Thickness Of Puborectalis Muscle Research Articles

Comparison of Cross-Sectional Area of Pubovisceral Muscle in Nulliparous and Primiparous Women

Introduction and HypothesisThe main risk factor for pelvic floor disorders is vaginal delivery, which may cause levator ani muscle (LAM) injury and denervation. LAM includes pubovisceral muscle (PVM, pubococcygeus), puborectalis muscle (PRM), and iliococcygeus muscle. We hypothesize that primiparous women with low pelvic floor muscle contraction have a reduced PVM cross-sectional area (CSA) compared to nulliparous women.Methods (Sample Size and Statistical Approaches)This single-centre prospective observational study compared healthy nulliparous (n = 40) to primiparous (n = 40) women after vaginal delivery without LAM avulsion and Oxford score ≤ 3. Demographics, questionnaires (ICIQ-UI-SF, OAB-Q-SF, PISQ-12), POP-Q, Oxford score, ultrasound measurements (minimal anteroposterior and lateral diameters, hiatal area, PRM thickness, levator-urethra gap) and magnetic resonance imaging (MRI)—PVM CSA were evaluated. Normality was tested, and an appropriate test was used to compare the groups. Power calculation suggested 40 participants per group.ResultsThe primiparous group was older, had a higher BMI, and their hiatal area on ultrasound at contraction was larger compared to the nulliparous group. The CSA of the left-sided PVM (1.15 ± 0.50 cm2) was larger compared to the right side (1.03 ± 0.50 cm2), p = 0.02 in nulliparous women. The PVM CSA of primiparous women with low Oxford score was reduced compared to nulliparous (0.87 ± 0.30 versus 1.09 ± 0.50 cm2, p = 0.006). The intra-rater reliability for PVM CSA had an ICC of 0.90 and inter-rater ICC of 0.77.ConclusionsPrimiparous women after vaginal delivery with low pelvic floor contraction force had reduced PVM CSA on MRI images compared to nulliparous women.

Inter-observer variability in male pelvic-floor MRI measurements that might predict post-prostatectomy incontinence.

Current studies are focusing on the relationship between anatomical variables in preoperative prostate MRI and the development of post-prostatectomy incontinence (PPI). Nevertheless, there is little evidence regarding the reliability of these measurements. The objective of this study was to analyze the concordance between urologists and radiologists for anatomical measurements that might be PPI predictors. Pelvic floor measurements with 3T-MRI were performed by two radiologists and two urologists independently and blindly. Interobserver agreement was determined using the intraclass correlation coefficient (ICC) and the Bland-Altman plot. The concordance was good-acceptable for most measurements, except for the levator ani and puborectalis muscle thickness (some ICC values < 0.20/p value > 0.05). The anatomical parameters with the highest degree of agreement were intravesical prostatic protrusion (IPP) and prostate volume (most of the ICC values > 0.60). The membranous urethral length (MUL) and the angle of the membranous urethra-prostate axis (aLUMP) presented ICC > 0.40. The obturator internus muscle thickness (OIT), urethral width and intraprostatic urethral length presented a fair-moderate degree of agreement (ICC > 0.20). Regarding the agreement between different specialists, the highest degree was obtained for the two radiologists and for urologist 1-radiologist 2 (moderate median agreement), while urologist 2 with each of the radiologists had a regular median agreement. MUL, IPP, prostate volume, aLUMP, OIT, urethral width and prostatic length show acceptable inter-observer concordance and they would be reliable as possible predictors of PPI. Levator ani and puborectalis muscle thickness show bad agreement. Interobserver agreement might not be greatly influenced by previous professional experience.

Pelvic floor muscle assessment by digital palpation and translabial ultrasound of women with cervical or endometrial cancer after pelvic radiotherapy: a cross-sectional study.

We hypothesized that anatomical changes in the pelvic floor muscles (PFM) could be detected using four-dimensional translabial ultrasound (4D TLUS) in patients with cervical (CC) or endometrial cancer (EC) who underwent pelvic radiotherapy (RT) as digital palpation may present sensitivity limitations. This was a cross-sectional study that included 64 women (26 with CC and 38 with EC). PFM function was assessed by digital palpation, grading muscle strength according to the Modified Oxford Scale and by 4D TLUS. Ultrasonographic variables were: levator plate angle, hiatal area, puborectalis muscle thickness, puborectalis strain and levator ani muscle integrity. These variables were also correlated with clinical and sociodemographic data from all these patients. A 5% significance level was adopted. When assessed by digital palpation, no significant difference was found in PFM strength between women with CC and those with EC (p = 0.747). However, when assessed by 4D TLUS, women with CC presented greater thickening of the left (p = 0.039) and right (p = 0.014) lower portion of the puborectalis muscle during PFM contraction compared to those with EC. After pooling the groups, higher cancer staging (p = 0.028) was associated with smaller narrowing in the symphysis-levator distance, and shorter RT finishing duration (< 60 months) was associated with higher thickening in the left (p = 0.029) and right (p = 0.013) upper portion of the puborectalis muscle during PFM contraction as well as a shorter menopause duration (p = 0.007 and p = 0.002, respectively). Anatomical changes in the puborectalis muscle during PFM contraction were detected by 4D TLUS within gynecological cancer patients after pelvic RT.

Is pelvic floor muscle strength and thickness associated with pelvic organ prolapse in Nepali women? – A cross-sectional study

BackgroundPelvic floor muscle function has been shown to be inversely associated with pelvic organ prolapse in Western women, however differences have been documented between ethnic groups. ObjectiveTo determine if pelvic floor muscle strength and thickness and hiatal area are associated with pelvic organ prolapse in Nepali women. MethodsThis cross-sectional study included non-pregnant Nepali women ≥18 years attending an outpatient gynecology clinic in Kathmandu, Nepal. A clinical examination included the pelvic organ prolapse quantification (POP-Q)- system examination and Modified Oxford Scale. Puborectalis muscle thickness and hiatal area were assessed using 3D/4D translabial ultrasound. Statistical analysis included Pearson's correlation and multiple regression (p<0.05). ResultsOf the 123 women; 14 (11%) had POP-Q stage 0 prolapse, 29 (24%) stage I, 69 (56%) stage II, 8 (7%) stage III, and 3 (2%) stage IV. Mean±SD Modified Oxford Scale was 3.37±0.48 and muscle thickness was 1.14±0.21cm, hiatal area at rest was 14.67±3.11cm2 and on contraction was 11.29±2.51cm2. No associations were found between pelvic floor muscle strength or thickness and POP-Q stages 0–IV. There was a positive correlation found between hiatal area at rest and pelvic organ prolapse stage (r=0.34, p<0.001)and hiatal area on contraction and prolapse stage (r=0.30, p<0.001) and a negative correlation between pelvic floor muscle strength and hiatal area on contraction (r=−0.36, p<0.001). ConclusionIn contrast to previous findings, pelvic floor muscle strength and thickness are not associated with pelvic organ prolapse in this sample of Nepali women. It is important to consider these findings when developing pelvic organ prolapse treatment and management strategies in this population.

Value of high-frequency two-dimensional ultrasound on evaluating puborectalis muscle.

To explore the value of high-frequency two-dimensional (2D) ultrasound on demonstrating the morphology of puborectalis muscle and detect muscle avulsion. High-frequency 2D ultrasound and tomographic ultrasound image (TUI) were peformed to demonstrate puborectalis muscle and detect muscle avulsion respectively among 158 women with or without significant pelvic organ prolapse (POP) (POP quantification grade 2 or higher). Mean values were compared using student's t test between women with or without avulsion defects. We performed Cohen's Kappa analysis to examine the test agreement between high-frequency 2D ultrasound and TUI mode. Pearson correlation analysis was performed to explore the relationship between the thickness of puborectalis muscle and the measurements of levator-urethra gap (LUG). The result of high-frequency 2D ultrasound in detecting muscle avulsion agreed well with TUI mode (Kappa 0.88, P < 0.05). Women with muscle avulsion had thinner muscles and larger LUG measurements than those with normal muscle insertion (P < 0.05). Pearson correlation analysis revealed the negative relationship between the thickness of puborectalis muscle and LUG measurements (r = - 0.73). The study confirmed that it was feasible to observe the morphology of puborectalis muscle and detect muscle avulsion by high-frequency 2D ultrasound.

Four-dimensional translabial ultrasound concordance with digital palpation and surface electromyography during dynamic pelvic floor muscles assessment: A cross-sectional study.

To investigate whether pelvic floor muscle (PFM) morphological changes obtained through four-dimensional translabial ultrasound (4D TLUS) correlate with a PFM contraction as evaluated by digital palpation and PFM electromyographic activity evaluated by surface electromyography (sEMG). The secondary objective was to investigate which ultrasound parameter is more strongly associated with digital palpation. This cross-sectional study included 210 women and their PFMs were evaluated by digital palpation (graded according to the Modified Oxford Scale), sEMG and 4D TLUS. Offline analysis of ultrasound volume datasets was performed for measuring the change in levator plate angle, bladder neck elevation, hiatal area narrowing, puborectalis strain, and puborectalis muscle thickness at rest and during PFM contraction. Statistical analysis included Kruskal-Wallis, Dunn, and Spearman's tests in addition to univariate and multivariate logistic regression, adopting a significance level of 5%. A weak but significant correlation between the change in levator plate angle and sEMG (P = .04; r = 0.14) was found. All 4D TLUS measurements, except the puborectalis muscle thickness, significantly correlated with digital palpation (P < .0001); with the puborectalis strain and the change in levator plate angle having the strongest combined parameters associated with digital palpation (R2 = 21.77%), despite the low coefficient of determination. We found that 4D TLUS significantly correlates with digital palpation and sEMG, being the change in the levator plate angle the parameter that best correlates with both methods. While digital palpation is essential during a PFM functional assessment, 4D TLUS is recommended as a beneficial noninvasive clinical tool for a more in-depth evaluation.

Morphological characteristic of anal canal in patients with dyssynergic defecation and its correlation with anorectal manometry

Objective: To evaluate the diagnostic value of three-dimensional endoanal ultrasound (3D-EAUS) for dyssynergic defecation (DD). Methods: A case-control study was performed to retrospectively collectclinical data of 46 DD patients, including 16 males and 30 females with median age of 51 (20 to 70) years, at Nanjing Hospital of Chinese Medicine from February 2012 to April 2015.All the patients met the diagnostic criteria of functional constipation of Rome III. The paradoxical contraction of puborectalis (PR) muscle was found by both rectal examination and anorectal manometry. In the same period,45 healthy volunteers, including 22 males and 23 females with median age of 48 (21 to 72) years, without pelvic operation history, and with normal defecation in recent 6 months, were enrolled as the control group. No significant differences were observed in age and gender between two groups (both P>0.05). Cleveland constipation score of DD group was higher than that of control group [15(8-24) vs. 5(1-9), t=15.720, P<0.001]. 3D-EAUS examination was performed in all the subjects. Thickness and length of internal anal sphincter (IAS) (anterior side and posterior side), thickness of PR muscle, length of external anal sphincter (EAS) plus PR muscle, and puborectalis angle were measured and compared by using student t test between two groups. Correlation between these ultrasound parameters and anorectal manometry was examined by Pearson correlation analysis. Results: Both male and female in the DD group had the greater thickness of IAS, as compared to those in the control group [male: (1.7±0.5) mm vs.(1.5±0.2) mm, t=2.516, P=0.016; female: (1.9±0.4) mm vs.(1.6±0.5) mm, t=2.034,P=0.047]. No significant differences between the two groups were observed with respect to the posterior length of IAS, length of EAS plus PR muscle, and thickness of PR muscle (all P>0.05). Compared to the control group, male in the DD group had smaller puborectalis angle during straining [(87.0±3.6)° vs. (90.5±1.8)°,t=3.502,P=0.002];female in the DD group had smaller puborectalis angle both in resting and straining [resting:(86.5±3.8)° vs. (90.1±2.1)°,t=4.047, P<0.001;straining: (84.1±4.5)° vs. (90.2±2.3)°, t=5.938, P<0.001]. Correlation analysis showed that anterior length of IAS was positively correlated with anal resting pressure (r=0.321, P=0.030); the length of EAS plus PR muscle was positively correlated with anal squeeze pressure (r=0.415, P=0.004). There were no correlations between the thickness and the posterior length of IAS and the anal resting pressure, or between the thickness of PR muscle and the anal squeeze pressure (all P>0.05). Conclusions: The 3D-EAUS can accurately assess the morphological features of anal canal in DD patients. There is a certain positive correlation between 3D-EAUS and anorectal manometry.

EP22.10: Study on the effects of delivery modes on the integrity and thickness of puborectalis muscle using three‐dimensional transperineal ultrasound

EP22.10: Study on the effects of delivery modes on the integrity and thickness of puborectalis muscle using three‐dimensional transperineal ultrasound

Role of three-dimensional endoanal ultrasound in assessing the anal sphincter morphology of female patients with chronic proctalgia.

AIMTo assess the role of three-dimensional endoanal ultrasound (3D-EAUS) for morphological assessment of the anal sphincter of female patients with chronic proctalgia (CP).METHODSIn this unmatched case control study, 30 consecutive female patients with CP and 25 normal women (control group) were enrolled. 3D-EAUS was performed in all subjects. Thickness and length of internal anal sphincter (IAS), thickness of puborectalis muscle (PR), length of the external anal sphincter (EAS) plus PR, and puborectalis angle were measured and compared between the two groups.RESULTSPatients with CP had significantly shorter IAS length and greater PR thickness, as compared to those in normal individuals (26.28 ± 3.59 mm vs 28.87 ± 4.84 mm, P < 0.05 and 9.67 ± 1.57 mm vs 8.85 ± 0.97 mm, P < 0.05, respectively). No significant between-group differences were observed with respect to IAS thickness and the EAS plus PR length (P > 0.05). Puborectalis angle in the CP group was significantly decreased, both in resting (88.23° ± 1.81° vs 89.94° ± 2.07° in control group, P < 0.05) and straining (88.47° ± 3.32° vs 90.72° ± 1.87° in control group, P < 0.05) phases, which suggest the presence of paradoxical contraction of PR in patients with CP. In the CP group, no significant difference in puborectalis angle was observed between the resting and straining phases (88.23° ± 1.81° vs 88.47° ± 3.32° respectively, P > 0.05).CONCLUSIONThe association of greater PR thickness and paradoxical contraction of PR with CP suggest their potential value as markers of CP.

Pelvic floor musculature and bladder neck changes before and after continence recovery after radical prostatectomy in pelvic MRI

To evaluate the changes in pelvic floor anatomy using MRI before and after continence recovery after radical prostatectomy (RP). Thirteen men with prostate cancer who underwent RP (mean age, 67.4 ± 8.8 years) volunteered for this study. Prostate MRIs were performed during the preoperative (i), incontinent (ii), and continent (iii) periods. The membranous urethra length (MUL), puborectalis muscle (PRM) thickness, and the position of the bladder neck in relation to the pubic bone (Dx) and the pubococcygeous line (Dy) were measured. We compared all parameters in the preoperative, incontinent, and continent periods. MUL2 and MUL3 was significantly longer compared with MUL1, although no difference was found between MUL2 and MUL3. PRM3 thickness was significantly increased compared with PRM2 thickness. The Dx of the continence period was shorter than that of the incontinence period. The Dy of the continence period was longer than that of the incontinence period. The PRM thickened and the bladder neck moved upward and forward during the continence period. The changes in PRM thickness and the position of bladder neck may play an important role in the recovery of continence after RP.

Transperineal three‐dimensional ultrasound in evaluating anal sphincter muscles

To evaluate whether transperineal three-dimensional (3D) ultrasound can be used to depict normal anal sphincter anatomy and to measure the thickness of muscle layers and the anteroposterior length of the levator hiatus. The study included 22 normal nulliparous female volunteers. Transperineal 3D sonographic evaluation of the anal canal included assessment of sphincter shape, echogenicity, marginal definition and muscle thickness. Measurements of the thickness of the internal anal sphincter (IAS) and puborectalis muscle (PRM) were determined with the women at rest and during squeezing by two observers, and interobserver reliability was determined. The anteroposterior length of the levator hiatus at rest and during squeezing was measured. The proximal end of the anal canal (towards the rectum) consisted of overlapping IAS and PRM, and the distal end (towards the anus) consisted of overlapping IAS and external anal sphincter (EAS). At the PRM level, the mean +/- SD IAS thickness was 2.3 +/- 0.5 mm at rest and 2.5 +/- 0.4 mm during squeezing, and at the mid-EAS level it was 2.9 +/- 0.5 mm at rest and 2.8 +/- 0.5 mm during squeezing. The PRM thickness was 6.5 +/- 1.0 mm at rest and 6.4 +/- 1.2 mm during squeezing. The difference in muscle thickness of the sphincter layers with the woman at rest and during squeezing was not significant. The anteroposterior length of the levator hiatus was 51.7 +/- 5.0 mm at rest and 47.4 +/- 4.1 mm during squeezing (P < 0.01). Transperineal 3D ultrasound may be useful in evaluating the anatomy of the anal canal.

Levator ani abnormality 6 weeks after delivery persists at 6 months

Assess postpartum changes in the levator ani muscle using magnetic resonance imaging and relate these changes to obstetric events and risk factors associated with pelvic floor dysfunction. A board-certified radiologist specializing in abdominal imaging evaluated 146 pelvic magnetic resonance studies from 57 primiparous women 6 weeks and 6 months after first obstetric delivery and 32 nulliparous women. A yes/no determination of muscle body and insertion integrity, muscle thinning, and measurement of muscle thickness in millimeters was made for each of 4 muscle sites: right and left puborectalis and right and left ileococcygeous. Incidence of muscle abnormality and mean muscle thickness was tested in pairs between (1) nulliparous women and 6-week primiparous women; (2) 6 week and 6 month primiparous pairs; and (3) 3 age/race groups using test of 2 proportions and 1-way analysis of variance. Initial review indicated only 3 subjects not of African American or white race, and only 1 African American primiparous woman of age 30 years or older; therefore, statistical analysis was limited to 45 primiparous women and 25 nulliparous women. Incidence of any abnormality at any of the 4 sites was considered abnormal. In those subjects recovering to normal magnetic resonance by 6 months, an average of nearly 60% increase in right puborectalis muscle thickness compared with that seen at 6 weeks indicated the extent of the injury. Subjects with injury to both the puborectalis and ileococcygeous at 6 weeks did not recover to normal at 6 months, whereas those with injury only to the puborectalis tended to have normal magnetic resonance images at 6 months. Nulliparity did not guarantee a normal assessment of levator ani anatomy by our blinded reader, and frequency of injury in this series is somewhat greater than that previously reported for primiparous women. Younger white primiparous women had a better recovery at 6 months than older white women. Subjects experiencing more global injury, in particular to the ileococcygeous, tended not to recover muscle bulk.