of a potential protective role of HRT is also discussed although the recent results from the WHI would suggest a negative impact of HRT on urinary incontinence, especially when HRT is initiated in elderly women, far from the menopause. Nevertheless, environmental factors cannot explain the full pathogenesis of pelvic organ prolapse (POP) and the contribution of genetic factors to the development of pelvic floor disorders is widely recognized. Support for a genetic influence on POP derives from reports suggesting that heritability is a strong contributing factor and a familial history of POP is considered as a classical risk factor. However, the characterization of the underlying molecular mechanisms remains limited, since POP may be considered the end result of a multifactorial process leading to destruction of vaginal wall connective tissue. Experimental studies in mice with null mutations in the genes encoding different putative factors involved in elastic fibers remodeling and homeostasis are crucial in the understanding of the pathogenesis of POP. Mice with null mutation in the gene encoding lysyl oxidase-like 1 ( LOXL1) or fibulin-5, demonstrate signs of elastinopathy including the development of a POP in the postpartum. Likewise, homeobox genes such as HOXA11, which are essential in the embryonic development of the urogenital tract might also be involved in the pathogenesis of POP. The better understanding of the underlying determinants of pelvic floor disorders with a special focus on genetic factors may offer new therapeutic strategies, in addition to or replacement of surgical procedures.

OC176: Significance of levator ani obstetric trauma, assessed by 3D trans‐perineal ultrasound (3DTUS), in development of pelvic floor disorders

OC176: Significance of levator ani obstetric trauma, assessed by 3D trans‐perineal ultrasound (3DTUS), in development of pelvic floor disorders

Racial Differences in Pelvic Anatomy by Magnetic Resonance Imaging

To use static and dynamic magnetic resonance imaging (MRI) to compare dimensions of the bony pelvis and soft tissue structures in a sample of African-American and white women. This study used data from 234 participants in the Childbirth and Pelvic Symptoms Imaging Study, a cohort study of 104 primiparous women with an obstetric anal sphincter tear, 94 who delivered vaginally without a recognized anal sphincter tear and 36 who underwent by cesarean delivery without labor. Race was self-reported. At 6-12 months postpartum, rapid acquisition T2-weighted pelvic MRIs were obtained. Bony and soft tissue dimensions were measured and compared between white and African-American participants using analysis of variance, while controlling for delivery type and age. The pelvic inlet was wider among 178 white women than 56 African-American women (10.7+/-0.7 cm compared with 10.0.+0.7 cm, P<.001). The outlet was also wider (mean intertuberous diameter 12.3+/-1.0 cm compared with 11.8+/-0.9 cm, P<.001). There were no significant differences between racial groups in interspinous diameter, angle of the subpubic arch, anteroposterior conjugate, levator thickness, or levator hiatus. In addition, among women who delivered vaginally without a sphincter tear, African-American women had more pelvic floor mobility than white women. This difference was not observed among women who had sustained an obstetric sphincter tear. White women have a wider pelvic inlet, wider outlet, and shallower anteroposterior outlet than African-American women. In addition, after vaginal delivery, white women demonstrate less pelvic floor mobility. These differences may contribute to observed racial differences in obstetric outcomes and to the development of pelvic floor disorders.

Parity, Mode of Delivery, and Pelvic Floor Disorders

This study aimed to assess the associations between parity, mode of delivery, and pelvic floor disorders. The prevalence of pelvic organ prolapse, stress urinary incontinence, overactive bladder, and anal incontinence was assessed in a random sample of women aged 25-84 years by using the validated Epidemiology of Prolapse and Incontinence Questionnaire. Women were categorized as nulliparous, vaginally parous, or only delivered by cesarean. Adjusted odds ratios and 95% confidence intervals (CIs) for each disorder were calculated with logistic regression, controlling for age, body mass index, and parity. In the 4,458 respondents the prevalence of each disorder was as follows: 7% prolapse, 15% stress urinary incontinence, 13% overactive bladder, 25% anal incontinence, and 37% for any one or more pelvic floor disorders. There were no significant differences in the prevalence of disorders between the cesarean delivery and nulliparous groups. The adjusted odds of each disorder increased with vaginal parity compared with cesarean delivery: prolapse = 1.82 (95% CI 1.04-3.19), stress urinary incontinence = 1.81 (95% CI 1.25-2.61), overactive bladder = 1.53 (95% CI 1.02-2.29), anal incontinence = 1.72 (95% CI 1.27-2.35), and any one or more pelvic floor disorders = 1.85 (95% CI 1.42-2.41). Number-needed-to-treat analysis revealed that 7 women would have to deliver only by cesarean delivery to prevent one woman from having a pelvic floor disorder. The risk of pelvic floor disorders is independently associated with vaginal delivery but not with parity alone. Cesarean delivery has a protective effect, similar to nulliparity, on the development of pelvic floor disorders when compared with vaginal delivery. II-2.

Architectural differences in the bony pelvis of women with and without pelvic floor disorders

Objective To investigate the hypothesis that the architecture of the bony pelvis differs between women with and without pelvic floor disorders. Methods We designed a case-control study of women who had undergone magnetic resonance imaging (MRI) of the pelvis at our institution. Records were reviewed to identify women with and without pelvic floor disorders (urinary or anal incontinence, other symptoms of urinary tract dysfunction, or pelvic organ prolapse). Pelvimetry techniques were standardized. Relevant measures included transverse diameter of the inlet, angle of the pubic arch, intertuberous diameter, interspinous diameter, sacrococcygeal length, depth of sacral curvature, anteroposterior conjugate, obstetrical conjugate, and anteroposterior outlet. Multiple logistic regression analysis was used to identify women with pelvic floor disorders as a function of their pelvic dimensions, controlling for potentially confounding variables. Results Subjects included 59 women with pelvic floor disorders and 39 women without pelvic floor disorders. Women with pelvic floor disorders had a wider transverse inlet, wider intertuberous diameter, wider interspinous diameter, greater sacrococcygeal length, deeper sacral curvature, and narrower anteroposterior outlet. When controlling for the confounding effects of age, race, and parity, we found that a wider transverse inlet (odds ratio 3.425) and a shorter obstetrical conjugate (odds ratio 0.233) were significantly associated with pelvic floor disorders. Conclusion A wide transverse inlet and narrow obstetrical conjugate are associated with pelvic floor disorders. We speculate that these features of bony pelvic architecture may predispose the patient to neuromuscular and connective tissue injuries, leading to the development of pelvic floor disorders.

Pelvic floor dysfunction: a conceptual framework for collaborative patient-centred care.

Pelvic floor dysfunction is a disorder predominantly affecting females. It is common and undermines the quality of lives of at least one-third of adult women and is a growing component of women's health care needs. Identifying and supporting these needs is a major public health issue with a strong psychosocial and economic basis. The importance of the interdependence of mechanical, neural, endocrine and environmental factors in the development of pelvic floor dysfunction is well recognized. There is a paucity of data investigating the true prevalence, incidence, specific risk factors, poor outcome of treatment and subsequent prevention strategies for women with multiple pelvic floor symptomatology. The aim of this paper is to present a critical review of the literature on the mechanism, presentation and management of multiple symptomatology in pelvic floor dysfunction and to propose a conceptual framework by which to consider the impact and problems women with pelvic floor dysfunction face. A comprehensive although not exhaustive literature search was carried out using medical and nursing databases BIOMED (1966-2002) NESLI (1989-2002) and EMBASE (1980-2003) CINAHL (1982-2003) and Cochrane databases using the key words 'pelvic floor dysfunction', 'incontinence (urinary and faecal)', 'genital prolapse', sexual dysfunction, 'aetiology', epidemiology' and 'treatment'. Retrospective and prospective studies and previous clinical reviews were considered for review. The articles retrieved were hand searched for further citations and referrals were made to relevant textbooks. Particular attention was paid to papers that focused on multiple pelvic floor symptoms. Pelvic floor dysfunction affects women of all ages and is associated with functional problems of the pelvic floor. Pelvic floor dysfunction describes a wide range of clinical problems that rarely occur in isolation. Inaccurate knowledge, myths and misconceptions of the incidence, cause and treatment of pelvic floor dysfunction abound. Given the significance of the aetiological contribution of factors such as pregnancy and obstetric trauma, ageing, hormonal status, hysterectomy and lifestyle in the development of pelvic floor disorders, the assessment, management and prevention of pelvic floor dysfunction remains a neglected part of many health care professionals educational preparation. This not only has major economic but also psychosocial implications for women, the general population and women's health care providers. A conceptual framework is also discussed that considers not only the impact and difficulties women with pelvic floor dysfunction face but also areas in which health care professionals can improve assessment and eventual treatment outcomes. This paper demonstrates gaps in the current provision of women's health care services. Functional pelvic floor problems are perceived to have low priority compared with other health disorders, and treatment remains sub-optimal. Inherent in achieving and promoting better health care services for women is the need for better collaborative approaches to care. There is a need to identify and develop comprehensive interdisciplinary, multi-professional strategies that improve the assessment and treatment of pelvic floor dysfunction in primary, secondary and tertiary settings. If this area of women's health care is to be improved nurses, whether community- or hospital-based, must play a front-line role in challenging and changing current practices. Education needs to be given greater priority and the development of a specialist pelvic floor nurse role explored. Such strategies could substantially influence a more effective approach to women's health care needs, result in improved treatment outcomes and liberate women from the embarrassment, social and sexual isolation, restriction to employment and leisure opportunities and potential loss of independence that multiple symptomatology can generate.