Levator Hiatus Research Articles

The dynamic change of the anteroposterior diameter of the levator hiatus under Valsalva maneuver at term and labor outcome.

The aim of the present study was to evaluate the correlation between the proportional change of anteroposterior diameter (APD) of levator hiatus from rest to maximum Valsalva maneuver in nulliparous women at term and labor outcome. We prospectively recruited nulliparous women at term before the onset of labor. Women underwent a two-dimensional transperineal ultrasound, measuring the APD of the levator hiatus at rest and under maximum Valsalva's maneuver. APD change from rest to maximum Valsalva was described both in terms of absolute figures and proportional change. Correlation of APD change with the mode of delivery and with labor durations was assessed. Overall, 486 women were included in the analysis. No significant association between change in APD and the mode of delivery. We found a significant negative correlation between change of APD from rest to Valsalva and the duration of active second stage both in terms of absolute change (Pearson's r = -0.138, P = .009) and in terms of proportional change (Pearson's r = -0.154, P = .004). Survival outcomes based on Cox-regression model showed that APD was independently associated with the duration of active second stage of labor after adjusting for epidural analgesia, maternal age and body mass index (hazard ratio, 1.008; 95% confidence interval, 1.001-1.016; P = .04) CONCLUSION: Women with higher increase of the anteroposterior diameter of the levator hiatus from rest to Valsalva have a shorter active second stage of labor.

The use of 3D ultrasound in comparing surgical techniques for posterior wall prolapse repair: a pilot randomised controlled trial

The most appropriate method for repairing posterior vaginal wall prolapse is still debatable. Women with symptomatic prolapse scheduled to undergo surgical repair in the posterior compartment were randomised to standard posterior colporrhaphy (SPC) or fascial and vaginal epithelial plication (FEP). Participants were assessed with the Prolapse Quality of Life (P-QOL) questionnaire, pelvic organ prolapse quantification (POP-Q) examination and three-dimensional ultrasound (3D US) prior to surgery and 6 months postoperatively. The research hypothesis is that 3D US of the pelvic floor is a reliable tool in comparing the anatomical outcomes of the two different surgical techniques. Differences in anatomical outcomes, assessed clinically and by ultrasonographic evaluation, were compared between the two groups using the Independent Mann–Whitney U-test and the Wilcoxon signed-rank sum test. Twenty-two women were included in the analysis. Six months postoperatively, women in the FEP arm had better anatomical outcomes compared to those who had undergone SPC (p = .02). Repeatability of the ultrasound technique was confirmed, showing moderate to very good agreement in all parameters and the 3D US evaluation was corroborated with the clinical examination, showing a greater reduction in the urogenital size in the FEP group. Impact statement What is already known on this subject? The low cost and universal availability of the ultrasound (US) makes it the most commonly used diagnostic modality. The ability to see beyond surface anatomy is important and useful in the assessment of the posterior vaginal wall prolapse and the obstructed defaecation, where this method may replace the defaecation proctography (Dietz 2019). Recent advances in pelvic floor ultrasonography (3D US) have achieved repeatability in the measurement of the levator hiatal (LH) dimensions, introducing a valid and readily available tool for researchers and clinicians (Dietz et al. 2005). Ultrasound may distinguish a true rectocele due to the weakening of the rectovaginal fascia from an enterocele, a rectal intussusception, or just a deficient perineum (Guzman Rojas et al. 2016). What do the results of this study add? Our study demonstrates that 3D translabial pelvic floor ultrasound is a useful and reliable tool in assessing the anatomical outcome of prolapse surgery. What are the implications of these findings for clinical practice and/or further research? Our study demonstrates that 3D translabial ultrasound of the pelvic floor is a useful and reproducible method in evaluating the anatomical outcomes of surgical repair for posterior wall prolapse. Genital hiatus (GH) and levator hiatus (LH) dimensions measured by ultrasound can be used as surrogate anatomical markers in comparing the efficacy of different surgical techniques.

Type of levator ani muscle avulsion as predictor for the disappearance of avulsion.

The objective of our study was to establish whether the type of levator ani muscle (LAM) avulsion diagnosed 6 months after delivery influences the integrity of the LAM at 1 year after delivery and determine its influence on the levator hiatus area. This observational prospective cohort study included 192 primiparous women with vaginal delivery. Transperineal ultrasound examinations were performed at 6 months and 1 year postpartum. Levator hiatus measurements (anteroposterior diameter, transverse diameter, and area) were performed in the plane of minimal dimensions. Complete avulsion was defined based on maximum contraction in multislice mode. Type I LAM avulsion was present when most lateral fibers of the pubovisceral muscle were observed at its insertion at the pubic level (the arch of the elevator remained intact). Type II LAM avulsion was defined as a complete detachment of the pubovisceral muscle from its insertion at the pubic level. In total, 192 patients were recruited after delivery; 48 patients were diagnosed with complete LAM avulsion, and 13 patients with avulsion did not attend the second ultrasound follow-up at 1 year after delivery. Thirty-five patients with complete LAM avulsion were included in the study. At 6 months after delivery, 51 LAM avulsions were observed in 35 patients (including bilateral LAM avulsion in 16 cases), of which 54.9% were right avulsions and 45.1% left avulsions. Furthermore, 11 (five right and six left) were type I LAM avulsions at the 6-month assessment, and all of these had disappeared 1 year after delivery. However, none of the type II LAM avulsions (23 right and 17 left) observed at 6 months had disappeared at the second ultrasound examination. There were no differences between the LAM areas detected at the first and second ultrasound examinations (10.2 ± 3.3 vs 9.3 ± 1.8; P = .404). The type of LAM avulsion observed at 6 months after childbirth predicts LAM persistence at 1 year postpartum.

Factors involved in prolapse recurrence one year after anterior vaginal repair.

The aim of this study was to identify which factors are associated with anatomic and symptomatic prolapse recurrence in the anterior compartment 1 year after traditional anterior vaginal repair. Our study hypothesis was that major defects in pelvic floor support structures before surgery are associated with higher recurrence rates. This was a prospective multicenter study including women with symptomatic anterior compartment prolapse who underwent primary vaginal surgery. Prolapse examination was performed using the Pelvic Organ Prolapse Quantification (POP-Q) system, prolapse symptoms were described using the Pelvic Floor Distress Inventory short form (PFDI-20), and levator ani avulsion and hiatal area were identified by translabial 3D ultrasonography. During the inclusion period, 455 patients were recruited and 442 (97.1%) attended the 1-year follow-up. In three cases, ultrasound data were not available, and the remaining 439 formed the study group. Anatomic and symptomatic recurrence rates were 45.1% and 6.8%, respectively. Levator avulsion increased the risk of anatomic (OR: 1.96) and symptomatic (OR: 2.60) recurrence; abnormal distensibility of the levator hiatal area increased the risk of anatomic (OR: 2.51) and symptomatic (OR: 2.43) recurrence; advanced prolapse increased the risk of anatomic recurrence: POP-Q stage 3 (OR: 2.34) and POP-Q stage 4 (OR: 5.47). Major defects in pelvic floor support structures before surgery are associated with higher recurrence rates 1 year after native tissue vaginal repair. Advanced stage of prolapse increases the risk of anatomic recurrence, while levator avulsion and abnormal distensibility of the levator hiatus area increase the risk of both anatomic and symptomatic recurrence.

Pelvic floor morphology in the standing position using upright computed tomography: age and sex differences.

This study was aimed at comparing pelvic floor parameters between the standing and supine positions using upright computed tomography (CT) and evaluating the effects of sex and age in normal healthy volunteers. In total, 139 volunteers (70 men, mean 46.7years; 69 women, mean 47.3years) underwent both upright CT in the standing position and conventional CT in the supine position. The distances from the bladder neck to the pubococcygeal line (PCL) and anorectal junction (ARJ), defined as the posterior aspect of the puborectalis muscle, to PCL were measured. The length, width, and area of the levator hiatus (LH) were measured on oblique axial images. The bladder neck (men, 22.2 ± 4.9mm vs 28.3 ± 5.3mm; women, 9.0 ± 5.1mm vs 19.0 ± 4.0mm) and ARJ (men, -18.8 ± 5.5mm vs -12.1 ± 5.1mm; women, -20.0 ± 4.7mm vs -11.2 ± 4.3mm) were significantly lower in the standing position than in the supine position (all p < 0.0001). The LH area (men, 1,990 ± 380mm2 vs 1,697 ± 329mm2; women, 2,284 ± 344mm2 vs 1,811 ± 261mm2) was significantly larger in the standing position (both p < 0.0001). Differences in all parameters between the standing and supine positions were larger in women than in men. ARJ in women showed a significant tendency to descend with age only in the standing position (r = -0.29, p = 0.017). The bladder neck and ARJ descend and the LH area enlarges in the standing position. Pelvic floor mobility is greater in women than in men. Descent of the ARJ in the standing position is associated with aging in women.

Does size matter? Perineometer and digital examination of a model levator hiatus.

Evaluation of the female pelvic floor muscles is commonly carried out with digital examination and assigning a modified Oxford scale score or vaginal manometry. Racial differences can influence the size of the levator hiatus (LH) with "black" or African nulliparous women having a significantly larger LH compared to Caucasian women. The aim of this study was to assess the impact of LH size on manometry readings of simulated pelvic floor muscle contractions (PFMCs) using a small and large model LH. Small and large LH models were created using published data for size. Inflation of a pressure cuff placed circumferentially in the LH model represented a simulated PFMC. The models were examined in a supine position by three examiners and a perineometer twice each at varying simulated PFMC strength. Positive correlation was found between increasing simulated PFMC strength with a higher Oxford score following digital examination and manometry readings for both the small (rs = .87, rs = .98) and large (rs = .95, rs = .87) models. There was good to excellent inter and intraobserver correlation for digital assessment of both models. The manometry measurements showed a much larger incremental rise from baseline in the small model compared with the large model (P < .05). This study demonstrates that perineometer readings are affected by natural variations in LH size and PFMC strength. Therefore improvement to pelvic floor strength cannot be interpreted and measurements cannot be compared with others unless the LH size is known or digital examination is carried out.

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

(Abstracted from Female Pelvic Med Reconstr Surg 2020;26:61–66) Previous research has demonstrated that postpartum pelvic floor exercises can lead to an increase in strength of the pelvic floor muscles (PFMs) and a reduction in pelvic floor disorders. However, as many as 23% of patients perform these exercises incorrectly, which may be due to barriers from patient awareness, education, disagreement about techniques, and compliance.

58: Mind the gap – Changes in levator dimensions following sacrocolpopexy

Prior studies demonstrated that genital hiatus (GH) decreases following surgical correction of the vaginal apex. We hypothesized that the underlying levator hiatus (LH) and levator area (LA) would decrease following apical suspension in women with preoperative prolapse (POP) beyond the hymen. Our objective was to compare LH and LA on transvaginal 3D ultrasound (US) and the GH, as measured by POP-Q exam, before surgery and at 14 weeks following sacrocolpopexy without posterior repair or perineorrhaphy. This was a prospective cohort study of women undergoing minimally-invasive sacrocolpopexy +/- hysterectomy without posterior repair or perineorrhaphy for stage II or greater POP beyond the hymen. At baseline and 14-weeks after surgery, patients underwent POPQ exam and US performed at rest. US was performed using multi-frequency 360° rotational probe with a 3D automatic acquisition system (Type 20R3 BK Medical, Herlev, Denmark). Data from each study were de-identified and analyzed by two urogynecologists, blinded to image sequence. The LH was measured from the junction of the superior pubic rami to the posterior margin of the external anal sphincter in the axial plane with urethra, puborectalis muscle, and anal canal visible simultaneously. Based on prior studies of POPQ GH change, we calculated that 32 women were needed to find a 1cm change in GH with 80% power and an alpha of 0.05. Measurements and scores were compared in SPSS Version 25 using paired t-tests for continuous variables. Correlations of non-parametric data are reported as Spearman’s rho. 43 patients were enrolled in the study; 35 completed all preoperative and postoperative ultrasounds and are included in the analysis. Patients had a mean age ± SD of 55 ± 11. Most were white (89%), parous (94%), postmenopausal (66%), sexually active (63%) and had stage III POP (86%). The majority (89%) had concomitant total hysterectomy, and 60% had a midurethral sling. At baseline, mean PFDI scores were 98±50 and mean POPDI subscale scores were 42±22. Median (IQR) POP stage decreased after surgery from 3 (3-3) to 0 (0-1) (p<0.001) and mean PFDI scores decreased to 55±42 (p=0.002). At baseline, mean GH was 3.5 ± 0.7cm and mean perineal body (PB) was 2.4 ± 0.6. While the GH decreased by 0.5cm following surgery, PB was unchanged (Table 1). LH increased by 1mm at 14 weeks postoperatively while LA remained unchanged (Table 1). At 14 weeks, the change in LH was not correlated with the change in GH (ρ= -0.2, p=0.2) or POP stage (ρ= -0.2, p=0.9) as measured on POPQ exam. Repositioning the apex with sacrocolpopexy significantly reduces GH size on clinical exam; however, restoration of the apex does not impact the size of the underlying levator hiatus or levator area suggesting that size of the levator gap does not impact sacrocolpopexy outcomes.

70: Dynamic magnetic resonance imaging of pelvic anatomy following vaginal reconstructive surgery: A prospective study

To describe the impact of native tissue vaginal reconstruction, including vaginal vault suspension, on pelvic anatomy using dynamic magnetic resonance imaging (MRI). This IRB approved prospective cohort study investigated women undergoing intraperitoneal vaginal vault suspension for symptomatic pelvic organ prolapse (POP) with native tissue reconstruction. Enrolled participants underwent dynamic pelvic MRI preoperatively and 3 months postoperatively. Radiographic and anatomic measurements were compared. The H-line (or levator hiatus) was defined as the distance from the pubic symphysis to the posterior anal canal and the M-line (or muscular pelvic floor relaxation) was defined as the decent of the levator plate from the pubococcygeal line (PCL). The PCL represented the level of the pelvic floor and was measured from the inferior border of the pubic symphysis to the last coccygeal joint. Our primary outcome was to compare preoperative MRI measurements to those following surgical treatment. Secondary outcomes were evaluated via validated patient questionnaires pre- and post-operatively. A total of 17 participants were enrolled, 14 completed the study and were included in our analysis. The mean age was 62 years; all participants were white. The majority of participants had Stage III POP, as defined by the Pelvic Organ Prolapse Quantification (POP-Q) scale. Twelve participants (85.7%) underwent a concomitant hysterectomy and 5 participants (35.7%) received a concomitant midurethral sling procedure. There was a significant improvement in several radiographic measurements with straining and/or defecation following vaginal reconstruction, including the H-line, M-line, anorectal angle, and the extent of apical and anterior compartment prolapse. There was no difference regarding pubococcygeal line (PCL), anorectal decent, extent of enterocele, or posterior compartment prolapse. POP-Q measurements improved significantly in all compartments with the exception of perineal body and total vaginal length. Regarding validated questionnaires, PFDI-20 scores improved significantly (102 preop vs. 30 postop, p<0.001) following surgery. While PFIQ-7 scores also improved, this finding did not achieve significance (55 preop vs 24 postop, p=0.164). Native tissue reconstruction with intraperitoneal vaginal vault suspension for symptomatic pelvic organ prolapse not only improves pelvic anatomy and function as defined by POP-Q measurements and PFDI scores, but is also associated with significantly improved measurements on dynamic MRI at 3 months postoperatively.

Quantifying Levator Ani Muscle Elasticity Under Normal and Prolapse Conditions by Shear Wave Elastography: A Preliminary Study.

The primary purpose of this study was to determine whether elasticity quantification of the levator ani muscle (LAM) using shear wave elastography (SWE) is different between women with and without pelvic organ prolapse (POP) and to determine whether LAM elasticity is associated with the prolapse stage or the dimensions of the levator hiatus. The secondary aim was to evaluate the intraobserver and interobserver reliability of LAM elasticity measurements using SWE. The study participants included 20 women with normal pelvic support and 38 women with prolapse (stages I-III). The levator hiatus was imaged by transperineal 3-dimensional ultrasound, and LAM elasticity and the elastic modulus were measured by SWE at rest and while performing the Valsalva maneuver. The elastic modulus increased significantly from rest to during to maximal Valsalva maneuver (29.2 versus 54.1 kPa; P < .05) in all women. Levator ani muscle elasticity was significantly higher under prolapse conditions than under normal conditions at rest (27.9 versus 31 kPa; P < .001) but was lower during the maximal Valsalva maneuver than under normal conditions (57.3 versus 53.1 kPa; P < .05). Levator ani muscle elasticity at rest was associated with the hiatus area during the Valsalva maneuver (Spearman r = 0.608; P < .001) and distensibility of the levator hiatus (r = 0.594; P < .001), and the hiatus area decreased as the LAM elastic modulus increased during the maximal Valsalva maneuver (r = -0.414; P < .05). Moreover, LAM elasticity was associated with the severity of prolapse (P < .001). As a noninvasive quantitative method, SWE, may be used to assess the biomechanical properties of the pelvic floor muscle, providing some research basis for a thorough understanding of POP and its treatment and prevention.

The importance of using 3D ultrasound during pelvic organ prolapse surgery in relation to pre- and post-operative quality of life questionnaires

AimThe main aim of this study is to evaluate the interest of three-dimensional ultrasound perineal in the measurement of the levator hiatus area as an objective reflection of the surgical correction of pelvic organ prolapse (POP). Our hypothesis is that POP surgery decreases the size of the levator hiatus area. Materials and methodsA longitudinal and prospective study was conducted between April and July 2017 in the Department of Gynaecology & Obstetrics at University Hospital of Angers. Surgery was performed either by laparoscopy (sacrocolpopexy) or vaginal surgery (with or without the use of mesh). All patients were handed an information letter and signed an informed consent before being included in the study. A questionnaire was fullfilled before and one month after surgery. A clinical evaluation using the simplified POP-Q classification and a perineal 3D ultrasound were carried out before and after surgery by the same professional. The levator hiatus area was assessed before and after surgery in order to evaluate the impact of surgery on the levator hiatus area. Simplified POP-Q measurements and responses to PFDI-20 and PFDI-7 questionnaires were also collected. ResultsA total of 18 patients were included in the study and four were excluded. Seven underwent laparoscopic surgery and seven underwent vaginal surgery. The levator hiatus area decreased substantially from 20.87 to 16.55cm2 on mean (p=0.0001) at rest. Regarding patient satisfaction, the PFDI-20 score improved after surgery from 89.36 to 37.87 on mean (p=0.006), but the PFIQ-7 score did not reveal any significant changes (p=0.096). For the clinical examination, we used the simplified POP-Q with Ba measurement from 2.3 to -1.92cm (p=0.005) or Bp from -1.5 to -2.46cm, which is not a significant change (p=0.14). Points C (or D in cases with a history of hysterectomy) changed from -3.1 to -6.15cm (p=0.03). ConclusionThe levator hiatus area seems to decrease after POP surgery. 3D ultrasound seems a new and complementary procedure that allowed to evaluate objectively the levator hiatus area and thus the clinical findings of the surgery.

Эффективность физиотерапии в лечении недостаточности мышц тазового дна у женщин репродуктивного возраста

Study Objective: To compare the efficacy of two physical therapy techniques in the treatment of pelvic floor distress (PFD). Study Design: This was a prospective, randomized, double-blind, controlled study. Materials and Methods: Health information about ninety-five women who had had vaginal delivery and suffered from PFD was reviewed in the study. In Group I (n = 50) patients were treated using high-intensity focused electromagnetic (HIFEM) technology, and in Group II (n = 45) electrical stimulation therapy was delivered via an intracavity sensor. Assessments in the study included physical examination, instrumental investigations, and a discussion with patients (completion of a questionnaire and a scale-based assessment). To establish reference values for the parameters used in the study, a control group was made up of 30 apparently healthy women who had had a vaginal delivery. Study Results: Ultrasound of the pelvic floor showed that in Groups I and II the anteroposterior diameter of the levator hiatus (LH) decreased by 3.12 mm and 1.16 mm, respectively (2.7-fold difference), and the transverse diameter of the LH decreased by 3.04 mm and 1.04 mm (2.9-fold difference). The area of the LH decreased by 1.38 cm2 in Group I and 0.08 cm2 in Group II. After treatment the mean Pelvic Floor Distress Inventory (PFDI-20) score was 1.9 times lower (p&lt;0.001) in Group I and the number of women who reported a feeling of looseness in the vagina and urinary incontinence using a bimodal scale for complaint assessment was 1.5 and 1.9 times lower, respectively, than in Group II. Conclusion: Electromagnetic stimulation demonstrated higher efficacy than stimulation via an intracavitary sensor in the treatment of PFD. Keywords: pelvic floor distress, genital prolapse, high-intensity focused electromagnetic stimulation.

Role of three-dimensional ultrasound in females with obstructed defecation (in comparison with defecography)

BackgroundGrowing attention of pelvic floor disorders has led to development of new imaging techniques, with increasing importance of ultrasonography. The 3DUS technique is considered an accessible tool for imaging of the posterior pelvic compartment. The purpose of this study is to highlight the role of 3D ultrasound in evaluation of obstructed defecation in females and comparing the findings with defecography.ResultsStudy included 30 females classified into two groups: (1) 20 patients (case group complaining of obstructed defecation); (2) ten females (control group-normal nulliparous females). All of them were subjected to defecography and 3D ultrasound during resting, squeezing, and straining. Detection rate of rectocele and intussusception with 3D ultrasound was lower than defecography. By US, significant statistical difference between patients and controls in all measurements of levator hiatus, IS, ES, and PRS thickness during straining (P value < 0.001). During straining, cut-off value of 20.75 cm2 for hiatal area gives sensitivity of 100% and specificity of 95% and using ARA, cut-off value of 105° gives sensitivity of 98% and specificity of 90% for differentiation between patients and controls.ConclusionUltrasound can be considered a complementary test to defecography in investigation of patients with obstructed defecation. Ultrasound can diagnose levator muscle attenuation and avulsion, thickness of IS, ES, PRS, and distensibility of hiatal area.

Are there differences in the damage to the pelvic floor between malmstrom's and kiwi omnicup vacuums? A multicenter study.

The objective of this study is to investigate a multicenter study to establish if differences exist in the levator ani muscle avulsion (LAM) rates between deliveries performed with Malmstrom's vacuum and the Kiwi vacuum. A prospective, multicenter observational study with 199 primiparous subjects was performed. All patients had undergone vaginal delivery by vacuum (Malmstrom's or Kiwi). Avulsion was defined as an abnormal insertion of LAM in the lower pubic branch in the multiplanar mode, as identified in the three central sections by transperineal 3/4D echography 6 months after delivery. The area of ​​the levator hiatus was measured in the plane of minimum dimensions at rest, during the Valsalva maneuver and during contraction. LAM avulsion occurred in 33.1% of cases in which Malmstrom's vacuum was used and in 29.4% of cases in which the Kiwi vacuum was used (the difference was not statistically significant), which resulted in a crude odds ratio (OR) of 0.977 (0.426, 2.241; P = .957) and an adjusted OR of 2.90 (0.691; 12.20; P = .146). Women in the Malmstrom's vacuum group had a larger LHA at rest 14.77 vs 12.64 cm2 ; P = .001) and at maximum contraction (13.41 vs 10.83 cm2 ; P < 0.001) in comparison with the Kiwi group, although the difference did not reach statistical significance under Valsalva maneuver (18.71 vs 17.21 cm2 ; P = .051).Differences between both groups were detected in the measurements of the hiatus area levator at rest (14.77 vs 12.64 cm2 ), during the Valsalva maneuver (18.71 vs 17.21 cm2 ) and during maximum contraction (13.41 vs 10.83 cm2 ). In the present study, Malmstrom's vacuum was not associated with a higher risk of LAM in comparison with Kiwi's Omnicup.

Pelvic Organ Prolapse as a Function of Levator Ani Avulsion, Hiatus Size, and Strength

(Abstracted from Am J Obstet Gynecol 2019;221:41.e1–41.e7) Vaginal childbirth significantly increases the likelihood that a parous woman will develop pelvic organ prolapse (POP). Reasons for the association between vaginal childbirth and POP are unclear, but one postulated mechanism is injury to the obstetrical injury to the levator ani muscles.

480 High Resolution Transrectal Ultrasound Findings Predict Manometric Responders to Biofeedback Therapy for Anal Incontinence

INTRODUCTION: In the United States, over 8% of adults are affected by anal incontinence (AI), and a large percentage of these patients have a history of damage to their pelvic floor. High resolution three-dimensional transrectal ultrasound (TRUS) can be used to assess for microstructural damage to the pelvic floor muscles. Biofeedback (BFB) therapy is a key intervention for AI in addition to anti-diarrheal medications or fiber supplements but it relies on strengthening and improving coordination of existing pelvic floor structures. TRUS is a promising tool to predict meaningful improvement with BFB. METHODS: This is a retrospective analysis of patients enrolled in BFB for AI between 2015 and 2018 at a tertiary referral motility program. Survey and high resolution anorectal manometry (HR-ARM) data were collected at baseline and during each AI BFB visit. Of the 36 patients who met criteria, 9 had TRUS as part of their care. TRUS images were obtained using a high frequency (7-15MHz) ultrasound probe. Fisher's exact test and t-test were used for statistical analysis. Improvement in maximum squeeze pressure on HR-ARM was defined as increase by greater than 30% or ≥29 mmHg from baseline to final session. RESULTS: Patients were on average 62 years old (SD 10 years), one was male, and the mean BMI was 28.0 (SD 6.7). Five of the 8 women had a suspected obstetric etiology to their AI, while two patients attributed symptoms to surgery, one to radiation therapy, and one to neurologic injury. TRUS revealed microstructural defects in the external anal sphincter (66.7%), internal anal sphincter (77.8%), puborectalis muscle (55.6%), and perineal body (66.7%) as shown in Table 1 Three patients had damage to all 4 structures and this was significantly associated with lack of improvement in squeeze on ARM (P = 0.047). Absence of an external anal sphincter defect trended towards correlation with improvement in squeeze (P = 0.07). Baseline levator hiatus abnormalities did not predict lack of improvement in manometric characteristics (P = 0.17). CONCLUSION: TRUS is an emerging tool to identify microdamage to structures of the pelvic floor including internal and external anal sphincter complexes and other key support structures. As BFB for patient with AI aims to retrain muscle coordination, absence of multiple deficits identified on TRUS may predict positive responders to BFB therapy.

Aging effects on pelvic floor support: a pilot study comparing young versus older nulliparous women.

We sought to determine age-related changes to the pelvic floor in the absence of childbirth effects. A case-control study was conducted from June 2017 to August 2018 comparing two groups of nulliparous women: <40years old and ≥ 70years old. Clinical evaluation included POP-Q, instrumented speculum testing, and handgrip strength. Dynamic 3D-stress MRI was performed on all women to obtain genital and levator hiatus (LH) lengths, LH area, and levator bowl volume. LH shape was quantified using a novel measure called the "V-U index." Pubovisceral muscle (PVM) cross-sectional area (CSA) was also measured. Bivariate comparisons between the two groups were made for all variables. Effect sizes were calculated for MRI measurements. Twelve young and 9 older nulliparous women were included. Levator bowl volume at rest was 83% larger in older women (108.0 ± 34.5cm3 vs 59.2 ± 19.3cm3, p = 0.001, d = 1.82). MRI genital hiatus at rest was larger among the older group (2.7 ± 0.6cm vs 3.5 ± 0.6cm, p = 0.007, d = 1.34). V-U index, a measure of LH shape where 0 = "V" and 1 = "U," differed between groups indicating a more "U"-like shape among older women (0.71 ± 0.23 vs 0.35 ± 0.18, p = 0.001, d = 1.72). Handgrip strength was lower in the older vs young group (23.2 ± 5.2N vs 33.4 ± 5.2N, p < 0.0001); however, the Kegel augmentation force and PVM CSA were similar (3.2 ± 1.1N vs 3.3 ± 2.2N, p = 0.89, and 0.8 ± 0.3cm2 vs 0.7 ± 0.2cm2, p = 0.23 respectively). Levator bowl volume at rest was over 80% larger among older women, reflecting a generalized posterior distension with age.

A pilot study on surgical reduction of the levator hiatus-the puborectalis sling.

Female pelvic organ prolapse recurrence has been shown to be associated with levator hiatal distensibility. Reducing hiatal size surgically may reduce recurrence risk. This study aims to demonstrate a novel surgical procedure, the puborectalis sling (PR sling), designed to reduce the levator hiatal area, and to assess the medium-term safety and efficacy of this procedure. One hundred fifteen women undergoing prolapse repair with a pre-operative hiatal area on Valsalva of ≥ 35cm2 were recruited into this phase 1 prospective multicentre pilot study. All underwent a PR sling procedure after completion of standard repairs. Primary outcome was levator hiatal area measured on ultrasound. One hundred ten patients were evaluated at least 3months post-operatively. At 2.5yearsaverage follow-up, there was an average of 12cm2 (range 6-16cm2) reduction in hiatal area from a mean pre-operative hiatal area of 43.9 (35-63) cm2. Thirty per cent (28/93) were symptomatic of prolapse, 66% (61/93) had clinical prolapse recurrence whilst 49% (46/93) had sonographic recurrence. Three patients required a return to theatre; one case of infection resulted in mesh removal, one had severeobstructed defecation requiring sling loosening and another had buttock pain with faecal impaction that resolved after manual disimpaction. There were no long-term sequelae. The levator hiatal area can be reduced surgically, with almost 30% reduction in area seen in this pilot study. The reduction was significant and sustained up to 2years with no major long-term complications.

Application of ultrasound in diagnosis of uterine prolapse by measuring area of levator hiatus

Objective: To investigate the value of the area of levator hiatusin diagnosis of uterine prolapse. Methods: From September 2017 to December 2018, 80 patients diagnosed with uterine prolapse by Department of Gynecology, Xiangya Hospital of Central South University were selected as the case group, and 80 cases of normal women in the same period were selected as the control group. All subjects in both groups were examined by transperineal three-dimensional ultrasound. The anteroposterior and transverse diameters and the area of levator hiatus were measured at rest and during maximum Valsalva maneuver respectively. The ROC curve was drawn to determine the cut-off value of area of levator hiatus in diagnosis of uterine prolapse and to evaluate its diagnostic value. Results: At rest and during maximum Valsalva maneuver, the anteroposterior and transverse diameters and the area of levator hiatus in study group were larger than those in control group, the difference was statistically significant (P<0.05). During maximum Valsalva maneuver, the above values in both groups were greater than those of the same group at rest state, but there was no significant difference between the two groups (P>0.05). During maximum Valsalva maneuver, the best cut-off value of area of levator hiatus for the diagnosis of uterine prolapse was 22.09 cm(2), the area under curve was 0.893. The sensitivity, specificity and accuracy were 90.0%, 95.0% and 92.5%, respectively. Conclusion: Transperineal three-dimensional ultrasound can evaluate the morphological changes of levator hiatus in patients with uterine prolapse, and the area of levator hiatus has high diagnostic value for uterine prolapse.

Levator bowl volume during straining and its relationship to other levator measures.

This study was aimed at measuring levator ani bowl volume at rest and while straining, comparing women with and without prolapse (controls), and assessing the ability of measures of the mid-sagittal bowl area, levator hiatus (LH), and urogenital hiatus (UGH) to predict bowl volume. Forty MRI scans previously acquired in case-control prolapse studies, including 20 women with prolapse and 20 women without prolapse, of similar age and parity, were selected. 3D models of rest and strain bowl volumes were made using sagittal scans and 3D Slicer®. Mid-sagittal bowl area, UGH, and LH were measured using ImageJ. Data were analyzed using two sample t tests, effect sizes, and Pearson's correlation coefficients at the 0.05 significance level. Data were acquired in a total of 40 total women. Levator bowl volume at strain had a correlation coefficient of 0.5 with bowl volume at rest. During straining, prolapse subjects had a 53% larger bowl volume than control subjects (254 ± 86cm3 vs 166 ± 44cm3, p < 0.001), but at rest, the difference was 34% (138 ± 40cm3 vs 103 ± 25cm3, p = 0.002). Effect sizes for all parameters were large (d > 0.75). The strongest correlation with straining bowl volume was mid-sagittal straining bowl area (r = 0.86), followed by LH strain (r = 0.80), then UGH strain (r = 0.76). Straining levator bowl volume is substantially different than measures made at rest, with only a quarter of straining values explained by resting measurements. The bowl area at strain is the best 2D measurement estimating bowl volume and explains 74% of straining bowl volume.