Female Pelvic Floor Research Articles

Racial Disparities in the Surgical Management of Stress Incontinence Among Female Medicare Beneficiaries

The relationship between urinary incontinence and race/ethnicity is poorly understood. We analyzed Medicare claims data to identify racial differences in the diagnosis, treatment and outcomes of women with stress urinary incontinence. We analyzed the 1999 to 2001 Medicare Public Use Files provided by the Centers for Medicare and Medicaid Services on a 5% national random sample of beneficiaries. Women 65 years or older with a diagnosis of stress urinary incontinence were identified on the basis of International Classification of Diseases, 9th revision codes. Those who underwent an autologous or synthetic sling procedure during the index period were identified on the basis of Physicians Current Procedural Terminology Coding System, 4th edition codes. Racial differences in diagnosis, treatment and outcomes were compared. Of all female Medicare beneficiaries older than 65 years overall only 1.1% had a claim that listed a diagnosis of stress urinary incontinence. White women were more likely than nonwhite women to have a claim listing a diagnosis of stress urinary incontinence. Approximately 27,120 slings were performed on the Medicare population during the study period. Among women with a diagnosis of stress urinary incontinence white and Hispanic women were disproportionately more likely to undergo a sling than were black or Asian women (p<0.01). After controlling for age and comorbidities, nonwhite women undergoing sling surgery were twice as likely to develop nonurological complications, pelvic organ prolapse and urinary obstruction within 1 year postoperatively. We identified racial differences in the frequency of diagnosis of stress urinary incontinence, frequency of sling procedures and rate of postoperative complications after sling surgery. Further research is necessary to determine whether such differences are due to racial differences in incontinence incidence and severity or disparities in care for minorities.

Magnetic Resonance‐Based Female Pelvic Anatomy as Relevant for Maternal Childbirth Injury Simulations

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

Evaluation of the Dynamic Responses of Female Pelvic Floor Using a Novel Vaginal Probe

The female pelvic floor (PF) provides anatomical support to many visceral organs, such as uterus, bladder, urethra, vagina, and rectum. Physiologically, the PF is made up of a number of highly coordinated muscle groups organized to respond to postural and abdominal stresses to maintain continence. In this article, we describe a new methodology for the evaluation of PF strength using a novel vaginal probe design, having force and displacement sensors. This design was derived on the basis of imaging data showing that force/displacement characteristics are important determinants of the integrity of the PF function. The prototype probe used was constructed to evaluate the dynamic responses to slow voluntary contractions as well as reflex stress contractions. Initial clinical experiments were performed on nine healthy female subjects. The probe recorded the force and displacement signals on the anterior and posterior sides of the subjects' middle vaginal wall in voluntary PF muscle contraction and cough. The time domain and frequency domain characteristics of the dynamic responses, including the force and displacement responses, of the vaginal wall were measured and the power and energy associated with the dynamic responses of the PF were analyzed showing the differences between the dynamic characteristics of the voluntary PF muscle contraction and cough. Results show that voluntary PF muscle contractions have higher amplitudes, longer duration, and higher power than reflex contractions. The design of this probe enables the measurement of force and displacement during rapidly occurring events.

Functional Anatomy of the Female Pelvic Floor

The anatomic structures in the female that prevent incontinence and genital organ prolapse on increases in abdominal pressure during daily activities include sphincteric and supportive systems. In the urethra, the action of the vesical neck and urethral sphincteric mechanisms maintains urethral closure pressure above bladder pressure. Decreases in the number of striated muscle fibers of the sphincter occur with age and parity. A supportive hammock under the urethra and vesical neck provides a firm backstop against which the urethra is compressed during increases in abdominal pressure to maintain urethral closure pressures above the rapidly increasing bladder pressure. This supporting layer consists of the anterior vaginal wall and the connective tissue that attaches it to the pelvic bones through the pubovaginal portion of the levator ani muscle, and the uterosacral and cardinal ligaments comprising the tendinous arch of the pelvic fascia. At rest the levator ani maintains closure of the urogenital hiatus. They are additionally recruited to maintain hiatal closure in the face of inertial loads related to visceral accelerations as well as abdominal pressurization in daily activities involving recruitment of the abdominal wall musculature and diaphragm. Vaginal birth is associated with an increased risk of levator ani defects, as well as genital organ prolapse and urinary incontinence. Computer models indicate that vaginal birth places the levator ani under tissue stretch ratios of up to 3.3 and the pudendal nerve under strains of up to 33%, respectively. Research is needed to better identify the pathomechanics of these conditions.

Regulation of MMP-1 by sex steroid hormones in fibroblasts derived from the female pelvic floor

The aim of this study was to investigate the effect of sex steroid hormones on the overall expression profile of cellular matrix metalloproteinase-1 (MMP-1) in fibroblasts that are derived from arcus tendineus fasciae pelvis. Arcus tendineus fasciae pelvis fibroblasts that originated from a premenopausal woman and a postmenopausal woman who was undergoing a prolapse repair were treated with physiologic concentrations of 17-beta-estradiol (E2), progesterone, E2 plus progesterone, and E2 plus ICI 182,780. Cellular expressions of the latent, active, and fragment forms of MMP-1 were analyzed quantitatively by Western immunoblotting. The latent and fragment forms of MMP-1 were increased by E2, progesterone, and E2 plus progesterone. The active form of MMP-1 was not changed by either E2 or progesterone alone but was decreased significantly when both hormones were added together. ICI 182,780 inhibited the stimulatory effect of E2. Fragmentation is a site of regulation of MMP-1 expression by hormones. Only E2 combined with progesterone decreased the active form of MMP-1, which suggests that both hormones are necessary to maintain the integrity of female pelvic floor.

Ultrasound Evaluation of Dynamic Responses of Female Pelvic Floor Muscles

Ultrasound imaging of the pelvic floor carries diagnostically important information about the dynamic response of the pelvic floor muscles (PFM) to potentially incontinence-producing stress, which cannot be readily captured and assimilated by the observer during the scanning process. We presented an approach based on motion tracking quantitatively to analyze the dynamic parameters of PFM on the ano-rectal angle (ARA). Perineal ultrasonography was performed on 22 asymptomatic females and nine stress urinary incontinent (SUI) patients with a broad age distribution and parity. The ventral-dorsal and cephalad-caudad movements of the ARA were resolved and kinematic parameters, in terms of displacement, trajectory, velocity and acceleration, were analyzed. The results revealed the possible mechanisms of PFM responses to prevent the urine from incontinence in fast and stress events such as coughs. The statistical analyses showed that the PFM responses of the healthy subjects and the SUI patients are significantly different in both the supine and standing experiments. (E-mail: ceconst@stanford.edu)

Complications of grafts used in female pelvic floor reconstruction: Mesh erosion and extrusion

Introduction:Various grafts have been used in the treatment of urinary incontinence and pelvic prolapse. Autologous materials such as muscle and fascia were first utilized to provide additional anatomic support to the periurethral and pelvic tissues; however, attempts to minimize the invasiveness of the procedures have led to the use of synthetic materials. Complications such as infection and erosion or extrusion associated with these materials may be troublesome to manage. We review the literature and describe a brief overview of grafts used in pelvic floor reconstruction and focus on the management complications specifically related to synthetic materials.Materials and Methods:We performed a comprehensive review of the literature on grafts used in pelvic floor surgery using MEDLINE and resources cited in those peer-reviewed manuscripts. The results are presented.Results:Biologic materials provide adequate cure rates but have associated downfalls including potential complications from harvesting, variable tissue quality and cost. The use of synthetic materials as an alternative graft in pelvic floor repairs has become a popular option. Of all synthetic materials, the type I macroporous polypropylene meshes have demonstrated superiority in terms of efficacy and fewer complication rates due to their structure and composition. Erosion and extrusion of mesh are common and troublesome complications that may be managed conservatively with observation with or without local hormone therapy, with transvaginal debridement or with surgical exploration and total mesh excision, dependent upon the location of the mesh and the mesh type utilized.Conclusions:The ideal graft would provide structural integrity and durability with minimal adverse reaction by the host tissue. Biologic materials in general tend to have fewer associated complications, however, the risks of harvesting, variable integrity of allografts, availability and high cost has led to the development and use of synthetic grafts. Synthetic grafts have a tendency to cause higher rates of erosion and extrusion; however, these complications can be managed successfully.

Magnetic Resonance Imaging of Pelvic Floor Defects in Women

Contemporary fast magnetic resonance imaging techniques allow dynamic evaluation of the entire female pelvic floor with excellent visualization of pelvic organs and muscular and fascial supportive structures in a single noninvasive study that does not expose the patient to ionizing radiation. This article focuses on the role of magnetic resonance imaging in defining pelvic floor defects that can guide surgical management of women with pelvic organ prolapse, especially those who undergo evaluation for symptoms of multicompartmental involvement before a complex pelvic floor reconstruction or those who have failed previous repairs.

Editorial comment: The global burden of female pelvic floor disorders

Editorial comment: The global burden of female pelvic floor disorders

Robotic and laparoscopic female pelvic floor reconstruction

Robotic and laparoscopic female pelvic floor reconstruction

Editorial comment: Robotic and laparoscopic female pelvic floor reconstruction

BJU InternationalVolume 98, Issue s1 p. 69-69 Editorial comment: Robotic and laparoscopic female pelvic floor reconstruction ANTHONY SMITH, ANTHONY SMITH Consultant Urogynaecologist, The Warrell Unit, Saint Mary’s Hospital for Women & Children, Manchester, UKSearch for more papers by this author ANTHONY SMITH, ANTHONY SMITH Consultant Urogynaecologist, The Warrell Unit, Saint Mary’s Hospital for Women & Children, Manchester, UKSearch for more papers by this author First published: 27 July 2006 https://doi.org/10.1111/j.1464-410X.2006.06363.x Anthony Smith, Consultant Urogynaecologist, Department of Urological Gynaecology, Saint Mary’s Hospital for Women & Children, Manchester, UK.e-mail: [email protected] Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article. Volume98, Issues1September 2006Pages 69-69 RelatedInformation

The global burden of female pelvic floor disorders

BJU InternationalVolume 98, Issue s1 p. 1-5 The global burden of female pelvic floor disorders KIMBERLY KENTON, KIMBERLY KENTON Loyola University Medical Center, Maywood, IL, USASearch for more papers by this authorELIZABETH R. MUELLER, ELIZABETH R. MUELLER Loyola University Medical Center, Maywood, IL, USASearch for more papers by this author KIMBERLY KENTON, KIMBERLY KENTON Loyola University Medical Center, Maywood, IL, USASearch for more papers by this authorELIZABETH R. MUELLER, ELIZABETH R. MUELLER Loyola University Medical Center, Maywood, IL, USASearch for more papers by this author First published: 27 July 2006 https://doi.org/10.1111/j.1464-410X.2006.06299.xCitations: 65 Kimberly Kenton, Division of Female Pelvic Medicine & Reconstructive Surgery, Departments of Urology and Obstetrics & Gynecology, Loyola University Medical Center, 2160 South First Avenue, Maywood, IL 60153, USA.e-mail: [email protected] Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Citing Literature Volume98, Issues1September 2006Pages 1-5 RelatedInformation

Urogynecology practice patterns among Air Force obstetricians and gynecologists: survey results

The objective of this study was to describe the practice patterns of physicians in the United States Air Force regarding the evaluation and treatment of female pelvic floor disorders including urinary incontinence and pelvic organ prolapse. A self-administered survey of 22 questions was electronically mailed to all active duty Air Force obstetricians & gynecologists. Fifty-one surveys were returned for a 51% response rate. Eighty-four percent of physicians treat urinary incontinence. A smaller percentage perform advanced reconstructive techniques, using biomaterials (35%), colpocleisis (39%), overlapping sphincter repairs (45%), and abdominal sacrocolpopexy (27%). When questioned about urogynecology training during residency, most respondents report inadequate training in advanced pelvic surgery techniques. In conclusion, the majority of Air Force obstetricians and gynecologists feel comfortable treating uncomplicated urinary incontinence but do not routinely perform advanced urogynecology surgeries. There is a continued need to train physicians in female pelvic medicine to treat a unique patient population.

Pelvic Organ Support and Prevalence by Pelvic Organ Prolapse-Quantification (POP-Q) in Korean Women

We evaluated pelvic organ support and the prevalence of pelvic organ prolapse in Korean women using the Pelvic Organ Prolapse-Quantification system as the assessment tool. The study population consisted of 713 women 18 to 72 years old who were seen for annual Papanicolaou testing and pelvic examinations. Pregnant patients and patients who had delivered within the previous 6 weeks were not recruited. All pelvic examinations were performed by a single examiner. The patient was examined in the dorsal lithotomy position in a pelvic examination chair positioned at a 15-degree angle. All 9 measurements except total vaginal length were taken with the patient performing the maximal Valsalva maneuver. Mean patient age was 41.6 years (range 18 to 72), mean weight +/- SD was 55.8 +/- 7.4 kg (range 40 to 83), mean height was 158.7 +/- 5.4 cm (range 138 to 177), mean body mass index was 22.3 +/- 8.1 kg/m2 (range 15.7 to 32) and median parity was 2 (range 0 to 6). Mean scores for the position of the cervix and posterior fornix, and total vaginal length were -5.0, -6.6 and 7.0 cm, respectively. In the 713 women with a uterus the incidence of anterior vaginal, uterine and posterior vaginal prolapse was 27.6%, 2.0% and 25.4%, respectively. The overall distribution of pelvic organ prolapse quantification system stage was stages 0 to 4 in 68.3%, 19.9%, 11.2%, 0.6% and 0.0% of patients, respectively. Vaginal size in Korean women differs from that in Western women. The prevalence of any degree of prolapse was approximately 31.7%. Korean women were at relatively higher risk for anterior and posterior vaginal prolapse than for uterine prolapse.

Follow up of surgical repair of female pelvic floor disorders by a mailed questionnaire

This study was conducted to determine whether surgical repair of pelvic prolapse enhances patients' quality of life (QOL) in the long term. A total of 91 patients (median age, 68.0 years) with pelvic prolapse including cystoceles underwent bladder neck suspension with anterior/posterior colporrhaphy between 1997 and 2003. Postoperative QOL was longitudinally assessed by three disease-specific items (sensation of vaginal bulging, obstructive symptoms, urinary incontinence), and one overall health-related QOL (HR-QOL) item. A longitudinal study demonstrated that a significant improvement in these symptoms was sustained at a median follow up of 65.5 months, although poor HR-QOL was significantly higher in patients whose age was more than 70 years at surgery (P = 0.0234, Fisher's test). Multivariate analysis revealed update urinary incontinence, update obstructive symptoms, and basic comorbidity to be independent prognostic factors for predicting postoperative moderate-to-poor HR-QOL. Longer follow up with adequate assessment of patients' QOL may be crucial for the management of postoperative patients, in particular those having basic comorbidity and aged 70 years or more at surgery.

Childbirth and pelvic floor dysfunction: An epidemiologic approach to the assessment of prevention opportunities at delivery

Female pelvic floor dysfunction is integral to the woman's role in the reproductive process, largely because of the unique anatomic features that facilitate vaginal birth and also because of the trauma that can occur during that event. Interventions such as primary elective cesarean delivery have been discussed for the primary prevention of pelvic floor dysfunction; however, existing data about potentially causal factors limit our ability to evaluate such strategies critically. Here we consider the conceptual principles of epidemiologic function and the availability of data that are necessary to make informed recommendations about prevention opportunities for pelvic floor dysfunction at delivery. Available epidemiologic data on pelvic floor dysfunction suggest that there may be substantial opportunities for the primary prevention of pelvic organ prolapse at delivery. Although definitive recommendations await further epidemiologic studies of the potential risk and benefits of obstetric practice change, it is hoped that this discussion will provide a novel, quantitative framework for the assessment of pelvic floor dysfunction prevention opportunities.

Female pelvic floor. Descriptive anatomy and clinical exploration by transvaginal ultrasound

In order to assess the state and pathology of the woman's pelvis minor, a number of methods are commonly used among practitioners, encompassing clinical exploration, radiology, MRN, urodynamics, en...

Failure of Elastic Fiber Homeostasis Leads to Pelvic Floor Disorders

Pelvic floor disorders, a group of conditions affecting adult women, include pelvic organ prolapse and urinary incontinence. Vaginal childbirth and aging are risk factors, and weakening of the pelvic support structures is a major aspect of the pathology. However, the underlying molecular mechanism remains unknown. Female reproductive organs are rich in elastic fibers that turn over slowly in most adult tissues but undergo massive remodeling in the reproductive organs through pregnancy and birth. Here we show that a failure to maintain elastic fiber homeostasis in mice causes pelvic floor disorders. Lysyl oxidase-like-1 (LOXL1), a protein essential for the postnatal deposition of elastic fibers, was highly expressed and regulated in the reproductive tract of the mouse, and its expression was diminished during aging. LOXL1 deficiency caused an inability of reproductive tissues to replenish elastic fibers after parturition, leading to pelvic organ prolapse, weakening of the vaginal wall, paraurethral pathology, and lower urinary tract dysfunction. These data demonstrate the importance of elastic fibers for maintaining structural and functional integrity of the female pelvic floor. Our findings raise the possibility that a failure of elastic fiber homeostasis, either due to genetic predisposition or advancing age, could underlie the etiology of pelvic floor dysfunction in women.

Female pelvic floor dysfunction in the Middle East: a tale of three factors—culture, religion and socialization of health role stereotypes

Female pelvic floor dysfunction in the Middle East: a tale of three factors—culture, religion and socialization of health role stereotypes

Female pelvic floor. Descriptive anatomy and clinical exploration by transvaginal ultrasound

In order to assess the state and pathology of the woman's pelvis minor, a number of methods are commonly used among practitioners, encompassing clinical exploration, radiology, MRN, urodynamics, endoscopy and echography.Echography has been poorly used in clinical pelvic exploration and its reliability is actually a matter of controversy [1]. However, echographic surveys can provide us with valuable gynecological data on the state and pathologies of the soft pelvis, within the genital regions or even going beyond them, i.e. the rectal channel, bladder, urethra, anus, vascular plexuses, and all of their supporting tissues.At our research unit, we have been employing Transvaginal Ultrasound echography (TVU) for a long time in conjunction with other pelvis-focused methods in order to study different kinds of pelvic alterations. TVU has proven to be friendly to use, fast, harmless and inexpensive, allowing serial explorations and producing high-quality dynamic images (loop-cinema, video-tape). Furthermore, this method is fairly aseptic in that the occurrence of faeces in the rectal ampolla is not a nuisance but a bonus in tracking the contours of the rectum walls and other topographical features which would be otherwise difficult to survey.A complete pelvic floor TVU may add no longer than 5–8 minutes to a routine gynecological examination, can be implemented by the general gynecologist and generates data that can be further studied by the appropriate specialist for a more insightful evaluation [2].