Normal Pelvic Floor Research Articles

Inter-rater and Intra-rater Reliability of Het’s MMT in Pelvic Floor Assessment

Abstract Objective: Pelvic floor dysfunctions (pfds) such as urinary incontinence, pelvic organ prolapse, and vaginismus are very common and are affecting the quality of life of the female suffering through it. The pelvic floor muscles can be in spasm, thus resulting in the inability to relax or the pelvic floor muscles can be extremely weak or loose, resulting in the inability to contract strongly and completely. The spasmodic pelvic floor can result in vaginismus, dyspareunia, chronic pelvic pain, constipation, etc., Moreover, a weak pelvic floor can lead to issues such as urinary incontinence, pelvic organ prolapse, and sexual dysfunction. There is a scarcity of a valid and reliable scale that assesses both the components of pfd. Subjects and Methods: The present study was conducted on 1349 participants which were divided into three groups on the basis of their symptoms. Group A – No symptoms (n = 439), Group B – Hypotonus pfd (n = 658), and Group C – Hypertonus pfd (n = 252). Examination: Vaginal examination to assess the pelvic floor muscles relaxation and contraction was done by Het’s Manual Muscle Testing (MMT). Inter rater reliability was assessed by comparing the data of two independent examiners on the same day. The intra rater reliability was assessed by comparing the data of test and retest at an interval of 1 week. Results: The intra rater reliability at 95% confidence interval (CI) was 0.92 – Normal pelvic floor function, 0.96 – Hypotonus pfd, and 0.97 – Hypertonus pfd. Moreover, inter rater reliability at 95% CI was 0.93 – normal pelvic floor function, 0.95 for hypotonus pfd, and 0.98 – hypertonus pfd. Conclusions: This study concludes Het’s MMT is a highly reliable manual muscle testing tool to assess the pelvic floor muscles.

Screening for Incidence and Effect of Pelvic Floor Dysfunction in College-Aged Athletes.

Pelvic floor dysfunction (PFD) occurs when muscles of the pelvic floor become weakened, impaired, or experience tension leading to a variety of complications. Due to the reactive nature and high demands of many sports, athletes are at increased susceptibility and of particular interest concerning PFD. The purpose of this study was to explore the prevalence of PFD among college-aged athletes, assess how PFD impacted athletic performance, and identify contributing factors for increased likelihood of PFD in athletes. Cross-Sectional Study. All fully active LVC NCAA Division 3 athletes were recruited for screening for PFD using the Cozean Pelvic Dysfunction Screening Protocol and were surveyed on their self-knowledge of PFD. Athletes who scored ≥ 3 on this tool completed an additional survey, created by the investigators, to identify the impact PFD had on their athletic performance and personal life and were then randomly assigned to one of three investigators to undergo a noninvasive coccygeal assessment to determine underactive, overactive, or normal pelvic floor muscle (PFM) activity. Fifty-three Division III male and female athletes between the ages of 18-25 years old participated in the study. Statistically significant differences were found between Cozean scores and demographic factors of age (p \<0.001), gender (p \<0.05), self-knowledge of PFD (p \<0.001), and sport (p \<0.001) among all participants that contributed to the increased likelihood of PFD. Thirteen athletes scored ≥ 3 on the Cozean with the 92.3% experiencing under/over active PFM activity and the majority indicating that PFD significantly impacted their athletic performance and quality of life. The results indicate that older female NCAA Division III college athletes who participate in swimming and who possess self-knowledge of PFD are more likely to experience PFD. Additionally, these athletes are likely to encounter a significant impact on their athletic performance and quality of life. These results provide preliminary evidence on the need of PFD awareness and assessment among college athletes. Level 3b.

(135) DYSORGASMIA IN A FEMALE PATIENT FOLLOWING TRAM RECONSTRUCTIVE SURGERY

Abstract Introduction Many women struggle with sexual dysfunction, either in desire, arousal, orgasm, and/or pain. Despite the incidence of dysorgasmia in the general population, there is a paucity of literature focusing on its causes and treatment, especially when attributed to medical conditions and surgery. Objective This case report describes an unusual presentation of post-orgasmic pain following breast reconstruction surgery using abdominal tissue. Methods A 73-year old woman presented with chronic orgasmic pain in the deep pelvic area following transverse rectus abdominal muscle (TRAM) flap reconstruction for a mastectomy in the setting of breast cancer treatment. The patient was diagnosed with ductal carcinoma breast cancer in 2011, where she received a lumpectomy with radiation. After 2 years, in 2013, she was diagnosed with a recurrence of breast cancer. She underwent a mastectomy with no complications, with a transverse rectus abdominal muscle flap reconstruction surgery conducted five days later. Following the TRAM reconstruction, the patient consistently began to observe pain with orgasm. Results Prior to this surgery, the patient had experienced normal sexual intercourse and orgasm throughout her life. The patient describes pain with orgasm associated with self-stimulation, manual stimulation, oral stimulation, and vaginal penetration. The patient describes the pain associated with orgasm as a “deep, dull pain” causing nausea and is often associated with abdominal spasms. The pain lasts 2-3 minutes following orgasm and is rated as a 5-6/10 on the pain scale. The pain is not associated with urinary incontinence, urinary fullness, or bowel dysfunction. Physical exam revealed a tense abdominal wall consistent with TRAM reconstruction, well healed incisions, a normal clitoris in terms of appearance and sensation and normal pelvic floor muscles. Conclusions An orgasm is a complex process which involves interplays between the clitoris, the glans pubis, and the sympathetic activation system. A four-phase model for orgasm has been explored, which separates the orgasm response into: desire (the urge to participate in sexual activities), arousal (increased genital blood flow and clitorial erection), orgasm (after the threshold for stimulation has been reached), and resolution. Dysorgasmia can be multifactorial, and while still unclear, etiologies include pelvic floor dysfunction and/or spasm. While the pathophysiology of how the pelvic floor is connected to orgasm is not exactly understood, it is theorized to be due to dysregulated coordination of pelvic floor muscles. A transverse rectus abdominis muscle (TRAM) flap is a common breast reconstructive procedure following mastectomy. The most common complications of a TRAM flap surgery are hernias/abdominal bulges, fat necrosis, and loco-regional occurance. Interestingly, TRAM surgeries have previously been associated with pelvic floor dysfunction in women due to an increase in abdominal pressure. Since the pelvic floor is tightly connected to the mechanism of an orgasm, it is possible that disruptions to the pelvic floor may lead to painful spasms during orgasms. This is also consistent with the patient’s sensation of abdominal “spasms” during/after orgasm. While not all TRAM surgeries cause dysorgasmia, this patient’s dysorgasmia may be postulated to be secondary to pelvic floor dysfunction. Disclosure No.

Biomechanical Integrity Score of the Female Pelvic Floor for Stress Urinary Incontinence

Introduction and hypothesisThis study is aimed at developing and validating a new integral parameter, the Biomechanical Integrity score (BI-score) of the female pelvic floor for stress urinary incontinence conditions.MethodsA total of 130 subjects were included in the observational cohort study; 70 subjects had normal pelvic floor conditions, and 60 subjects had stress urinary incontinence (SUI). A Vaginal Tactile Imager (VTI) was used to acquire and automatically calculate 52 biomechanical parameters for eight VTI test procedures (probe insertion, elevation, rotation, Valsalva maneuver, voluntary muscle contractions in two planes, relaxation, and reflex contraction). Statistical methods were applied (t test, correlation) to identify the VTI parameters sensitive to the pelvic SUI conditions.ResultsTwenty-seven parameters were identified as statistically sensitive to SUI development. They were subdivided into five groups to characterize tissue elasticity (group 1), pelvic support (group 2), pelvic muscle contraction (group 3), involuntary muscle relaxation (group 4), and pelvic muscle mobility (group 5). Every parameter was transformed to its standard deviation units using the dataset for normal pelvic conditions, similar to the T-score for bone density. Linear combinations with specified weights led to the composition of five component parameters for groups 1–5 and to the BI-score in standard deviation units. The p value for the BI-score has p = 4.0 × 10–28 for SUI versus normal conditions.ConclusionsQuantitative transformations of the pelvic tissues, support structures, and functions under diseased conditions may be studied with the SUI BI-score in future research and clinical applications.

Assessment of Involuntary PFM Contractions in Comparison with Existing Literature and IUGA/ICS Terminology Reports

Introduction and HypothesisInvoluntary pelvic floor muscle (PFM) contractions are thought to occur during an increase in intra-abdominal pressure (IAP). Although no studies have assessed their presence in women with normal pelvic floor (PF) function, existing literature links the absence of involuntary PFM contractions to various PF dysfunctions. This study rectifies this lacuna by evaluating involuntary PFM contractions during IAP in healthy nulliparous women with no PF dysfunction, using visual observation and vaginal palpation. Results were compared with the literature and the IUGA/ICS Terminology Reports.MethodsNulliparous (n=149) women performed three sets of three maximal coughs. Visual observation and vaginal palpation were conducted in the standing and supine positions. The women were not instructed to contract their PFMs. Occurrence rates were calculated for each assessment method and position; differences between positions were analyzed using the Chi-squared test.ResultsRates of occurrence of involuntary PFM contraction were low across both assessments and positions (5–17%). Significant differences were found between standing (5%) and supine (15%) positions for visual observation, but not vaginal palpation (15%, 17% respectively). Occurrence rates also differed compared with the literature and terminology reports.ConclusionsContrary to clinical expectations, rates of occurrence of involuntary PFM contraction among our cohort of nulliparous women were extremely low. Digital palpation results showed high agreement with the terminology reports, but only partial agreement was observed for the visual observation results. Our study underscores the need for more research aimed at defining normal involuntary PF functions, a review of our understanding of involuntary PFM contractions, and better standardized guidelines for involuntary PFM assessment methods.

The influence of the combined impairments and apical mesh surgery on the biomechanical behavior of the pelvic floor system.

Objective: The prolapse mechanism of multifactorial impairment of the female pelvic floor system and the mechanics of the pelvic floor after apical suspension surgery are not yet understood, so we developed biomechanical models of the pelvic floor for the normal physiological state (0°) and 90° pathological state. Methods: Under different types and levels of the impairments and uterosacral suspensions, the possible changes in the morphometric characteristics and the mechanical characteristics of suspension and support functions were simulated based on the biomechanical models of the pelvic floor. Results: After the combined impairments, the descending displacement of the pelvic floor cervix and the stress and displacement of the perineal body reached maximum values. After surgical mesh implantation, the stresses of the normal pelvic floor were concentrated on the uterine fundus, cervix, and top of the bladder and the stresses of the 90° pathological state pelvic floor were concentrated on the uterine fundus, uterine body, cervix, middle of the posterior vaginal wall, and bottom of the perineal body. Conclusion: After the combined impairments, the biomechanical support of the bladder and sacrococcyx in the anterior (0°) and 90° pathological state pelvic floor system is diminished, the anterior vaginal wall dislodges from the external vaginal opening, and the posterior vaginal wall forms "kneeling" profiles. The pelvic floor system may evolve with a tendency toward the cervical prolapse with anterior and posterior vaginal wall prolapse and eventually prolapse. After surgical mesh implantation, the cervical position can be better restored; however, the load of combined impairment of the pelvic floor is mainly borne by the surgical mesh suspension, the biomechanical support function of pelvic floor organs and sacrococcyx was not repaired by the physiological structure, and the results of uterosacral suspension alone may be poor.

Analysis of the anatomical and biomechanical characteristics of the pelvic floor in cystocele.

Stress urinary incontinence (SUI) occurs due to disruption of the pelvic floor anatomy; however, the complexity of the pelvic floor support structures and individual patient differences make it difficult to identify the weak points in the pelvic floor support that cause SUI to occur, develop, and recur. This study aimed to analyze the pelvic floor anatomy, structural features, and biomechanics of cystoceles to develop more effective treatment plans with individualized and precise healthcare. In this observational case-controlled study (clinical trial identifier BOJI201855L), 102 women with normal pelvic floor function and 273 patients diagnosed with cystocele degrees I-III were identified at Shanghai General Hospital from October 2016 to December 2019. We combined ultrasound and vaginal tactile imaging (VTI) to assess the anatomy and biomechanical functions of the anterior and posterior vaginal walls. Both examinations included relaxation and muscle tension tests. Of the 42 VTI parameters, 13 were associated with the degree of cystocele, six with an increase in the urethral rotation angle (pointing to the mobility of the urethra), and six with a decrease in the retrovesical angle (pointing to hypsokinesis and decrease in bladder position). According to these data, the strength of tissues, especially the muscles in both the anterior and posterior compartments, contributes to the stability of the pelvic floor structure. The strength of the levator ani muscle (LAM) is important for the degree of cystocele, mobility of the urethra, hypsokinesis, and decrease in bladder position. In general, the biomechanical status of the pelvic floor in patients with cystocele is complex and involves various muscles, ligaments, tendons, and fascia. Of these, repair and exercise of the LAM have not received much attention in the treatment of patients with cystoceles, which may be an important risk factor for the high recurrence rate.

Investigation and influencing factors on pelvic floor muscle strength of 929 adult females in gynecological outpatient department

Objective: To investigate the present situation of pelvic floor muscle strength, and to analyze the factors affecting pelvic floor muscle strength. Methods: The data of patients who were admitted into the general outpatient department of gynecology, Peking University People's Hospital from October 2021 to April 2022 were collected, and the patients who met the exclusion criteria were included in this cross sectional study. The patient's age, height, weight, education level, defecation way and defecation time, birth history, maximum newborn birth weight, occupational physical activity, sedentary time, menopause, family history and disease history were recorded by questionnaire. Morphological indexes such as waist circumference, abdomen circumference and hip circumference were measured with tape measure. Handgrip strength level was measured with grip strength instrument. After performing routine gynecological examinations, the pelvic floor muscle strength was evaluated by palpation with modified Oxford grading scale (MOS). MOS grade>3 was taken as normal group and ≤3 as decreased group. Binary logistic regression was used to investigate the related factors of deceased pelvic floor muscle strength. Results: A total of 929 patients were included in the study, and the average MOS grade was 2.8±1.2. By univariate analysis, birth history, menopausal time, defecation time, handgrip strength level, waist circumference and abdominal circumference were related to the decrease of pelvic floor muscle strength (all P<0.05). By binary logistic regression analysis, the level of handgrip strength (OR=0.913, 95%CI: 0.883-0.945; P<0.001) was correlated with normal pelvic floor muscle strength; waist circumference (OR=1.025, 95%CI: 1.005-1.046; P=0.016), birth history (OR=2.224, 95%CI: 1.570-3.149; P<0.001), sedentary time> 8 hours (OR=2.073, 95%CI: 1.198-3.587; P=0.009) were associated with the decrease of pelvic floor muscle strength. Conclusions: The level of handgrip strength is related to the normal pelvic floor muscle strength of females, while the waist circumference, birth history and sedentary time>8 hours are related to the decrease of pelvic floor muscle strength of females. In order to prevent the decrease of pelvic floor muscle strength, it is necessary to carry out relevant health education, enhance exercise, improve the overall strength level, reduce daily sedentary time, maintain symmetry, and carry out comprehensive overall intervention to improve pelvic floor muscle function.

Pathophysiological basis, clinical assessment, investigation and management of patients with obstruction defecation syndrome.

Obstructed defecation syndrome (ODS) is a clinical syndrome manifest as difficulty in faecal evacuation despite no mechanical obstruction. It is the final clinical pathway of a number of anatomical and physiological pathologies they can result in considerable misery to the lives of the patients it afflicts. Herein, the authors seek to breakdown the syndrome into its component parts, looking first at normal pelvic floor anatomy and physiology; followed by each pathological element; clinical features and investigation; individual management and management of the patient as a whole. It must be stated that correction of anatomy is not the sine qua non, as this does not always correlate to improvement of symptoms. There is a complex interplay of all elements, and a holistic approach appreciating the gestalt principle of "the whole is greater than the sum of its parts" is paramount. Causes of pelvic pain (levator ani syndrome, coccygodynia, proctalgia fugax and pudendal neuralgia) do not fall into ODS and are beyond the scope of this paper.

Hypothesis generation: Quantitative research to levator ani muscle injury based on MRI texture analysis.

Patients with pelvic organ prolapse (POP) mostly have injury to the levator ani muscle (LAM). We aimed to assess LAM injury in POP patients by quantifying texture feature (TF) ratios between the LAM and the obturator internus muscle (OIM) using texture analysis. This study retrospectively enrolled 32 participants, including 24 patients with POP and eight people with normal pelvic floor muscles. TFs of the LAM and the OIM were extracted using LIFEx version 6.30, and an independent samples t-test was performed to determine TF ratios characterizing LAM injury. After dimension reduction and binary logic analysis, the optimal TF ratio was obtained and the LAM injury quantitative evaluation was proposed. Spearman's correlation was performed to explore the correlations between TF ratios and clinical characteristics. We compared the diagnostic performance of quantitative evaluation and visual evaluation. There were significant differences in 13 TF ratios between the POP and control groups. The area under the receiver operating characteristic curve of the integrated TF ratio was 0.948. Integrated TF ratio was significantly correlated with body mass index, pregnancies, and vaginal deliveries but had no correlation with LAM volume, hiatal area or abortions. Compared with the visual evaluation, the diagnostic accuracy of the quantitative evaluation had improved by 63.2% and 14.3% in the "minor defect" and "major defect" categories, respectively. The integrated TF ratio can be used as a new quantifiable index to characterize LAM injury. The TF evaluation provides a potential role in LAM injury noninvasive diagnostic.

Unilateral pectineal suspension - A new surgical approach for apical correction of pelvic organ prolapse.

There are numerous vaginal and abdominal surgical approaches for the treatment of pelvic organ prolapse (POP). Even the standard techniques show great variability due to modifications depending on anatomy, available instruments and materials. Recently, the role of hysterectomy in prolapse surgery as well as the use of synthetic meshes have been questioned. Here, we present a standardised mesh-free minimally invasive pelvic floor reconstruction technique with uterus preservation. Unilateral pectineal suspension (UPS) is carried out in five defined steps with the use of the da Vinci Xi ® surgical system. The desired anatomical result is simulated by intraoperative uterus manipulation. The cranial part of the pectineal ligament is used for lateral fixation. A non-absorbable suture is placed between the pectineal ligament and the anterior cervix to suspend the uterus in its natural anatomical position. For outcome measurement, degree of prolapse was assessed pre- and postoperatively according to the POP-Q system. Unilateral pectineal suspension offers several advantages. Medial tension-free positioning of the uterus is achieved. The use of the cervix as fixation structure allows for excellent pelvic floor support and stable results. Normal pelvic floor mobility and natural axis of the vagina are restored. Unilateral pectineal suspension is an efficient minimal-invasive mesh-free procedure which allows uterus preservation and offers reliable level I support respecting the physiological pelvic anatomy. In addition, there is no need for ureteral dissection or bowel manipulation. The technique offers clinical standardization and can easily be integrated into the spectrum of modern surgical POP repair.

Multilevel musculo-fascial defect magnetic resonance study of female pelvic floor: retrospective case control study in women with pelvic floor dysfunction after the first vaginal delivery.

Magnetic resonance imaging (MRI) provides a detailed display of the pelvic floor structures responsible for normal pelvic floor anatomy. The aim of the study is to assess the appearance of musculo-fascial defects in women with pelvic floor dysfunction following first vaginal delivery. Analysis of axial T3 (Tesla 3) MRI scans from a case control study of symptomatic (n=149) and asymptomatic (n=60) women after first vaginal delivery. Presence and severity of pelvic organ support and attachment system defects in three axial pelvic planes were assessed. In the symptomatic group, major muscular defects were found in 67.1% (for pubovisceral muscle complex) and 87.9% (for iliococcygeal muscle). Only 6.7% of major pubovisceral and 35.0% of major iliococcygeal defects were identified in the controls (p=0.000). Prolapse patients had an odds ratio (OR) of 22.1 (95% CI 8.94-54.67) to have major pubovisceral muscle complex defect and OR of 4.9 (95% CI 1.51-15.71) to have major iliococcygeal muscle defect. Fascial defects were found in 60.4% and 83.2% the symptomatic group, respectively. Those with prolapse had an OR of 29.1 (95% CI 9.77-86.31) to have facial defect at the level of pubovisceral muscle complex and an OR of 16.9 (95% CI 7.62-37.69) to have fascial defect at the level of iliococcygeal muscle. Uterosacral ligaments detachment was associated with prolapse with an OR of 10.1 (95% CI 4.01-25.29). For the model based on combination on all MRI markers, the area under the receiver operating characteristic curve is 0.921. This study provides comprehensive data about first vaginal delivery-induced changes in the levator ani muscle and endopelvic fascial attachment system. These changes are seen also in asymptomatic controls, but they are significantly less expressed.

Biomechanical integrity score of the female pelvic floor

Introduction and HypothesisThe aim of this study is to develop and validate a new integral parameter, the Biomechanical Integrity score (BI-score), for the characterization of the female pelvic floor.MethodsA total of 253 subjects with normal and pelvic organ prolapse (POP) conditions were included in the multi-site observational, case-control study; 125 subjects had normal pelvic floor conditions, and 128 subjects had POP stage II or higher. A Vaginal Tactile Imager (VTI) was used to acquire and automatically calculate 52 biomechanical parameters for eight VTI test procedures (probe insertion, elevation, rotation, Valsalva maneuver, voluntary muscle contractions in two planes, relaxation, and reflex contraction). Statistical methods were applied (t-test, correlation) to identify the VTI parameters sensitive to the pelvic conditions.ResultsTwenty-six parameters were identified as statistically sensitive to POP development. They were subdivided into five groups to characterize (1) tissue elasticity, (2) pelvic support, (3) pelvic muscle contraction, (4) involuntary muscle relaxation, and (5) pelvic muscle mobility. Every parameter was transformed to its standard deviation units against the patient age similar to T-score for bone density. Linear combinations with specified weights led to the composition of five component parameters for groups (1)–(5) and the BI-score in standard deviation units. The p-value for the BI-score has p = 4.3 × 10−31 for POP versus normal conditions. A reference BI-score curve against age for normal pelvic floor conditions was defined.ConclusionsQuantitative transformations of the pelvic tissues, support structures, and functions under diseased conditions may be studied with the BI-score in future research and practical applications.

ATF3 regulates oxidative stress and extracellular matrix degradation via p38/Nrf2 signaling pathway in pelvic organ prolapse

Pelvic organ prolapse (POP) is a common disorder in women, and it is characterized by weakening of pelvic supportive structure with extracellular matrix (ECM) degradation. Activating transcription factor 3 (ATF3) was upregulated in anterior vaginal wall tissues of POP patients. We hypothesized that upregulation of ATF3 might contribute to POP development. This study aims to unveil the role of ATF3 in the pathogenesis of POP using a H2O2-induced in vitro model. Vaginal fibroblasts were isolated from woman with POP-Q stage greater than II and asymptomatic women with normal pelvic floor support. Knockdown of ATF3 enhanced cell viability and decreased cell apoptosis. Flow cytometry and immunnofluorescence showed that ATF3 deficiency inhibited H2O2-induced ROS production and the expression of 8 OHdG and 4-HNE. Western blot and Real-time PCR analysis revealed that ATF3 deficiency attenuated ECM component degradation (increasing collagen I, collagen III and elastin) and MMPs/TIMPs imbalance (decreasing MMP2 and MMP9 and increasing TIMP2). Moreover, knockdown of ATF3 induced the activation of p38/Nrf2/HO-1 signaling pathway. Further treatment with p38 inhibitor SB203580 abolished the protection of ATF3 deficiency against H2O2-induced cell damage, which was reverted by Nrf2 activator TBHQ. Thus, ATF3 likely contributes to POP progression by inducing cell apoptosis, oxidative stress and ECM degradation via regulating p38/Nrf2 pathway, which provides a potential therapeutic target for POP.

Investigating the association of the dimensions of genital hiatus and levator hiatus with pelvic organ prolapse: a systematic review.

Pelvic organ prolapse (POP) is a very common and distressing problem that affects women's quality of life. This systematic review aimed to investigate the association of the dimensions of the genital hiatus and levator hiatus at rest and Valsalva with POP. The Cochrane Library, PubMed, Scopus, Embase and Web of Science were searched on 25 April 2020. All data were analyzed using Review Manager 5.3. Of the 1288 papers reviewed, 21 (n= 5145: 2909 women with POP and 2236 controls) were considered for meta-analysis. Compared with the normal pelvic floor group, the urogenital hiatus size in the POP group was significantly higher at rest (mean difference: 0.49; 95% CI: [0.43, 0.55], P < 0.00001) and at Valsalva (mean difference: 0.79; 95% CI: [0.70, 0.89], P < 0.00001). Also, the levator ani hiatus size in the POP group was significantly higher at rest (mean difference: 0.52, 95% CI: [0.25, 0.78], P < 0.0001) and at Valsalva (mean difference: 1.01; 95% CI: [0.73,1.28], P < 0.00001) compared with that in the normal pelvic floor group. This systematic review showed that the sizes of the urogenital hiatus and levator ani hiatus and area of the levator hiatus in the POP group were significantly higher than those in the normal pelvic floor groups in both positions (rest or Valsalva maneuver). Also, in the POP group, the levator hiatus length at rest was significantly lower than that in the Valsalva maneuver.

Assessment of the anterior osteotomy role in the restoration of normal pelvic floor anatomy for bladder exstrophy patients using pre and postoperative pelvic floor MRI

Our aim was to evaluate the effectiveness of anterior osteotomy in the restoration of normal pelvic floor anatomy in classic bladder exstrophy repair using pelvic floor MRI as an imaging tool for evaluation. This study is a pilot prospective randomized controlled study that included 20 infants with classic bladder exstrophy older than three months with no history of previous surgical operations. All patients underwent complete primary repair and were randomized into two groups, with or without osteotomy. Both groups were assessed preoperatively & postoperatively after three months with pelvic floor MRI and compared to age & gender-matched control group infants with normal pelvic anatomy infants who underwent pelvic MRI for other medical conditions. There was not any significant statistical difference between osteotomy and non-osteotomy groups in pre-operative demographic data and all pelvic floor MRI measurements, emphasizing that both groups were equal in all characters at the start point of the study before the operation. The mean change difference between pre-operative and post-operative pelvic floor MRI measurements were compared in both groups, and there was not any significant statistical difference in all pelvic floor MRI measurements. Both groups showed the same statistical significance when compared with the control group in all pelvic floor MRI measurements except the posterior bladder neck distance, which was in favor of the osteotomy group, closer to the normal pelvic floor anatomy. Anterior osteotomy did not have a significant difference in the restoration of the normal pelvic floor anatomy when combined with complete primary repair of classic bladder exstrophy in newly diagnosed neonates older than three months, except for a single measurement, posterior bladder neck distance. Future studies needed to determine the effect of osteotomy on continence.

High-density surface electromyographic assessment of pelvic floor hypertonicity in IC/BPS patients: a pilot study.

To assess the feasibility of objectively assessing pelvic floor hypertonicity (PFH) in women with interstitial cystitis/bladder pain syndrome (IC/BPS) using an intra-vaginal high-density surface electromyography (HD-sEMG) probe. Seven female subjects (mean age 44 ± 13years) with a prior diagnosis of IC/BPS were recruited. A full digital pelvic examination was administered to identify hypertonic muscles. Intra-vaginal HD-sEMG was acquired during rest. Root-mean-squared (RMS) amplitude during rest was calculated for each channel to define a hypertonicity index and hypertonic zone. Innervation zones (IZs) were identified from the bipolar mapping of decomposed HD-sEMG signals and summarized into an IZ distribution mapping. Of the seven subjects recruited, five had normal pelvic floor muscle tone and two exhibited hypertonicity upon muscle palpation. Subjects with PFH demonstrated a higher hypertonicity index (12.6 ± 3.5 vs. 4.5 ± 1.2) in sessions 1 and 2. The hypertonic zone defined by the 64-channel RMS mapping coincided with the digital pelvic examination findings. The corresponding IZs were localized for each motor unit. The hypertonicity indices between two consecutive sessions were well correlated (CC = 0.95). This study represents the first effort to employ intra-vaginal HD-sEMG to assess PFH in women with IC/BPS. Our results demonstrate the feasibility of HD-sEMG to provide a quantitative diagnosis of PFH and the precise localization of hypertonic muscles and IZs. The proposed HD-sEMG-based techniques provide promising tools for clinical diagnosis and treatment of PFH, such as the personalized guidance of BoNT injections.

High-Density Surface Electromyography Assessment of Pelvic Floor Dysfunction in Women with Interstitial Cystitis/Bladder Pain Syndrome.

Up to 85% of women with interstitial cystitis/bladder pain syndrome have pelvic floor dysfunction and hypertonicity. Current evaluation methodologies lack objective measures of pelvic floor muscle activity. We examined the ability of using intravaginal high-density surface electromyography to quantitatively, objectively and noninvasively map pelvic floor muscle activity and innervation zone locations in patients with interstitial cystitis/bladder pain syndrome. Fifteen women with interstitial cystitis/bladder pain syndrome and 15 controls underwent 2 sessions of digital pelvic examinations and high-density surface electromyography assessments. The root mean squared amplitude of high-density surface electromyography was first calculated, and the resting root mean squared ratio was then calculated by normalizing the resting electromyography root mean squared to the peak electromyography amplitude reached during maximum voluntary contraction. Innervation zone distributions were obtained from decomposed high-density surface electromyography signals. The correlation between the root mean squared ratio and interstitial cystitis/bladder pain syndrome symptom scores and pelvic floor muscle alignment were investigated in patients with interstitial cystitis/bladder pain syndrome and healthy controls. Women with interstitial cystitis/bladder pain syndrome demonstrated significantly increased resting root mean squared ratios compared to controls (0.155±0.048 vs 0.099±0.041, p=0.0019). Significant correlations were found between resting root mean squared ratio and patient reported pain (rs=0.523, p=0.003), interstitial cystitis symptom (rs=0.521, p=0.003) and problem indices (rs=0.60, p <0.001). In addition, women with interstitial cystitis/bladder pain syndrome were more likely to have shortened pelvic floor muscles (80%, 12 vs 13.3%, 2, p <0.01). Women with shortened pelvic floor muscles demonstrated significantly higher resting root mean squared ratio compared to those with normal pelvic floor muscle length (0.155±0.046 vs 0.107±0.040, p=0.0058). Intravaginal high-density surface electromyography offers an objective and quantitative strategy to noninvasively assess pelvic floor muscle dysfunction in women with interstitial cystitis/bladder pain syndrome. Abundant spatiotemporal muscle activity information captured by high-density surface electromyography allows for mapping innervation zone distributions for major pelvic floor muscles.

MP07-16 MAPPING PELVIC FLOOR HYPERTONICITY IN WOMEN WITH IC/BPS USING HIGH-DENSITY SURFACE EMG

INTRODUCTION AND OBJECTIVE: Pelvic floor hypertonicity (PFH) is a debilitating symptom of interstitial cystitis/bladder pain syndrome (IC/BPS). The diagnosis and assessment of PFH are based on subjective pelvic examinations, and results between examiners may vary. Precise assessment is critical to the clinical diagnosis and management of PFH. The objective of this study is to provide innovative techniques to objectively assess neurogenic PFH in women with IC/BPS using an intra-vaginal high-density surface electromyography (HD-sEMG) probe. METHODS: Seven female subjects (44±13 yr.) with IC/BPS were recruited. A full pelvic exam was administered to identify hypertonic muscles. Intra-vaginal HD-sEMG was then acquired at rest from a novel 64-channel HD-sEMG probe, as shown in Figure 1(a). Z-scores were calculated using the subjects without hypertonicity as a reference population, as shown in Figure 1(b). Root-mean-squared (RMS) amplitude during resting state was calculated from differential signals for each channel to define a hypertonicity index. Innervation zones (IZs) were identified from the bipolar mapping of decomposed signals, and summarized into an IZ distribution mapping. RESULTS: Of the 7 subjects recruited, 5 had normal pelvic floor muscle tone and 2 exhibited hypertonicity upon muscle palpation. Women with PFH demonstrated a much higher hypertonicity index (12.6±3.5 vs. 4.5±1.2). The hypertonic zone defined by the RMS mapping coincided with the digital hypertonic muscle assessment, as shown in Figures 1(c) and 1(d) for two subjects without hypertonicity, and Figures 1(e) and 1(f) for the two subjects with hypertonicity. Motor units were decomposed, and the corresponding IZs were localized, as shown in Figures 1(g) and (h) for two women without hypertonicity, and Figures 1(i) and (j) for the women with hypertonicity. CONCLUSIONS: This study represents the first effort to employ intra-vaginal HD-sEMG to assess PFH in women with IC/BPS. Our results demonstrate the feasibility of HD-sEMG to provide a quantitative analysis of PFH and provide a precise localization of hypertonic muscles and IZs. The proposed HD-sEMG based techniques provide promising tools for clinical diagnosis and treatment of PFH, such as the personalized guidance of BoNT injections.Source of Funding: This study received funding support from the SUFU Foundation and NIH DK113525.

Multimodality imaging of pelvic floor anatomy.

The pelvic floor is composed of a network of muscles, ligaments, and fasciae, which provide active and passive support for the pelvic organs. Impairment of these pelvic floor elements can result in a variety of functional abnormalities and single or multicompartment organ prolapse. Knowledge of normal pelvic floor anatomy can aid the radiologist in understanding the complex nature of pelvic floor dysfunction and is important for comprehensive image interpretation. This article provides an overview of normal anatomy of the pelvic floor as seen on magnetic resonance imaging, ultrasound, and fluoroscopic studies performed in the evaluation of pelvic floor function.