Levator Hiatal Area Research Articles

The Effect of Commonly Performed Exercises on the Levator Hiatus Area and the Length and Strength of Pelvic Floor Muscles in Postpartum Women.

The aim oft his study was to compare the effects of 10 common exercises to traditional pelvic floor muscle (PFM) contractions (Kegel) on levator hiatus (LH) area and PFM length and strength. This is a cross-sectional study of 15 healthy postpartum women. Ten exercises were studied. These were common variations of leg, core, and back exercises used in yoga, Pilates, strength training, and physical therapy. Each participant performed all 10 exercises at a single visit in 2 examination settings: transperineal ultrasound and perineometry. Ultrasound measured the LH area and PFM length, and perineometry measured the muscle strength (peak squeeze pressure). Kegel generates an increase in squeeze pressure (24.3 cm H2O), shortens the muscles (-0.46 cm) and narrows the LH (-0.13 cm). The bird-dog and plank exercises were not different from Kegel in any measurement. While the leg-lift ultrasound dimensions are similar to Kegel, leg lifts generated peak squeeze pressures stronger than any other exercise (including Kegel). Whereas ultrasound dimensions were similar to Kegel, tucked and untucked squats and thigh adductions generated weaker contractions than Kegel. While crunch generated a squeeze pressure similar to Kegel, the ultrasound dimensions showed a significantly wider LH and longer muscle than Kegel. Bridge, clam, and plié exercises affected the PFMs differently than Kegel in all measures. Bird-dog, plank, and leg-lift exercises should be evaluated as alternative exercises to Kegel as they affect PFM strength and length and LH area similarly to Kegel, and leg lifts generate a stronger contraction than Kegel.

Evaluating Z Scores to Quantify Levator Hiatal Distensibility by 3-Dimensional Ultrasonography in Nulliparas and Women With Pelvic Organ Prolapse.

To use Z scores to quantify hiatal distensibility and to test the performance of Z scores for levator hiatal areas in predicting substantial pelvic organ prolapse (POP). We undertook a retrospective study of the data from 145 nulliparas and 166 patients with POP who had a clinical POP examination with 3-dimensional translabial ultrasonography. Z scores were used to normalize levator hiatal areas of nulliparas. The Z score model for the hiatal area was built by the formula Z score = (measured value - predicted mean value)/predicted standard deviation and was used to evaluate hiatal ballooning in women with POP. Valid data were gathered from 134 nulliparas and 159 patients with POP. POP stage 1 was found in 46 women, stage 2 in 62, stage 3 in 43, and stage 4 in 8. We built the Z score model as follows: Z-Av = (measured value - 17.15)/3.11, where Av represented the minimal levator hiatal area on the maximum Valsalva maneuver. The levator hiatal area was strongly related to the POP stage (P < .001). On a receiver operating characteristic curve analysis, the cutoff of Z-Av was 1 for POP stage 2 or higher (sensitivity, 77%; specificity, 60%) and substantial POP on ultrasonography (sensitivity, 84%; specificity, 75%). Hiatal distensibility can be exactly evaluated by Z-Av. A Z-Av value of less than 1.0 was defined as a "normal hiatal expansion," 1 to 3 as "mild ballooning," 3 to 5 as "moderate ballooning," 5 to 7 as "marked ballooning," and 7 or greater as "severe ballooning."

Relationships Between 3-Dimensional Transperineal Ultrasound Imaging and Digital Intravaginal Palpation Assessments of the Pelvic Floor Muscles in Women With and Without Provoked Vestibulodynia

BackgroundDigital intravaginal palpation remains the favored method for clinical assessment of pelvic floor muscle (PFM) function in women; however, there is growing interest in using transperineal ultrasound imaging (TPUSI). TPUSI does not involve vaginal penetration, making it particularly relevant for PFM assessment in women with genito-pelvic pain and penetration disorders. AimsTo study the relations between measures of PFM morphology and function assessed using 3-dimensional (3D) TPUSI and PFM assessment through intravaginal palpation. Methods77 nulliparous premenopausal women with (n = 38) and without (n = 39) PVD participated. 3D TPUSI was used to measure levator hiatal dimensions at rest, at maximal voluntary contraction (MVC) of the PFMs, and at maximal Valsalva maneuver (MVM). Intravaginal palpation was used to assess PFM strength, PFM tone, PFM relaxation after contraction, and vaginal flexibility; each was scored using an ordinal grading scale. Ultrasound and palpation outcomes were compared using Spearman correlation coefficients and Kruskal-Wallis 1-way analyses of variance by rank. OutcomesOutcomes included ultrasound measures of the levator hiatal area, anteroposterior diameter, and left-right transverse diameter at rest, at MVC, and at MVM; raw and relative changes in hiatal dimensions between rest and MVC and between rest and MVM; and palpation measures of PFM strength, tone, and relaxation after contraction, and vaginal flexibility. ResultsWeak to fair correlations were found between ultrasound and palpation measures. A smaller levator hiatus at rest was associated with greater PFM tone, less PFM relaxation, and less vaginal flexibility. Greater levator hiatal constriction and shortening of the hiatal anteroposterior diameter at MVC were associated with greater palpated PFM strength. Greater hiatal distention at MVM was associated with lower PFM tone and greater relaxation. Clinical Translation3D TPUSI and intravaginal palpation provide related but distinct information about PFM function in young women with and without PVD with high functioning PFMs. Strengths and LimitationsThis was the first study to compare PFM assessment using 3D TPUSI and intravaginal palpation in nulliparous premenopausal women. A main strength of the study was the inclusion of women with PVD and asymptomatic controls, which provided a wide range in outcomes because differences in PFM morphology and function exist between women with and without PVD. The lack of inclusion of older women and women with weaker and/or hypotonic PFMs limits the generalizability of the findings. ConclusionAlthough TPUSI has several advantages, including painless application, it is not recommended as a replacement for digital palpation in the clinical assessment of PFM function.Thibault-Gagnon S, Goldfinger C, Pukall C, et al. Relationships Between 3-Dimensional Transperineal Ultrasound Imaging and Digital Intravaginal Palpation Assessments of the Pelvic Floor Muscles in Women With and Without Provoked Vestibulodynia. J Sex Med 2018;15:346–360.

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

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.

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.

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.

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.

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

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

Levator ani muscle injuries associated with vaginal vacuum assisted delivery determined by 3/4D transperineal ultrasound

Objectives: To determine the rate of pelvic floor trauma, levator ani muscle (LAM) avulsion as well as the mean difference in levator hiatus area, after normal vaginal deliveries (NVD) and vacuum assisted deliveries (VD), assessed with three-dimensional transperineal ultrasound (3D-TpUS).Materials and methods: Prospective observational study with 151 nulliparous women with NVD or VD at ≥37 weeks between 9-2012 and 6-2013. 3D-TpUS was performed six months after every patient’s delivery, during which LAM, anteroposterior diameter, transverse diameter and levator hiatus area were assessed.Results: A total of 146 nulliparous were studied, comprising 73 NVD and 73 VD. No differences in obstetric, intrapartum or neonatal characteristics were observed between study groups, with the following exceptions: maternal age (28.1 ± 5.4 versus 30.4 ± 5.5; p = 0.008, OR = 1.1) and episiotomy rate (35.6% versus 97.3%; p = 0.011, OR = 4.3). LAM avulsion rate was 9.6% in NVD versus 34.2% in VD (p = 0.001, OR 3.99), while levator hiatus area at rest was 16.5 ± 3.2 versus 18.2 ± 3.9 (p = 0.016).Conclusions: Vacuum assisted deliveries present a higher rate of LAM avulsion, as well as a greater increase in levator hiatal area than in NVD.

Can Abdominal Hypopressive Technique Change Levator Hiatus Area?: A 3-Dimensional Ultrasound Study.

This study aimed to evaluate the levator hiatus area (LHA) at rest and during the performance of maximal pelvic floor muscle (PFM) contractions, during the abdominal hypopressive technique (AHT), and during the combination of PFM contractions (PFMCs) and the AHT. The study included 17 healthy nulliparous women who had no history of pelvic floor disorders. The LHA was evaluated with the patients in the lithotomy position. After a physiotherapist instructed the patients on the proper performance of the PFM and AHT exercises, 1 gynecologist performed the 3-dimensional translabial ultrasound examinations. The LHA was measured with the patients at rest. The PFMC alone, the AHT alone or the AHT in combination with a PFMC with 30 seconds of rest between the evaluations were performed. Each measurement was performed 2 times, and the mean value was used for statistical analysis. The Wilcoxon test was used to test the differences between the 2 maneuvers. Similar values were observed when comparing the LHA of the PFM at rest (12.2 ± 2.4) cm and during the AHT (11.7 ± 2.6) cm (P = 0.227). The AHT+ PFMC (10.2 ± 1.9) cm demonstrated lower values compared with AHT alone (11.7 ± 2.6) cm (P = 0.002). When comparing the PFMC (10.4 ± 2.1) cm with the AHT + PFMC (10.2 ± 1.9) cm, no significant difference (P = 0.551) was observed. During PFMC, the constriction was 1.8 cm; during the AHT, the constriction was 0.5 cm; and during the AHT + PFMC, it was 2 cm. The LHA assessed by 3-dimensional ultrasound did not significantly change with AHT. These results support the theory that AHT does not strengthen PFM.

Effectiveness of adding voluntary pelvic floor muscle contraction to a Pilates exercise program: an assessor-masked randomized controlled trial

The purpose of this study was to evaluate the effectiveness of adding voluntary pelvic floor muscle contraction (PFMC) to a Pilates exercise program in sedentary nulliparous women. Fifty-seven healthy nulliparous and physically inactive women were randomized to a Pilates exercise program (PEP) with or without PFMC. Forty-eight women concluded this study (24 participants for each group). Each woman was evaluated before and after the PEP, by a physiotherapist and an urogynecologist (UG). Neither of the professionals was revealed to them. This physiotherapist measured their pelvic floor muscle strength by using both a perineometer (Peritron) and vaginal palpation (Oxford Scale). The UG, who performed 3D perineal ultrasound examinations, collected their data and evaluated the results for pubovisceral muscle thickness and the levator hiatus area (LA). Both professionals were blinded to the group allocation. The protocol for both groups consisted of 24 bi-weekly 1-h individual sessions of Pilates exercises, developed by another physiotherapist who specializes in PFM rehabilitation and the Pilates technique. The PEP+ PFMC group showed significantly greater strength improvements than the PEP group when comparing the Oxford scale, vaginal pressure and pubovisceral muscle thickness during contraction measurements at baseline and post-treatment. Our findings suggest that adding a voluntary PFMC to a Pilates exercise program is more effective than Pilates alone in improving PFM strength in sedentary nulliparous women.

Effect of Spinal Manipulation on Pelvic Floor Functional Changes in Pregnant and Nonpregnant Women: A Preliminary Study

ObjectiveThe aim of this study was to investigate whether a single session of spinal manipulation of pregnant women can alter pelvic floor muscle function as measured using ultrasonographic imaging. MethodsIn this preliminary, prospective, comparative study, transperineal ultrasonographic imaging was used to assess pelvic floor anatomy and function in 11 primigravid women in their second trimester recruited via notice boards at obstetric caregivers, pregnancy keep-fit classes, and word of mouth and 15 nulliparous women recruited from a convenience sample of female students at the New Zealand College of Chiropractic. Following bladder voiding, 3-/4-dimensional transperineal ultrasonography was performed on all participants in the supine position. Levator hiatal area measurements at rest, on maximal pelvic floor contraction, and during maximum Valsalva maneuver were collected before and after either spinal manipulation or a control intervention. ResultsLevator hiatal area at rest increased significantly (P < .05) after spinal manipulation in the pregnant women, with no change postmanipulation in the nonpregnant women at rest or in any of the other measured parameters. ConclusionSpinal manipulation of pregnant women in their second trimester increased the levator hiatal area at rest and thus appears to relax the pelvic floor muscles. This did not occur in the nonpregnant control participants, suggesting that it may be pregnancy related.

Assessment of pelvic floor muscle contraction with palpation, perineometry and transperineal ultrasound: a cross-sectional study.

To study the correlation between palpation, perineometry and transperineal ultrasound for assessment of pelvic floor muscle contraction and to define a contraction scale for ultrasound measurements. This was a cross-sectional study of 608 women examined with palpation of pelvic floor muscle contraction, using the Modified Oxford Scale, and measurement of the vaginal squeeze pressure with a vaginal balloon connected to a fiber-optic microtip transducer (perineometry). Transperineal ultrasound was used for measurements of levator hiatal area and anteroposterior (AP) diameter in the plane of minimal hiatal dimensions, at rest and on contraction. The pelvic floor muscle contraction was expressed as the percentage difference between values at rest and on contraction. Spearman's rank was used to test for correlation between the different methods of assessment. Significant correlations were found between all assessment methods (P < 0.001). Palpation correlated with perineometry (rs = 0.74) and with proportional change in hiatal area (rs = 0.67) and AP diameter (rs = 0.69) on ultrasound. Perineometry correlated with proportional change in hiatal area (rs = 0.60) and AP diameter (rs = 0.66) on ultrasound. We defined a contraction scale based on the proportional change in AP diameter. In this population, a change in AP diameter of < 7% corresponded to absence of contractions, 7-18% corresponded to weak contractions, 18-35% corresponded to normal contractions and > 35% corresponded to strong contractions. We found moderate to strong correlation between ultrasound measurements, palpation and perineometry for assessing pelvic floor muscle contraction. The proportional change in levator hiatal AP diameter was the ultrasound measurement with strongest correlation to palpation and perineometry and formed the basis for the contraction scale for ultrasound measurements. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Variability of the pubic arch architecture and its influence on the minimal levator hiatus area

ObjectiveTo investigate the association between the minimal levator hiatus (MLH) area at rest with its surrounding soft-tissue and bony structures in nulliparous asymptomatic women with a normal levator ani muscle. MethodsA subanalysis was undertaken of a prospective study of the appearance of the levator ani in asymptomatic nulliparous women conducted between September 2010 and September 2011. The subanalysis included women with a normal levator ani muscle. Three-dimensional ultrasonography volumes were used to obtain pelvic floor measurements. ResultsThe analysis included 56 women with mean age of 43.0±13.4years. The mean MLH area was 13.1±1.8cm2 (range 9.0–17.3). The pubic arch angle had no influence on the MLH area (Pearson correlation coefficient r=0.13). Height and pubic arch length were positively correlated with the MLH area (r=0.26 [P=0.52] and r=0.50 [P<0.001], respectively). ConclusionThe MLH size of nulliparous women varied widely and was positively correlated with the height and pubic arch length of the women. Therefore, caution is warranted when interpreting the MLH area as an indicator of a levator ani defect or a predictor of pelvic organ prolapse without taking a woman’s pelvic bone characteristics into account.

Anatomical Cystocele Recurrence: Development and Internal Validation of a Prediction Model.

To develop a prediction model that estimates the risk of anatomical cystocele recurrence after surgery. The databases of two multicenter prospective cohort studies were combined, and we performed a retrospective secondary analysis of these data. Women undergoing an anterior colporrhaphy without mesh materials and without previous pelvic organ prolapse (POP) surgery filled in a questionnaire, underwent translabial three-dimensional ultrasonography, and underwent staging of POP preoperatively and postoperatively. We developed a prediction model using multivariable logistic regression and internally validated it using standard bootstrapping techniques. The performance of the prediction model was assessed by computing indices of overall performance, discriminative ability, calibration, and its clinical utility by computing test characteristics. Of 287 included women, 149 (51.9%) had anatomical cystocele recurrence. Factors included in the prediction model were assisted delivery, preoperative cystocele stage, number of compartments involved, major levator ani muscle defects, and levator hiatal area during Valsalva. Potential predictors that were excluded after backward elimination because of high P values were age, body mass index, number of vaginal deliveries, and family history of POP. The shrinkage factor resulting from the bootstrap procedure was 0.91. After correction for optimism, Nagelkerke's R and the Brier score were 0.15 and 0.22, respectively. This indicates satisfactory model fit. The area under the receiver operating characteristic curve of the prediction model was 71.6% (95% confidence interval 65.7-77.5). After correction for optimism, the area under the receiver operating characteristic curve was 69.7%. This prediction model, including history of assisted delivery, preoperative stage, number of compartments, levator defects, and levator hiatus, estimates the risk of anatomical cystocele recurrence.

Differences in the Biometry of the Levator Hiatus at Rest, During Contraction, and During Valsalva Maneuver Between Women with and Without Provoked Vestibulodynia Assessed by Transperineal Ultrasound Imaging

Pelvic floor muscle (PFM) involvement is suspected in the pathophysiology of provoked vestibulodynia (PVD); however, the underlying mechanisms are unclear. PFM morphology can be inferred from the biometry of the levator hiatus determined through dynamic ultrasound imaging. The aim of this study was to determine the nature of PFM involvement in women with PVD via an evaluation of the biometry of the levator hiatus at rest, upon maximal voluntary contraction (MVC) of the PFMs, and upon maximal Valsalva maneuver (MVM). Thirty-eight women with PVD and 39 asymptomatic controls were imaged using 3D transperineal ultrasound. Levator hiatal dimensions (area; left-right [LR] and anteroposterior [AP] diameters) were measured at rest, on MVC, and on MVM. Differences in hiatal dimensions and in relative changes in dimensions from rest to MVC and from rest to MVM were compared between groups using separate 1-way analyses of variance for each measure and task. Analysis of covariance models were used to investigate the impact of levator hiatal dimensions at rest on the relative changes in the levator hiatal dimensions during MVC and MVM. Levator hiatal area, LR, and AP diameters, at rest, on MVC, and on MVM were the main outcome measures. Relative changes in hiatal dimensions were assessed as the percent change in hiatal area, LR diameter, and AP diameter. In comparison with controls, women with PVD had smaller hiatal areas at rest, on MVC, and on MVM, concurrent with smaller LR diameters on MVM. Women with PVD had a significantly smaller change in hiatal area on MVM than controls, but no differences were evident on MVC. In both groups, smaller levator hiatal dimensions at rest were associated with smaller relative decreases in dimensions on MVC and larger relative increases in dimensions on MVM. In comparison to controls, women with PVD appear to have narrower levator hiatus' and less capacity to distend their hiatus on Valsalva. The state of the PFMs at rest appears to significantly influence biometric changes in the PFMs during contraction and Valsalva.

Three-dimensional ultrasound of the female pelvic floor and 3D-power doppler angiography to assess endopelvic vascularization in pregnancy and puerperium

Introduction and hypothesis: We studied ten different three-dimensional ultrasound (3D-US) and three-dimensional Power-Doppler angiography (3D-PDA) variables to assess female pelvic floor status and endopelvic vascularization. We hypothesize that 3D-US is a reliable method to determine and evaluate changes occurring in the pelvic floor during normal pregnancy and puerperium, and can be used by any urogynecology specialist with US-imaging experience. We aimed to validate this method for clinical application. Materials and methods: We performed a prospective study of 162 nulliparous pregnant women evaluated at weeks 12, 28 and 36, and at 48 hours postpartum and three months post-delivery. At each of the five visits, we performed transperineal 3D-US of the pelvic floor and 3D-PDA to assess periurethral vascularization. Results: Quantification of the vaginal anterior vaginal wall anchors (AWA) is an anthropometric parameter sensitive to changes in pregnancy and puerperium. Significant differences in AWA were observed according to delivery mode, being lower in vaginal deliveries than cesarean sections and even lower in prolonged labor deliveries and those in which episiotomy was performed. Posterior uretrovesical angle (UVA) increased during pregnancy, partially recovering after delivery although less so in those with epidural analgesia. Urethral sphincter volume (USV) decreased significantly during labor and postpartum. Periurethral vascularization increased during pregnancy and decreased significantly after delivery. Levator hiatus area (LHA) increased during pregnancy and decreased after delivery. Patients who received epidural analgesia and oxytocin showed better LHA recovery. Prolonged labor and greater fetal head circumference increased LHA. The anorectal angle (ARA) increased during pregnancy and decreased postpartum. Conclusion: All 3D-US variables and their changes during pregnancy, childbirth and the postpartum period are measurable using the Virtual Computer-Aided Analysis (VOCAL method) with automatic threshold, which is more reliable and faster for measuring USV. AWA as an important new biometric parameter should be included in the study of the pelvic floor.

Characteristics associated with pelvic organ prolapse in women with significant levator ani muscle deficiency.

Age is a factor associated with symptomatic pelvic organ prolapse (POP) among women with significant levator ani deficiency. This cross-sectional study included patients who were referred for varied pelvic floor disorders, had 3D endovaginal ultrasound as part of their evaluation, and were diagnosed with significant levator ani muscle deficiency defined as a score of 12 or more on 3D endovaginal ultrasound. Patients were categorized as having no pelvic organ prolapse (stages 0 and 1), or symptomatic prolapse (stages 2-4). Seventy-six women were available for analysis and found to have significant levator ani muscle deficiency, including 51 with symptomatic POP and 25 without POP. Patients with symptomatic POP were older, (mean age 66 (SD ± 11.8) vs 48 (SD ± 17.3) years; p <0.0001), had greater mean minimal levator hiatus (MLH) area (19.7 cm(2) (SD ± 4.6) vs 17.5 cm(2) (SD ± 3.5); p = 0.048), and were more likely to be menopausal (91.3 % vs 54.5 %; p <0.001) compared with those with no POP. In a modified Poisson regression analysis excluding nulliparous women, increasing age (RR = 2.39, 95 % CI 1.03-5.55) and smoking (RR = 1.34, 95 % CI 1.08-1.67) remained associated with symptomatic POP after controlling for one another and the MLH area. Among women with significant levator ani deficiency, older women and smokers had an increased prevalence of symptomatic POP. On average, women without POP, but with significant levator ani deficiency were 18 years younger than women with POP and significant muscle deficiency.