Normal Pelvic Support Research Articles

MRI-Based Structural Failure Comparison between Chinese and American White Women With Prolapse: A Case-Control Study.

Although some evidence suggests that Chinese and white women might have different pelvic floor anatomy such as levator complex and connective tissue support for pelvic organs, it is unknown if these differences affect the mechanisms of pelvic organ prolapse. We sought to determine whether differences exist in MRI-based structural failure patterns between Chinese and American white women with prolapse. This is a case-control study in different racial cohorts recruited in China and the USA. The Chinese cohort included 19 women with anterior-predominant prolapse and 24 controls with normal pelvic support. The American white cohort included 30 women with anterior-predominant prolapse and 30 controls. Both cohorts underwent the same clinical evaluation and MRI protocol. Three structural support systems were quantified on stress 3D MRI at maximal Valsalva: vaginal factors (length, width); connective tissue attachment (cervix, lateral paravaginal height); and hiatus factors (urogenital hiatus size, major levator ani injury). Abnormal structural support was defined as any measurement outside the normal range defined as the 5th to 95th percentile in controls from the respective cohort. The percentages of the women with abnormal support in the two cohorts were compared. Among those with prolapse, Chinese women were more likely than white women to have abnormally long vaginal length and width (90% vs 40%, p < 0.001; 53% vs 23%, p = 0.031 respectively). The occurrence of abnormal apical location, paravaginal location, and genital hiatus size ranged from 89 to 100% in Chinese women and from 63 to 80% in white women. Prolapse in American white women most commonly involves structural failure of connective tissue attachments and hiatus factors and less frequently involves vaginal wall factors, whereas prolapse in Chinese women frequently involves all support structures.

Comparison of the Vaginal and Labial Dimensions of Ethnic Chinese and Western Nullipara.

Vaginal dimensions have clinical and surgical implications. We sought to quantify the differences between vaginal and labial dimensions in healthy ethnic Chinese and Western women with normal pelvic organ support. This is a cross-sectional study of a convenience sample of ethnic Chinese nulliparas (n = 33) and Western nulliparas (n = 33) recruited for research purposes. For each subject, magnetic resonance imaging was used to quantify the vaginal and labial dimensions. Specifically, we identified the anterior and posterior vaginal wall, the outline of the cervix in the mid-sagittal and coronal planes, and the distance from the labia majora to the hymenal ring at the urethral meatus. There were significant differences in age and weight between groups. Substantial variation in vaginal and labial dimensions was found within each group. The vaginal and labial dimensions of ethnic Chinese women ranged from 9-21% smaller than those of Western women; In the ethnic Chinese group, increasing weight and BMI correlated with greater labial distance (r = 0.66 and r = 0.63 respectively); as did height and the distance from the vaginal opening to the cervical os (r = 0.5). In the Western group, only weight correlated with the labial distance (r = 0.51). Significant group differences in vaginal and labial dimensions were found, with the dimensions of Chinese nulliparas being up to 21% smaller than those of Western nulliparas.

Usefulness of transperineal shear wave elastography of levator ani muscle in women with stress urinary incontinence.

This study aimed to quantitatively assess the quality of levator ani muscle (LAM) using shear wave elastography (SWE) and to evaluate the association between the elasticity of LAM and stress urinary incontinence (SUI). The study population included 32 women with SUI and 34 women with normal pelvic support. The thickness of LAM, bladder neck descent (BND), and urethral funneling (UF) were assessed by transperineal ultrasound. LAM elasticity was measured by SWE at rest and during the maximal Valsalva maneuver. Age, menopause, BND, and UF showed a positive correlation with SUI. There was no significant between-group difference in the elastic modulus values of LAM at rest. The thickness of LAM in women with SUI was greater than that in control group at rest and during the maximal Valsalva maneuver (P < 0.001). The elastic modulus values of Emax and Emean were significantly increased from rest to the maximal Valsalva maneuver in all participants (56.24 vs 82.43kPa and 47.92 vs 72.37kPa, P < 0.001). The change of these variables from rest to the maximal Valsalva maneuver in the control group was more obvious than that in the SUI group (34.09 vs 17.87kPa and 31.55 vs 16.82kPa, P < 0.05). The elasticity of LAM, as quantified by SWE, may potentially be used as an index for predicting SUI.

The Manchester operation – is it time for it to return to our surgical armamentarium in the twenty-first century?

We conducted a study to assess the efficacy and outcome results of Manchester operation for women with symptomatic elongation of uterine cervix between 2010 and 2020. Forty-five women were enrolled. Mean age was 54.2 ± 10.5 years, 57.5% were premenopausal. Mean follow up was 4.53 years. Most patients were pleased from the surgery: 29 (76.3%) very pleased and three (7.9%) quite pleased. There were four cases of late postoperative complications: hematometra, pyometra, vesicovaginal fistula and small bowel evisceration through the posterior vaginal fornix. All four cases required surgical interventions with complete recovery. Manchester operation is an effective procedure for symptomatic elongation of uterine cervix. The surgery is short, minimal blood loss and without significant intraoperative complications. However, it is not free of late postoperative complications and it is therefore important that the surgery will be carried out with a strict technique and by skilled surgeons who are capable to manage unique postoperative complications. Impact Statement What is already known on th is subject? Elongation of the uterine cervix is a condition that has not been sufficiently studied. Up-to-date data regarding the efficacy and safety of the Manchester operation for patients with cervical elongation and normal pelvic support are scarce, as most previously published studies included mainly patients with uterine prolapse. What do the results of this study add? The present study presents the efficacy, complications and clinical outcomes of Manchester operation for women with elongation of the uterine cervix. Our results show that Manchester operation is safe, effective method for symptomatic uterine cervix elongation. What are the implications of these findings for clinical practice and/or further research? This suggests Manchester operation is an effective procedure for symptomatic uterine cervix elongation should be implemented more widely. It must be carried out with a strict technique by skilled surgeons capable to manage unique postoperative complications.

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.

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.

Definition of apical descent in women with and without previous hysterectomy: A retrospective analysis.

BackgroundWhile normal pelvic organ support has been defined for women with intact uterus, this is not the case for post- hysterectomy vault descent. A recent systematic review found that definitions of apical prolapse are highly variable.ObjectivesTo investigate the relationship between prolapse symptoms and apical POP-Q measurements and establish cutoffs for ‘significant apical descent using receiver–operator characteristics (ROC) statistics.Study designRetrospective analysis of patients seen at a tertiary urogynecological unit. Evaluation included a standardized interview and clinical assessment using the Pelvic Organ Prolapse Quantification (POP-Q) system. ROC curves were prepared for the relationship between prolapse symptoms and POP-Q measure “C”.ResultsThe records of 3010 women were available for analysis. Prolapse symptoms were reported by 52.3% (n = 1573), with a mean bother of 5.9 (SD 3.0, range 0–10). POP-Q point “C” was associated with symptoms of prolapse (p <0.0001) and prolapse bother (p <0.0001) on both univariate and multivariate analysis. ROC curves for women with and without uterus were similar, although the relationship between apical descent and symptoms of prolapse was stronger for women with uterus (AUC 0.728 versus 0.678). After controlling for multi-compartment prolapse, the models improved, resulting in AUCs of 0.782 and 0.720. For prediction of prolapse symptoms, cutoffs were set at C = -5 (sensitivity 0.73, specificity 0.67 with uterus in situ, sensitivity 0.59, specificity, 0.73 after hysterectomy).ConclusionA cut- off for ‘significant central compartment descent’ of 5 cm above the hymen on Valsalva seems valid regardless of previous hysterectomy.

64: Performing the pelvic organ prolapse quantification system exam: a modern update

The aim of this video is to provide learners with a comprehensive and systematic approach to performing the POP-Q exam while also describing non-traditional techniques for evaluating vaginal caliber and perineal decent. The Pelvic Organ Prolapse Quantification (POP-Q) exam is a commonly used exam to demonstrate and measure pelvic organ prolapse in the office. The video demonstrates real-time exams on patients with both normal pelvic support and those with pelvic organ prolapse. Additionally, the video is augmented with computer generated cartoons to help learners better visualize the exam and pelvic organ prolapse. At the conclusion of this video, the techniques and definitions of the points measured in the POP-Q exam as well as vaginal caliber and perineal descent should be reproducible by a skilled learner.

The Association of Abdominal Striae With Pelvic Organ Prolapse.

Our objective was to estimate the prevalence of abdominal wall striae among women with and without pelvic organ prolapse (POP) in a population with pelvic floor disorders. This cross-sectional study included nonpregnant women with urinary incontinence and POP presenting to a tertiary urogynecology practice between December 2012 and August 2013. Participants completed a nonvalidated questionnaire about striae, and the degree of abdominal wall striae was quantified on physical examination. Baseline demographics, clinical characteristics, and Pelvic Organ Prolapse Quantification (POP-Q) measurements were recorded. One hundred thirty-two women were approached for participation, of which 110 (83%) completed study questionnaires. Of these 110, 59 had POP defined at POP-Q stages 2-4, whereas 51 had normal pelvic support, POP-Q stages 0-1. The mean (SD) age was 55.5 (12) years, and most (78/110) were sexually active. Women with POP were more parous than women without POP (median 2 vs 1, respectively; P = 0.03). However, there was no difference in medical comorbidities, smoking status, or steroid use between groups (P > 0.05). More women with POP reported striae (42/59 [71%] vs 23/51 [45%], P = 0.006) and had quantifiable abdominal wall striae compared with women with normal support (39/59 [66%] vs 22/51 [44%], P = 0.02). On multivariate logistic regression, women with POP were 2.5 times more likely to have striae compared with women without POP after adjusting for skin type and smoking status (odds ratio, 2.5; 95% confidence interval, 1.03-6.06; P = 0.04). Women with POP are more likely to have striae compared with women without POP.

Quantitative Assessment and Interpretation of Vaginal Conditions.

IntroductionFew means exist to provide quantitative and reproducible assessment of vaginal conditions from biomechanical and functional standpoints.AimTo develop a new approach for quantitative biomechanical characterization of the vagina.MethodsVaginal tactile imaging (VTI) allows biomechanical assessment of soft tissue and function along the entire length of the anterior, posterior, and lateral vaginal walls. This can be done at rest, with applied vaginal deformation, and with pelvic muscle contraction.ResultsData were analyzed for 42 subjects with normal pelvic floor support from an observational case-controlled clinical study. The average age was 52 years (range = 26–90 years). We introduced 8 VTI parameters to characterize vaginal conditions: (i) maximum resistance force to insertion (newtons), (ii) insertion work (millijoules), (iii) maximum stress-to-strain ratio (elasticity; kilopascals per millimeter), (iv) maximum pressure at rest (kilopascals), (v) anterior-posterior force at rest (newtons), (vi) left-right force at rest (newtons), (vii) maximum pressure at muscle contraction (kilopascals), and (viii) muscle contraction force (newtons). We observed low to moderate correlation of these parameters with subject age and no correlation with subject weight. 6 of 8 parameters demonstrated a P value less than .05 for 2 subject subsamples divided by age (≤52 vs >52 years), which means 6 VTI parameters change with age.ConclusionsVTI allows biomechanical and functional characterization of the vaginal conditions that can be used for (i) understanding “normal” vaginal conditions, (ii) quantification of the deviation from normality, (iii) personalized treatment (radiofrequency, laser, or plastic surgery), and (iv) assessment of the applied treatment outcome.Egorov V, Murphy M, Lucente V, et al. Quantitative Assessment and Interpretation of Vaginal Conditions. Sex Med 2018;6:39–48.

Biomechanical paradigm and interpretation of female pelvic floor conditions before a treatment.

BackgroundFurther progress in restoring a woman’s health may be possible if a patient with a damaged pelvic floor could undergo medical imaging and biomechanical diagnostic tests. The results of such tests could contribute to the analysis of multiple treatment options and suggest the optimal one for that patient.AimTo develop a new approach for the biomechanical characterization of vaginal conditions, muscles, and connective tissues in the female pelvic floor.MethodsVaginal tactile imaging (VTI) allows biomechanical assessment of the soft tissue along the entire length of the anterior, posterior, and lateral vaginal walls at rest, with manually applied deflection pressures and with muscle contraction, muscle relaxation, and Valsalva maneuver. VTI allows a large body of measurements to evaluate individual variations in tissue elasticity, support defects, as well as pelvic muscle function. Presuming that 1) the female pelvic floor organs are suspended by ligaments against which muscles contract to open or close the outlets and 2) damaged ligaments weaken the support and may reduce the force of muscle contraction, we made an attempt to characterize multiple pelvic floor structures from VTI data.ResultsAll of the 138 women enrolled in the study were successfully examined with the VTI. The study subjects have had normal pelvic support or pelvic organ prolapse (stages I–IV). The average age of this group of subjects was 60±15 years. We transposed a set of 31 VTI parameters into a quantitative characterization of pelvic muscles and ligamentous structures. Interpretation of the acquired VTI data for normal pelvic floor support and prolapse conditions is proposed based on biomechanical assessment of the functional anatomy.ConclusionVaginal tactile imaging allows biomechanical characterization of female pelvic floor structures and tissues in vivo, which may help to optimize treatment of the diseased conditions such as prolapse, incontinence, atrophy, and some forms of pelvic pain.

Intraoperative cervix location and apical support stiffness in women with and without pelvic organ prolapse

It is unknown how initial cervix location and cervical support resistance to traction, which we term "apical support stiffness," compare in women with different patterns of pelvic organ support. Defining a normal range of apical support stiffness is important to better understand the pathophysiology of apical support loss. The aims of our study were to determine whether: (1) women with normal apical support on clinic Pelvic Organ Prolapse Quantification, but with vaginal wall prolapse (cystocele and/or rectocele), have the same intraoperative cervix location and apical support stiffness as women with normal pelvic support; and (2) all women with apical prolapse have abnormal intraoperative cervix location and apical support stiffness. A third objective was to identify clinical and biomechanical factors independently associated with clinic Pelvic Organ Prolapse Quantification point C. We conducted an observational study of women with a full spectrum of pelvic organ support scheduled to undergo gynecologic surgery. All women underwent a preoperative clinic examination, including Pelvic Organ Prolapse Quantification. Cervix starting location and the resistance (stiffness) of its supports to being moved steadily in the direction of a traction force that increased from 0-18 N was measured intraoperatively using a computer-controlled servoactuator device. Women were divided into 3 groups for analysis according to their pelvic support as classified using the clinic Pelvic Organ Prolapse Quantification: (1) "normal/normal" was women with normal apical (C < -5 cm) and vaginal (Ba and Bp < 0 cm) support; (2) normal/prolapse had normal apical support (C < -5 cm) but prolapse of the anterior or posterior vaginal walls (Ba and/or Bp ≥ 0 cm); and (3) prolapse/prolapse had both apical and vaginal wall prolapse (C > -5 cm and Ba and/or Bp ≥ 0 cm). Demographics, intraoperative cervix locations, and apical support stiffness values were then compared. Normal range of cervix location during clinic examination and operative testing was defined by the total range of values observed in the normal/normal group. The proportion of women in each group with cervix locations within and outside the normal range was determined. Linear regression was performed to identify variables independently associated with clinic Pelvic Organ Prolapse Quantification point C. In all, 52 women were included: 14 in the normal/normal group, 11 in the normal/prolapse group, and 27 in the prolapse/prolapse group. At 1 N of traction force in the operating room, 50% of women in the normal/prolapse group had cervix locations outside the normal range while 10% had apical support stiffness outside the normal range. Of women in the prolapse/prolapse group, 81% had cervix locations outside the normal range and 8% had apical support stiffness outside the normal range. Similar results for cervix locations were observed at 18 N of traction force; however the proportion of women with apical support stiffness outside the normal range increased to 50% in the normal/prolapse group and 59% in the prolapse/prolapse group. The prolapse/prolapse group had statistically lower apical support stiffness compared to the normal/normal group with increased traction from 1-18 N (0.47 ± 0.18 N/mm vs 0.63 ± 0.20 N/mm, P= .006), but all other comparisons were nonsignificant. After controlling for age, parity, body mass index, and apical support stiffness, cervix location at 1 N traction force remained an independent predictor of clinic Pelvic Organ Prolapse Quantification point C, but only in the prolapse/prolapse group. Approximately 50% of women with cystocele and/or rectocele but normal apical support in the clinic had cervix locations outside the normal range under intraoperative traction, while 19% of women with uterine prolapse had normal apical support. Identifying women whose apical support falls outside a defined normal range may be a more accurate way to identify those who truly need a hysterectomy and/or an apical support procedure and to spare those who do not.

Comparative Characterization of Vaginal Cells Derived From Premenopausal Women With and Without Severe Pelvic Organ Prolapse.

This study tested a hypothesis that primary human vaginal cells derived from tissue of premenopausal women with severe pelvic organ prolapse (POP-HVCs) would display differential functional characteristics as compared to vaginal cells derived from asymptomatic women with normal pelvic floor support (control-HVCs). Vaginal tissue biopsies were collected from premenopausal patients with POP (n = 8) and asymptomatic controls (n = 7) during vaginal hysterectomy or repair. Primary vaginal cells were isolated by enzymatic digestion and characterized by immunocytochemistry. Cell attachment and proliferation on different matrices (collagen I, collagen II, collagen IV, fibronectin, laminin, tenascin, and vitronectin) were compared between POP-HVCs and control-HVCs. RNA was extracted, and the expression of 84 genes was screened using Human Extracellular Matrix and Adhesion Molecules RT(2) Profiler PCR array. The expression of selected genes was verified by quantitative reverse transcription-polymerase chain reaction. (1) Control-HVCs attached to collagen IV more efficiently than POP-HVCs; (2) control-HVCs and POP-HVCs show a similar proliferation rate when plated on proNectin and collagen I; (3) when seeded on collagen I, resting POP-HVCs expressed significantly (P < .05) increased transcript levels of collagen VII, multiple matrix metalloproteinases (MMP3, MMP7, MMP10, MMP12, MMP13, and MMP14), integrins (ITGA1, ITGA4, ITGA6, ITGA8, ITGB1, ITGB2, and ITGB3), and cell adhesion molecules as compared to control-HVCs. Collagen XV and tissue inhibitors of MMPs (TIMP1 and TIMP2) as well as genes involved in the biogenesis and maturation of collagen and elastin fibers (LOX, LOXL1-LOXL3, BMP1, and ADAMTS2) were significantly downregulated in POP-HVCs versus control-HVCs (P < .05). Resting primary POP-HVCs in vitro show altered cellular characteristics as compared to control-HVCs, which may influence their dynamic responses to external mechanical or hormonal stimuli.

Quantitative analyses of variability in normal vaginal shape and dimension on MR images.

We present a technique for quantifying inter-individual variability in normal vaginal shape, axis, and dimension, and report findings in healthy women. Eighty women (age: 28∼70years) with normal pelvic organ support underwent supine, multi-planar proton-density MRI. Vaginal width was assessed at five evenly-spaced locations, and vaginal axis, length, and surface area were quantified via ImageJ and MATLAB. The mid-sagittal plane angles, relative to the horizontal, of three vaginal axes were 90 ± 11, 72 ± 21, and 41 ± 22° (caudal to cranial, p < 0.001). The mean (± SD) vaginal widths were 17 ± 5, 24 ± 4, 30 ± 7, 41 ± 9, and 45 ± 12mm at the five locations (caudal to cranial, p < 0.001). Mid-sagittal lengths for anterior and posterior vaginal walls were 63 ± 9 and 98 ± 18mm respectively. The vaginal surface area was 72 ± 21cm(2) (range: 34 ∼ 164cm(2)). The coefficient of determination between any demographic variable and any vaginal dimension did not exceed 0.16. Large variations in normal vaginal shape, axis, and dimensions were not explained by body size or other demographic variables. This variation has implications for reconstructive surgery, intravaginal and surgical product design, and vaginal drug delivery.

The long and short of it: anterior vaginal wall length before and after anterior repair.

Anterior vaginal wall length (AVL) is on average 6.1 ± 1.3 cm in women with normal support and lengthened in women with cystocele. We hypothesize that AVL is reduced after anterior repair and that women with larger cystoceles will have greater reduction in AVL. Demographic, clinical, and surgical data were collected for women undergoing hysterectomy and anterior repair in whom intraoperative vaginal wall measurements had been made between November 2009 and April 2014. In the operating room, AVL was defined preoperatively as the distance from the hymenal ring to the anterior cervicovaginal junction at the hysterectomy incision site, and postoperatively, from the hymenal ring to the same location on the anterior cuff. During the anterior repair the fibromuscular tissues were plicated using an interrupted technique. Measurements were available for 40 women. Average age was 61.7 ± 10 years, median parity was 2.5 and median preoperative Pelvic Organ Prolapse Quantification System (POP-Q) point Ba was 3 cm distal to the hymen. On average, AVL was reduced after surgery by 2.5 cm. Mean postoperative AVL was similar to mean AVL in women with normal pelvic support (6.4 ± 0.8 cm vs 6.1 ± 1.3 cm, p = 0.15). Longer preoperative AVLs had greater AVL change (R (2) = 0.78, p = <0.0001). In women undergoing anterior repair, mean AVL was reduced by 28 % and returned to the normal range after surgery. These data highlight a rarely discussed effect of anterior repair, which is restoration of normal anterior vaginal wall length.

Genes responsible for vaginal extracellular matrix metabolism are modulated by women's reproductive cycle and menopause

To analyze the expression of genes involved in extracellular matrix (ECM) biogenesis and remodeling in vaginal tissue of women with clinically normal pelvic floor support (defined as controls) according to the phase of menstrual cycle and postmenopausal women with and without pelvic organ prolapse (POP). This study examined the expression of matrix metalloproteinases (MMPs), their tissue inhibitors (TIMPs), and the Lysyl oxidase (LOX) family genes in the anterior vaginal wall of Caucasian women by real-time RT-PCR. Initially, mRNA expression was assessed in premenopausal controls in the secretory (group 1, n = 10) vs. proliferative (group 2, n = 8) phase of menstrual cycle. In addition, we compared premenopausal controls in the proliferative phase (group 2) vs. postmenopausal controls (group 3, n = 5). Finally, we analyzed postmenopausal controls (group 3) vs. postmenopausal women with advanced POP (group 4, n = 13). According to the phase of menstrual cycle, MMP1 was significantly reduced (p = 0.003), whereas the expression of TIMP1 and LOXL4 was significantly up-regulated during proliferative phase (both p < 0.01) when compared to the secretory phase in premenopausal control women. Regarding menopausal status/ageing, all MMPs were down-regulated, while TIMP3, TIMP4 and LOXL2 were significantly up-regulated in postmenopausal control women when compared to premenopausal controls (p = 0.005, p = 0.01 and p < 0.001, correspondingly). TIMP4 and LOXL2 mRNA levels were significantly decreased in postmenopausal POP patients compared to asymptomatic postmenopausal controls (p < 0.01 for both). Our results indicate that ovarian cycle and age-related changes influence the expression of genes encoding proteins responsible for ECM metabolism in human vagina. Moreover, POP is associated with alteration in vaginal ECM components after menopause.

Is cervical elongation associated with pelvic organ prolapse?

It is commonly believed that pelvic organ prolapse (POP) is associated with cervical elongation. However, cervical lengths have not been formally compared between women with prolapse and those with normal support. Cervix and uterine corpus lengths were measured on magnetic resonance images in a case-control study of 51 women with prolapse and 46 women with normal support determined by the Pelvic Organ Prolapse Quantification (POP-Q) examination. Group matching ensured similar demographics in both groups. Ranges for normal cervical lengths were determined from the values in the control group in order to evaluate for cervical elongation amongst women with prolapse. The cervix is 36.4 % (8.6 mm) longer in women with prolapse than in women with normal pelvic support (p < 0.001). Linear regression modeling suggests the feature most highly associated with cervical length is the degree of uterine descent (POP-Q point C). Approximately 40 % of women with prolapse have cervical elongation; 57 % of cervical elongation in prolapse can be explained by a logistic regression-based model including POP-Q point C, body mass index, and menopausal status. Cervical elongation is found in one third of women with POP, with the extent of elongation increasing with greater degrees of uterine descent.

Perineal body anatomy in living women: 3-dimensional analysis using thin-slice magnetic resonance imaging

The objective of the study was to describe a framework for visualizing the perineal body's complex anatomy using thin-slice magnetic resonance (MR) imaging. Two millimeter thick MR images were acquired in 11 women with normal pelvic support and no incontinence/prolapse symptoms. Anatomic structures were analyzed in axial, sagittal, and coronal slices. Three-dimensional (3-D) models were generated from these images. Three distinct perineal body regions are visible on MR imaging: (1) a superficial region at the level of the vestibular bulb, (2) a midregion at the proximal end of the superficial transverse perineal muscle, and (3) a deep region at the level of the midurethra and puborectalis muscle. Structures are best visualized on axial scans, whereas craniocaudal relationships are appreciated on sagittal scans. The 3-D model further clarifies interrelationships. Advances in MR technology allow visualization of perineal body anatomy in living women and development of 3-D models that enhance our understanding of its 3 different regions: superficial, mid, and deep.

Proteomic analysis of pubocervical fascia in women with and without pelvic organ prolapse and urodynamic stress incontinence

This pilot study compares protein expression patterns in the pubocervical fascia of women with pelvic organ prolapse (POP) and stress urinary incontinence (SUI) and asymptomatic women with normal pelvic support. Samples of pubocervical fascia were collected from four women with POP and SUI and from three asymptomatic (control) women. These were analyzed using two-dimensional electrophoresis and matrix-assisted laser desorption/ionization time-of-flight mass spectrometry. The expression levels of transgelin, smooth muscle gamma-actin, myosin light polypeptide 6, and alpha-1 antitrypsin precursor were more than twofold higher in patients than in controls. An additional five proteins were overexpressed (more than twofold) in patients, while three proteins were detected only in the patients. This pilot study is the first study to estimate changes in protein expression in the pubocervical fascia of human patients with POP. These changes could be related to the pathophysiology of POP.

Increased expression of matrix metalloproteinase‐1 in uterosacral ligament tissue from women with pelvic organ prolapse

Mechanical stability of the urogenital tract depends on intact collagen fibers. Because of difficulties in quantitating collagen, some authors have investigated collagen breakdown by measuring matrix metalloproteinases expression. We biopsied 68 post-menopausal women during operation to evaluate matrix metalloproteinase-1 (MMP-1) expression in uterosacral ligament biopsies from women with pelvic organ prolapse (POP) (n = 34) and controls with normal pelvic support (n = 34). The controls were matched to the POP group by age, body mass index, parity and duration of postmenopausal state. Immunohistochemistry for MMP-1 was performed on formalin fixed and paraffin embedded sections. Women with POP had a significantly higher MMP-1 expression (p = 0.047) which confirms an association, although not a causal relation, between POP and increased MMP-1 expression.