Hiatal Area Research Articles

Caractéristiques et symptômes pelvi-périnéaux dans les douleurs de la ceinture pelvienne : une revue de la littérature

Pelvic girdle pain (PGP) is characterized by the presence of pain in the posterior pelvic area, distally and laterally to the fifth lumbar vertebra, and/or at the pubic symphysis. PGP is a very common pain condition in women, especially during pregnancy and postpartum. After delivery, pain prevalence decreases to 7% in the first three months. The currentliterature describes an association between pelvic girdle pain and different perineal characteristics and symptoms. A better understanding of perineal structures influence on PGP could assist towards the management of this condition. The aim of this review is to describe the peer-reviewed literatureabout perineal function in patients with PGP. A bibliographic search on PubMed was conducted. The key words used were: pelvic girdle pain, pregnacy-related low back pain, lumbopelvic pain, posterior pelvic pain, peripartum pelvic pain, pelvic girdle relaxation, pelvic joint instability, peripartum pelvic pain, sacroiliac joint pain, sacroiliac joint dysfunction, sacroiliac-joint related pelvic pain and pelvic floor. Two hundred and twenty-one (221) articles were identified. Out of them, a total ofnine articles were selected. The level of evidence was determined using Oxford's scale. Patients with PGP showed increased activity of the pelvic floor muscles (P=0.05) (LE3), decreased urogenital hiatus area (PGP 12.4cm2±2.7, control 13.7cm2±2.8, P=0.015) (LE3), shorter endurance time (PGP 17.8s; control 54.0s, P=0.00) (LE3), significantly later onset time during affected side leg elevation (PGP 25ms, control -129ms, P=0.01) (LE3), levator ani and obturator internus tenderness (PGP 25/26; control 5/25, P<0.001) (LE3) and a higher prevalence of vesico-sphincteric disorders compared to asymptomatic subjects (LE3). This review confirms that subjects suffering PGP present particular perineal characteristics regarding morphology and biomechanics. It would be interesting to develop clinical research concerning pelvic floor release effect in PGP.

The Degree of Cystocele and Rectocele with Hiatal Area Levator Ani

Objective: To investigate the degree of cystocele and rectocele with a maximum of levator hiatal area (AHL) during Valsava.&#x0D; Methods: Secondary data analysis of 90 patients with uterine prolapse January 2012 to November 2013 in the clinic Uroginekologi RSCM, Jakarta. 3D/4D ultrasound measurement and pelvic organ prolapse system Quantification (POP-Q) stage I-IV cystocele and rectocelestage I-IV. All statistical analyses were analyzed using Stata 20 for Windows.&#x0D; Results: Significant difference cystocele stage I-II (n = 25) with stage III-IV (n = 65), the maximum AHL with a difference of 4.33 cm2 (p = 0.040). In rectocele stage I-II (n = 64) and stage III-IV (n = 26) of 3.85 cm2 (p = 0.130). AUC values for stage I-II and III-IV cystocele was 0.607 (IK95% from 0.467 to 0.738), and the ROC for rectocele was 0.603 (IK95% from 0.472 to 0.734). The ROC optimal cut point for cystocele stage I-II with III-IV with the highestsensitivity and specificity is 29 cm2 (0.523 sensitivity, specificity 0.520), the rectocele is 30 cm2 (0.538 sensitivity, specificity 0.584).&#x0D; Conclusion: There is a significant relationship between the degree of cystocele and area of the levator ani muscles when Valsava, but there is no relationship at rectocele. The value of maximum area under the curve (AUC) hiatal area of the levatorani muscle in distinguishing stage I-II and III-IV cystocele are relatively similar to rectocele stage I-II and III-IV. Optimal cut point hiatal area of the levatorani muscle in distinguishing stage I-II and III-IV cystoceleis 29 cm2, while for rectocele is 30 cm2 with sensitivity and specificity values were quite good.&#x0D; Keywords: cystocele, levatorani hiatal area, pelvic organ prolapse, rectocele

Levator ani muscle avulsion is a risk factor for expulsion within 1 year of vaginal pessary placed for pelvic organ prolapse

The aim of this study was to investigate whether the presence of levator ani muscle (LAM) avulsion is associated with expulsion within 1 year of a vaginal pessary placed for pelvic organ prolapse (POP). This was a prospective observational study of consecutive women with symptomatic POP, who had not received treatment for the condition before the consultation and opted for vaginal pessary placement in our center. Volume acquisition was performed before pessary insertion and offline analysis of the 3D/4D transperineal ultrasound volume data was performed. LAM was assessed on maximum pelvic floor muscle contraction (PFMC) and hiatal dimensions were assessed at rest, on PFMC and on maximum Valsalva. Results were compared between women in whom the pessary was retained for 1 year and those in whom the pessary was expelled within 1 year. The datasets of 255 women were analyzed including 147 (57.6%) women who had a vaginal pessary continuously in place over 1 year and 108 (42.4%) with pessary expulsion. Mean age was 63.2 (SD, 9.9) years and median parity was 3 (2-4). Eighteen (7.1%) had Stage I, 164 (64.3%) Stage II, 67 (26.3%) Stage III and six (2.4%) Stage IV POP. Women with vaginal pessary expulsion within 1 year had significantly larger hiatal dimensions at rest and on Valsalva, larger hiatal area during rest, PFMC and Valsalva and higher rate of LAM avulsion (53.7% vs 27.2%, P < 0.01) compared with women in whom the pessary was retained for 1 year. After controlling for potential confounders, LAM avulsion remained a risk factor (OR, 3.18, P < 0.01) of vaginal pessary expulsion within 1 year. Women in whom a vaginal pessary was expelled within 1 year of placement for POP had a larger hiatus. Presence of LAM avulsion was associated with a three-fold increase in the risk of expulsion of a vaginal pessary within 1 year. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Diagnostic Accuracy and Clinical Implications of Translabial Ultrasound for the Assessment of Levator Ani Defects and Levator Ani Biometry in Women With Pelvic Organ Prolapse: A Systematic Review.

The aim of this study was to assess the diagnostic accuracy and clinical implications of translabial 3-dimensional (3D) ultrasound for the assessment of levator ani defects and biometry in women with pelvic organ prolapse (POP). We performed a systematic literature search through computerized databases including MEDLINE (via PubMed), EMBASE (via OvidSP), and the Cochrane Library using both medical subject headings and text terms from January 1, 2003, to December 25, 2015.We included articles that reported on POP status and diagnostic accuracy measurements with translabial 3D ultrasound or transperineal ultrasound for the detection of levator ani defects or for measuring pelvic floor biometry, that is, levator ani hiatus, or reported on the clinical relevance of using translabial 3D ultrasound for levator ani defects or measuring pelvic floor biometry in women with POP. Thirty-one articles were selected in accordance with parts of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines that can be applied to studies of diagnostic accuracy. Twenty-two articles (71%) are coauthored by 1 expert in this field. Detecting levator ani defects with translabial 3D ultrasound compared with magnetic resonance imaging showed a moderate to good agreement, whereas measuring hiatal biometry on translabial 3D ultrasound compared with magnetic resonance imaging showed a moderate to very good agreement.The interobserver agreement for diagnosing levator ani defects and measuring the levator hiatal area showed a moderate to very good agreement. Furthermore, levator ani defects increase the risk of cystocele and uterine prolapse, and levator ani defects are associated with recurrent POP.Finally, a larger hiatus was associated with POP and recurrent POP. Translabial 3D ultrasound is reproducible for diagnosing levator ani defects and ballooning hiatus. Both levator ani defects and a larger hiatal area are, in a selected population of patients with pelvic floor dysfunction, associated with POP and recurrent POP. More research is needed concerning external validation because most data in this article are coauthored by 1 expert in this field.

Can We Evaluate Hiatal Ballooning by Measuring the Anteroposterior Diameter With 2-Dimensional Translabial Ultrasonography?

To analyze the association between the anteroposterior hiatal diameter and pelvic organ prolapse and to determine whether 2-dimensional translabial ultrasonography can evaluate hiatal ballooning by measuring the anteroposterior diameter. This study was a retrospective analysis of 312 women seen for lower urinary tract symptoms or pelvic organ prolapse between December 2014 and July 2016. All women had an International Continence Society (ICS) Pelvic Organ Prolapse Quantification (POP-Q) system examination and 4-dimensional translabial ultrasonography. The anteroposterior hiatal diameter was measured in the midsagittal plane, and the hiatal area was measured in the minimal axial plane during the maximal Valsalva maneuver. Valid data from 294 patients were analyzed. International Continence Society POP-Q stage 0 was found in 121 women, stage 1 in 49, stage 2 in 78, stage 3 in 42, and stage 4 in 4. The anteroposterior diameter had an excellent linear correlation (r = 0.814; P < .001) with the hiatal area during the Valsalva maneuver and was strongly related to ICS POP-Q stages (P < .01). A receiver operating characteristic curve analysis proposed a cutoff of 6.0 cm for the anteroposterior diameter against ICS POP-Q stage 2 and higher (sensitivity, 73%; specificity, 52%) and prolapse symptoms (sensitivity, 74%; specificity, 64%). The anteroposterior hiatal diameter, which represents hiatal distensibility in the midsagittal plane, can be used to evaluate hiatal ballooning. "Mild" ballooning was defined as an anteroposterior diameter measurement of 6.0 to less than 6.5 cm, "moderate" ballooning as 6.5 to less than 7.0 cm, and "marked" ballooning as 7.0 cm or greater.

Pelvic Floor Morphometric Differences in Elderly Women with or without Urinary Incontinence.

Purpose: Urinary incontinence (UI) affects as many as 50% of women aged 60 years and older, but UI pathophysiology, specifically in elderly women, remains unclear. A better understanding of morphometric differences between continent and urinary incontinent elderly women is needed to improve the effectiveness of conservative treatment approaches. We hypothesized that morphometric differences in the pelvic floor muscles (PFM) among elderly women with and without UI could be observed using three- and four-dimensional (3D/4D) transperineal ultrasound (TPU) imaging. Method: A total of 40 elderly women (20 women with and 20 women without UI), with a mean age of 67.10 (SD 4.94) years, participated in the study. This was a case-control study in which TPU images were taken under three conditions: rest, maximal voluntary contraction (MVC), and Valsalva. Independent t-tests were conducted to compare measurements between the groups. Results: The study revealed statistically significant differences between the groups. At rest, the levator hiatal area and transverse diameter were bigger, and the PFM position was lower in the incontinent group. During MVC, all axial plane parameters were bigger in the incontinent group. In the sagittal plane, PFM position was again lower in the incontinent group. During Valsalva, the anorectal angle was wider in the women with incontinence. Conclusion: PFM morphometric differences were present and were observed using 3D/4D TPU imaging in elderly women with and without UI.

Using Z-scores to evaluate levator hiatal dimensions with four-dimensional translabial ultrasound.

This study represents the first attempt to use 'Z-scores' to assess levator hiatal dimensions and quantify hiatal expansion. We undertook a retrospective study on the data of 110 nulliparae and 73 pelvic organ prolapse (POP) patients who had a clinical POP exam and translabial 4-D ultrasound. We used Z-scores to normalize the dimensions of nulliparae levator hiatus and to build a Z-score model to evaluate the 'hiatal ballooning' against the POP staging. Valid data were gathered from 102 nulliparae and 64 POP patients. We built the Z-score models as follows: Z-Av = (measured value - 17.19) / 2.98, Z-Lv = (measured value - 55.65) / 5.48, where 'Av' and 'Lv' represented the 'hiatal area' and the 'anterior-posterior diameter' on Valsalva, respectively. The '90% reference range' of Z-Av was (-1.8-+1.8) and that of Z-Lv was (-2.0-+2.0). On receiver-operator curve analysis, the cut-off against POP stage 2 for Av was 20 cm2 (sensitivity of 79%, specificity of 66%), and that for Lv was 6.0 cm (sensitivity of 68%, specificity of 65%), which were approximately equal to a Z-Av of 1.0 and a Z-Lv of 1.0, correspondingly. For POP stage 3, the cut-off was an Av of 24 cm2 (sensitivity of 85%, specificity of 83%) or an anterior-posterior diameter of 6.3 cm (sensitivity of 77%, specificity of 80%), which was approximately equal to a Z-Av of 2.0 or a Z-Lv of 1.5, respectively. 'Normal hiatal dimension' was defined as Z-Av ≤ 1.0 or Z-Lv ≤ 1.0, and 'hiatal ballooning' was defined as Z-Av ≥ 2.0 or Z-Lv ≥ 1.5.

Risk factors for prolapse recurrence: systematic review and meta-analysis.

Female pelvic organ prolapse (POP) is a common condition, with a lifetime risk for surgery of 10-20%. Prolapse procedures are known to have a high reoperation rate. It is assumed that etiological factors for POP may also be risk factors for POP recurrence after surgery. There are few reviews available evaluating risk factors for prolapse and recurrence or recently updated meta-analysis on this topic. Our aim was to perform a systematic review and quantitative meta-analysis to determine risk factors for prolapse recurrence after reconstructive surgery. Four electronic databases (MEDLINE, PubMed, EMBASE, and Google Scholar) were searched between 1995 and 1 January 2017, with no language restrictions. Twenty-five studies met inclusion criteria for a total of 5082 patients with an average recurrence rate of 36%. Variables on which a meta-analysis could be performed were body mass index (BMI) (n=12), age (n=11), preoperative stage (n=9), levator avulsion (n=8), parity (n=8), constipation/straining (n=6), number of compartments involved (n=4), prior hysterectomy (n=4), familiy history (n=3), and several other predictors evaluated in only three studies. The following meta- analyses identified significant predictors: levator avulsion [odds ratio (OR) 2.76, P< 0.01], preoperative stage 3-4 (OR 2.11, P< 0.001), family history (OR 1.84, P=0.006), and hiatal area (OR 1.06/cm2, P=0.003). Levator avulsion, prolapse stage, and family history are significant risk factors for prolapse recurrence.

Obesity: how much does it matter for female pelvic organ prolapse?

The objective was to determine the association between body mass index (BMI) and symptoms and signs of female pelvic organ prolapse (POP). An observational cross-sectional study of 964 archived datasets of women seen for symptoms and signs of lower urinary tract and pelvic organ dysfunction between September 2011 and February 2014 at a tertiary urogynaecology centre in Australia was carried out. An in-house standardised interview, the International Continence Society Pelvic Organ Prolapse Quantification (ICS POP-Q) and 4-D translabial ultrasound, followed by analysis of ultrasound volumes for pelvic organ descent and hiatal area on Valsalva, were performed, blinded against other data. There is a positive association between BMI and posterior compartment prolapse on clinical examination and ultrasound imaging, but not for the anterior and central compartments. There was no association with prolapse symptom bother and a negative association with symptoms of prolapse. In this observational study, we found a strong association between all tested measures of posterior compartment descent and BMI, both clinical and on imaging.

Pelvic floor muscle dysfunction on 3D/4D transperineal ultrasound in patients with deep infiltrating endometriosis: a pilot study.

Pelvic floor muscle (PFM) dysfunction seems to play an important role in the pathophysiology of pelvic pain, including that associated with deep infiltrating endometriosis (DIE). The aim of this study was to evaluate the static and dynamic morphometry of the PFM using three-dimensional (3D) and four-dimensional (4D) transperineal ultrasound in women with DIE compared with asymptomatic healthy women. This was a pilot, prospective study conducted at our tertiary center between March and November 2015. Fifty nulliparous women with DIE (study group) and 35 nulliparous asymptomatic healthy women (control group) were included. 3D/4D transperineal ultrasound examination of the PFM was performed in both groups. Levator hiatal area (LHA) and anteroposterior and left-right transverse diameters were evaluated at rest, on maximum PFM contraction and on maximum Valsalva maneuver. Persistent levator ani muscle (LAM) coactivation during Valsalva maneuver was investigated. Compared with the control group, women with DIE had a smaller LHA at rest (P = 0.03) and during Valsalva maneuver (P < 0.01). Furthermore, reduction in LHA during PFM contraction (P < 0.001) and enlargement in LHA during Valsalva maneuver (P = 0.01) were significantly less marked. In comparison with controls, women with DIE presented a higher frequency of LAM coactivation during Valsalva maneuver, although this difference did not reach statistical significance (P = 0.05). 3D and 4D transperineal ultrasound is an objective and non-invasive method for PFM morphometry and may have a role in detecting PFM dysfunction in women with DIE. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Vaginal laxity: what does this symptom mean?

Vaginal laxity is a poorly understood symptom of pelvic floor dysfunction. The purpose of this study was to investigate associations between the symptom of vaginal laxity and its bother on the one hand, and demographic data, other symptoms, and findings on examination on the other hand. This was a retrospective observational study at a tertiary urogynecological unit. A total of 337 patients were seen for a standardized interview, clinical examination (ICS POP-Q) and 4D translabial ultrasonography. Stored imaging data were analyzed offline to evaluate functional pelvic floor anatomy and investigate associations with symptoms and other findings. Of the 337 women seen during the study period, 13 were excluded due to missing data, leaving 324. Vaginal laxity was reported by 24% with a mean bother of 5.7. In a univariate analysis, this symptom was associated with younger age, vaginal parity, POP symptoms and bother, clinically and sonographically determined POP and hiatal area on Valsalva maneuver. Vaginal laxity or 'looseness' is common in our urogynecology service at a prevalence of 24%. The associated bother is almost as high as the bother associated with conventional prolapse symptoms. It is associated with younger age, vaginal parity, symptoms of prolapse, prolapse bother and objective prolapse on POP-Q examination and imaging, suggesting that vaginal laxity may be considered a symptom of prolapse. The strongest associations were found with gh+pb and hiatal area on Valsalva maneuver, suggesting that vaginal laxity is a manifestation of levator ani hyperdistensibility.

Differences in urinary incontinence symptoms and pelvic floor structure changes during pregnancy between nulliparous and multiparous women.

BackgroundThis study was performed to compare changes in urinary incontinence (UI) symptoms and pelvic floor structure during pregnancy between nulliparous and multiparous women.MethodsA cross-sectional survey was performed among pregnant women from July 2016 to January 2017. In total, 358 pregnant women from two hospitals underwent an interview and pelvic floor transperineal ultrasound assessment. A questionnaire regarding sociodemographic, gynecological, obstetric features and the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) were used for the interview. Imaging data sets were analyzed offline to assess the bladder neck vertical position (BNVP), urethral angles (α, β, and γ angles), and hiatal area (HA) at rest and at maximal Valsalva maneuver (VM).ResultsAfter excluding 16 women with invalid data, 342 women were included. The prevalence (χ2 = 9.15, P = 0.002), frequency (t = 2.52, P = 0.014), usual amount of UI (t = 2.23, P = 0.029) and scores of interference with daily life (t = 2.03, P = 0.045) during pregnancy were higher in multiparous than nulliparous women. A larger bladder neck descent (BND) (F = 4.398, P < 0.001), HA (F = 6.977, P < 0.001), α angle (F = 2.178, P = 0.030), β angle (F = 4.404, P < 0.001), and γ angle (F = 2.54, P = 0.011) at VM were discovered in pregnant women with UI than without UI. Multiparous women had a significantly higher BND (t = 2.269, P = 0.024) and a larger α angle (F = 2.894, P = 0.004), β angle (F = 2.473, P = 0.014), and γ angle (F = 3.255, P = 0.001) at VM than did nulliparous women.ConclusionMultiparous women experienced more obvious UI symptoms and pelvic floor structure changes during pregnancy than did nulliparous women.

Ethnic differences in the levator hiatus and pelvic organ descent: a prospective observational study.

To date, most studies on functional anatomy of the pelvic floor have focused on Caucasian women. There is scant information on this topic involving other ethnic groups. The aim of this study was to investigate levator hiatal area and pelvic organ descent in three racially diverse ethnic groups of healthy nulliparous South Asian, Caucasian and black South African women, using three/four-dimensional (3D/4D) transperineal ultrasound (TPS). Nulliparous women aged 18-40 years from three different ethnic groups were recruited for this prospective observational study between June 2012 and April 2015. After informed consent and clinical examination of the pelvic floor, all patients underwent a 3D/4D-TPS examination. Ultrasound volumes were captured at rest, on maximum pelvic floor muscle contraction (PFMC) and on maximal Valsalva maneuver. Analyses of variance and covariance were performed to compare the three ethnic groups, and a post-hoc Bonferroni pairwise test was applied. A total of 207 nulliparous women were recruited, comprising 41 South Asian, 69 Caucasian and 97 black women. After controlling for age and body mass index, all measurements of mean levator hiatal area at rest, on PFMC and on Valsalva were higher in black women (all P < 0.0001). Post-hoc Bonferroni pairwise comparison revealed that black women had greater pelvic organ descent and levator hiatal area compared with South Asian and Caucasian women (P < 0.0001). This comparative study indicates that there are significant differences in levator hiatal area and pelvic organ mobility between Caucasian, South Asian and black ethnic groups. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Interethnic variation in pelvic floor morphology in women with symptomatic pelvic organ prolapse

There is a lack of epidemiological studies evaluating female pelvic organ prolapse in developing countries. Current studies have largely focused on women of white ethnicity. This study was designed to determine interethnic variation in pelvic floor functional anatomy, namely, levator hiatal distensibility and pelvic organ descent, in women with symptomatic pelvic organ prolapse in a multi-ethnic South African population. This prospective observational study included 258 consecutive women referred for pelvic organ prolapse assessment and management at a tertiary urogynaecological clinic. After a detailed history and clinical examination, including POPQ assessment, patients underwent a 4D transperineal ultrasound. Offline analysis was performed using 4D View software. Main outcome measures included levator muscle distensibility, pelvic organ descent, and levator ani defects (avulsion). Mean age was 60.6 (range, 25-91) years, mean BMI 29.83 (range, 18-53). Points Ba and C were lower and the genital hiatus more distensible in black women (all p<0.05). They were found to have greater hiatal area (p=0.017 at rest, p=0.006 on Valsalva) compared with South Asians and whites and showed greater pelvic organ mobility (all p<0.05) than Caucasians on ultrasound. Levator defects were found in 32.2% (n=83) of patients and most were bilateral (48.2%, n=40), with significant interethnic differences (p=0.014). There was significant variation in clinical prolapse stage, levator distensibility, and pelvic organ descent in this racially diverse population presenting with pelvic organ prolapse, with South Asians having a lower avulsion rate than the other two ethnic groups (p=0.014).

Comparison of the Levator Hiatal Area

Objective: To determine the relationship of the levator hiatal area&#x0D; among nulliparous, primiparous, and multiparous women so that&#x0D; we can assess the prevalence of avulsion.&#x0D; &#x0D; Method: A cross-sectional study design was used by evaluating the&#x0D; transperineal ultrasound results of all nulliparous, primiparous, and&#x0D; multiparous women in the Obstetrics and Gynecology Clinic of&#x0D; Dr. Cipto Mangunkusumo hospital from May to December 2015. We&#x0D; analyzed the data through SPSS using one way ANOVA to compare&#x0D; the levator hiatal dimension among the groups of women during&#x0D; Valsava maneuver and at rest.&#x0D; &#x0D; Result: There were significant differences in levator hiatal area&#x0D; among nulliparous, primiparous, and multiparous women during&#x0D; Valsalva maneuver and at rest, which the mean (SD) was 22.26&#x0D; (5.45) cm2 (p=0.028) and 10.70 (2.26) cm2 (p=0.012), respectively.&#x0D; Levator ani muscle avulsion was occurred in 1 out of 46 (2.2%)&#x0D; women from the primiparous and multiparous group.&#x0D; &#x0D; onclusion: There are significant differences in levator hiatal area&#x0D; during Valsalva and at rest among the groups.&#x0D; [Indones J Obstet Gynecol 2016; 4-4: 208-211]&#x0D; &#x0D; Keywords: avulsion, levator hiatal area, multiparous, nulliparous,&#x0D; primiparous

Pelvic organ support several years after a first birth.

Female pelvic organ prolapse is highly prevalent and childbirth has been shown to be an important risk factor. The study was carried out to observe if pelvic organ support deteriorates over time following a first birth. This is a retrospective review using archived data sets of women seen in the context of two prospective perinatal imaging studies. All subjects had undergone a standardised interview, a clinical examination and 4D translabial ultrasound, 3months and 2-5years post-partum. Main outcome measures were pelvic organ descent and hiatal area at maximum Valsalva manoeuvre. Means at the two time points were compared using paired Student's t test. Predictors of change over time in continuous variables were explored using linear modelling methods. A total of 300 women had at least two postnatal follow-ups. They were first seen on average 0.39 (SD 0.2, range 0.2-2.1) years and again 3.1 (SD 1.5, range 1.4-8) years after the index delivery, with a mean interval of 2.71 (SD 1.5, range 0.7-7.7) years, providing a total of 813 (300 × 2.71) woman-years of observation. On univariate analysis, there was a significant decrease in mobility over time of the bladder neck, bladder, and rectal ampulla (P = < 0.004) and hiatal area (P = 0.012). The degree of improvement was less marked in women with levator avulsion. A significant reduction in pelvic organ descent and hiatal area was noted over a mean of 2.7years after a first birth.

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.

Prolapse symptoms are associated with abnormal functional anatomy of the pelvic floor.

The etiology of pelvic organ prolapse (POP) likely includes over-distension or tears (avulsion) of the levator ani muscle. However, there is a lack of studies evaluating the association between symptoms of POP and these factors. This study was designed to determine the association between POP symptoms and clinical prolapse stage on the one hand, and pelvic floor functional anatomy on the other hand. This prospective observational study included 258 patients seen at a tertiary urogynecological unit with symptoms of POP as defined by pertinent ICIQ questions. After informed consent and a detailed history including ICIQ responses, 3D transperineal ultrasonography was performed using a GE Voluson i ultrasound system. Offline analysis was performed on de-identified datasets. The mean age of the patients was 60.6years (25-91years) and their mean BMI was 29.8kg/m2 (18-53kg/m2). Levator defects were found in 78 (32.4%) of the patients and the defect was bilateral in almost half of these patients (n = 36). There were significant associations between awareness and visualization of a vaginal lump on the one hand and hiatal area measurements as well as diagnosis of avulsion on the other. Interference with everyday life was significantly associated with hiatal area and prolapse stage, but not with avulsion. There is a significant association between awareness, visualization and/or feeling of a vaginal lump and abnormal pelvic floor functional anatomy, that is, hiatal ballooning and levator avulsion.

Usefulness of anorectal and endovaginal 3D ultrasound in the evaluation of sphincter and pubovisceral muscle defects using a new scoring system in women with fecal incontinence after vaginal delivery.

This study aims to evaluate pubovisceral muscle and anal sphincter defects in women with previous vaginal delivery and fecal incontinence and to correlate the findings with the severity of symptoms using the combined anorectal and endovaginal 3D ultrasonography with a new ultrasound scoring system. Consecutive female patients with previous vaginal delivery and fecal incontinence symptoms were screened. Fecal incontinence was assessed with the Cleveland Clinic Florida fecal incontinence scale, and the extent of defects was assessed by an ultrasound score based on results of anorectal and endovaginal 3D ultrasound. Fecal incontinence was assessed with the Cleveland Clinic Florida fecal incontinence scale. Of 84 women with previous vaginal delivery and fecal incontinence, 21 (25%) had intact pubovisceral muscles and anal sphincters; 63 (75%) had a pubovisceral muscle or anal sphincter defect, or both. Twenty-eight (33%) had a pubovisceral muscle defect [23% with an external anal sphincter (EAS) defect or combined EAS/internal anal sphincter defects; 11% with intact anal sphincters]. Thirty-five (42%) had intact pubovisceral muscles and an anal sphincter defect. Compared with women with intact pubovisceral muscles/anal sphincter defects, patients with pubovisceral muscle defects had significantly higher incontinence scores and significantly higher ultrasound scores indicating more extensive defects. Incontinence symptoms correlated positively with the ultrasound score, measurements of sphincter defects, and area of the levator hiatus. Evaluation of both pubovisceral muscles and anal sphincters is important to identify defects and determine treatment for women with fecal incontinence after vaginal delivery. The severity of fecal incontinence symptoms is significantly related to the extent of defects of the pubovisceral muscles and anal sphincters.

Improvement of postpartum pelvic floor by rehabilitation training assessed with transperineal real-time ultrasound

Objective To investigate the improvement of postpartum pelvic floor by rehabilitation training assessed with three-dimensional transperineal ultrasound. Methods One hundred cases of healthy postpartum women were randomly divided into two groups: control group and training group.The control group received the customary education,and the training group received pelvic floor rehabilitation training. At 6 and 12 weeks postpartum,levator hiatus area,thickness of the levator ani muscle,bladder neck mobility,and bladder posterior horn were measured with three-dimensional transperineal ultrasound in all the subjects. Meanwhile,the muscle strength situations were tested. Results At 12 weeks postpartum,the anal levator hiatal area,bladder neck mobility and bladder posterior horn in the training group were lower than those of the control group (P<0.05). Compared with control group,the thickness of the levator ani muscle increased in training group (P<0.05). The incidence of stress urinary incontinence in the training group (5%) was significantly lower than the control group (12.5%) at 12 weeks postpartum (χ2=5.487,P=0.025). The muscle strength had no significant difference at 6 weeks postpartum. At 12 weeks postpartum,the pass rate of class Ⅰ muscle fiber was 78.5%,and that of class Ⅱ muscle fiber was 83.3% in the training group; the pass rate of class Ⅰ muscle fiber was 28.5%,and class Ⅱ muscle fiber was 37.3% in the control group,the improvement was significant at 12 weeks postpartum. Conclusions The result of the transperineal real-time ultrasonographic evaluation of post-natal pelvic floor rehabilitation training has high consistency with the measurement of muscle strength. The ultrasound examination is simple and accurate,and has highly applicable value in evaluating the effect of post-pelvic rehabilitation training. Key words: Ultrasonography,three-dimensional; Pelvic floor; Postpartum rehabilitation training of pelvic floor; Muscle function of pelvic floor