Pelvic floor dysfunction at transperineal ultrasound and chronic constipation in women with endometriosis

Letter: Light in the lumen-The expanding role of intestinal ultrasound for functional symptoms in inflammatory bowel disease

This article is linked to Aliu et al papers. To view these articles, visit https://doi.org/10.1111/apt.17988 and https://doi.org/10.1111/apt.18196

Feasibility and reproducibility of new technique for measurement of transverse diameter of levator ani muscle hiatus using two-dimensional transperineal ultrasound in nulliparous women with term pregnancy

OBJECTIVES

The aim of the present study was two-fold. Firstly, we aimed to develop and describe a technique for measurement of the transverse diameter (TD) of the levator ani muscle (LAM) hiatus in the coronal view using two-dimensional (2D) transperineal ultrasound (TPUS) in nulliparous women with a term pregnancy. Secondly, we aimed to evaluate the feasibility and reproducibility of 2D-TPUS assessment of LAM hiatal TD and assess intermethod agreement between 2D-TPUS and three-dimensional (3D) TPUS measurement of TD in the axial plane, which is considered the gold standard in nulliparous women with term pregnancy.

METHODS

We recruited a group of nulliparous women with term pregnancy before the onset of labor. The study was conducted in two phases: Phase 1 involved developing and describing the 2D-TPUS technique for measuring LAM hiatal TD, and Phase 2 focused on assessing the technique's feasibility, reproducibility and intermethod agreement with 3D-TPUS measurement of LAM hiatal TD. In Phase 1, we enrolled 30 women. Each woman underwent acquisition of a 3D-TPUS volume, which was analyzed using multiplanar mode to identify and determine the appearance of the lateral borders of the LAM in the coronal plane, at the level of the plane of minimal hiatal dimensions. These borders were used as landmarks for TD measurement. Additionally, we measured the distance between the plane used for TD measurement and the center of the urethra in the axial view. In Phase 2, we recruited 100 women. Each woman underwent acquisition of three 2D-TPUS videoclips in the coronal plane, each encompassing a sweep of the entire LAM hiatus, and a 3D volume, all obtained during rest. On the 2D videoclips, TD was measured twice by one operator and once by another operator. In the 3D volume, TD was measured once, by one operator, in the axial plane; this measurement was considered the gold standard. Each operator was blinded to all other measurements during their assessments. We analyzed intraobserver and interobserver reproducibility and performed an intermethod (2D vs 3D) comparison. Bland-Altman analysis was conducted, and Levene's W0 test and Student's t-test were performed to explore clinical factors that might contribute to systematic differences.

RESULTS

In Phase 1, we identified successfully the landmarks denoting the lateral borders of the LAM hiatal TD in the coronal view. These appeared as two symmetrical hypoechogenic indentations located at the inner border of the hyperechogenic structure of the LAM, at the point of maximum distance between the two sides of the LAM. The distance between the urethra and the plane where TD should be measured using 3D-TPUS in the axial plane had a median of 4 mm and varied from 0 to 9 mm. This enabled us to describe a method for assessing LAM hiatal TD in the coronal plane using 2D-TPUS. In Phase 2, LAM hiatal TD was measured successfully in all 2D and 3D acquisitions from the entire group of 100 women. The analyses for intraobserver and interobserver reproducibility and the intermethod comparison (2D vs 3D) revealed almost perfect agreement in TD measurements using 2D-TPUS, with intraclass correlation coefficients of 0.95 (95% CI, 0.92-0.96), 0.87 (95% CI, 0.78-0.92) and 0.85 (95% CI, 0.78-0.90), respectively. The average differences between measurements were 0.1 mm for intraobserver, 1.0 mm for interobserver and 0.2 mm for intermethod repeatability. No systematic differences were observed in any of the measurement sets, except in the interobserver analysis, although this difference was clinically not significant (38.2 vs 37.2 mm, P = 0.01). None of the examined clinical factors (maternal body mass index and maternal age) exhibited a statistically significant impact on intraobserver, interobserver or intermethod reliability.

CONCLUSIONS

Utilizing our technique, described herein, to measure the LAM hiatal TD in the coronal view using 2D-TPUS is not only feasible but also highly reproducible and accurate in nulliparous women with term pregnancy. Moreover, it yields measurements that are comparable to those obtained in the reconstructed axial plane generated by 3D-TPUS. © 2024 International Society of Ultrasound in Obstetrics and Gynecology.

A preoperative predictive model for stage IV endometriosis

This was a retrospective study that evaluated a total of 280 patients who underwent surgery for complete removal of endometriosis to develop and validate the predictive model for stage IV endometriosis. The differences between stage I-III and stage IV endometriosis were performed by logistic regression. A model for the prediction of stage IV endometriosis was constructed, which was subsequently validated. The independent variables were visual analogue scale (VAS)≥4 [3.855, 95% confidence interval (CI): 1.675-8.871, p = 0.002], painful nodularity on uterosacral ligaments (13.954, 95% CI: 1.658-117.423, p = 0.015), and bilateral endometriosis (5.933, 95% CI: 1.931-18.225, p = 0.002). The AUC of the model was 0.777, with a sensitivity of 71.9% and specificity of 76.3% for stage IV endometriosis. Therefore, a complete collection of patient information prior to surgery, asking about pain and VAS scores, careful completion of pelvic examinations, and application of imaging techniques are conducive to better diagnosis and prediction of advanced endometriosis.IMPACT STATEMENTWhat is already known on this subject? Endometriosis, a chronic disease causing pain and infertility, is characterised by endometrial-like tissue outside the uterine cavity, which is often treated via surgery at present. Considering the risks of surgery, it is necessary to identify patients with stage IV endometriosis through non-invasive predictive models for adequate preparation for surgery. However, there is no reliable non-invasive predictive model now, despite utilisation of patient medical history, symptoms especially pain-related ones, pelvic examinations, laboratory examinations, and images in the preoperative diagnosis of endometriosis in the clinic.What do the results of this study add? A model developed based on three simple, accessible and non-invasive indicators displays good performance in predicting stage IV endometriosis.What are the implications of these findings for clinical practice and/or further research? It is conducive to diagnosing and predicting advanced endometriosis before surgery, so as to reduce the difficulty and improve the safety of surgery.

An Evaluation of the Effects of Gestational Weight Gain on the Early Postpartum Pelvic Floor Using Transperineal Ultrasound

OBJECTIVES

We herein evaluated the effects of gestational weight gain (GWG) on postpartum pelvic floor function using transperineal ultrasound (TPUS).

METHODS

We analyzed retrospectively the data from 228 primiparous women with singleton pregnancies who were evaluated for postpartum pelvic floor function between February 2022 and October 2022. According to the 2009 Institute of Medicine guidelines regarding GWG, subjects were separated into three groups: inadequate GWG, recommended GWG, and excessive GWG. All underwent TPUS 6-10 weeks postpartum to assess bladder neck descent between rest and Valsalva (BND), retrovesical angle at Valsalva (RVA), urethral rotation angle between rest and Valsalva (URA), the area of levator hiatus at Valsalva (LHA), and abnormal pelvic floor function. Univariate and multivariate regression analyses were applied to explore the association measures between GWG and the pelvic floor. A P-value <.05 was considered statistically significant.

RESULTS

Of the 228 primiparous women, 113 (49.6%) showed excessive GWG. Univariate analysis revealed that there were no statistical differences in ultrasonic parameters of the pelvic floor among the three groups (P > .05). After adjusting for potential confounders and using the recommended GWG group as a reference group, inadequate GWG was significantly associated with BND ≥25 mm (OR = 0.36, 95% CI = 0.14-0.93), and excessive GWG was significantly associated with uterine prolapse (OR = 2.79, 95% CI = 1.13-6.92).

CONCLUSIONS

GWG was associated with the ultrasonic parameters of the female pelvic floor in the early postpartum period.

Endometriosis, infertility and occupational life: women's plea for recognition

The objective of this study was to explore and describe the specificities of the occupational life of infertile endometriotic women treated by in vitro fertilization. We conducted a qualitative monocentric study between December 2020 and June 2021. Twelve semi-structured in-depth interviews using a theme-based interview guide with open questions were undertaken with infertile women with deep infiltrating endometriosis. Data analysis was conducted using an inductive approach according to the grounded theory method. Three main themes emerged from the interviews: (i) barriers to reconciling illness and work life, (ii) facilitating factors for well-being at work, and (iii) consequences and outlooks. It appeared that the time of infertility treatment represents a particular period of change in the working lives of women with endometriosis. For most women, these changes are experienced negatively, often with a renunciation of goals. For others, this is the time to communicate the difficulties linked to their illness to their professional entourage. There is a long path ahead to finally achieving recognition of endometriosis in the context of professional life.

Applicability of polygenic risk scores in endometriosis clinical presentation

Background

Risk prediction is an essential part of preventative medicine and in recent years genomic information has become an interesting factor in risk models. Polygenic risk scores (PRS) combine the effect of many genetic variations into a single score which has been shown to have predictive value for many diseases. This study aimed to investigate the association between PRS for endometriosis and the clinical presentation of the disease.

Methods

Women with endometriosis (N = 172) were identified at the Department of Gynecology. All participants answered questionnaires regarding sociodemographic factors, lifestyle habits and medical history, registered bowel symptoms on the Visual Analog Scale for Irritable Bowel Syndrome and passed blood samples. DNA was extracted and samples were genotyped, and a PRS was calculated based on previous genome-wide association studies of endometriosis. Inflammatory proteins and TSH receptor antibodies (TRAb) in serum were analyzed.

Results

Inverse associations were identified between PRS and spread of endometriosis, involvement of the gastrointestinal tract and hormone treatment. However, significance was lost when calculated as p for trend and the specificity and sensitivity were low. There were no correlations between PRS and TRAb or inflammatory proteins.

Conclusion

The findings indicate that specific PRS should be developed to predict clinical presentations in patient with endometriosis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-022-01788-w.

Efficacy of Magnetic Therapy in Pain Reduction in Patients with Chronic Pelvic Pain: A Systematic Review

Chronic pelvic pain (CPP), also known as chronic pelvic pain syndrome (CPPS), is a common and painful condition. However, its treatment is still a challenge. The findings about the beneficial effects of electromagnetic therapy provide a new, potentially valid, therapeutic alternative for the management of patients with CPP. Objectives: to analyze the efficacy of magnetic field therapy in pain reduction in patients with CPP and for other variables, such as urinary symptoms and quality of life, as well as to review the evidence, in order to establish an action protocol. A qualitative systematic review was carried out, based on the PRISMA protocol and registered in PROSPERO (CRD42022285428). A search was performed in the PubMed, Medline, Scopus, Cochrane, PEDro, BVS, and WOS databases, including those articles in which the patients suffered from CPP; the study variable was pain, and the intervention was based on the application of magnetic fields. Results: Among the 81 articles found, five clinical trials were considered (with an average score of 7.2 in the PEDro scale), with a total of 278 participants, most of whom presented improvements in perceived pain (p ≤ 0.05), as well as in quality of life (p < 0.05) and urinary symptoms (p = 0.05), evaluated through the NIH-CPSI and VAS scales. The therapy was conducted as a monotherapy or in combination with a pharmacological treatment. There was no common protocol among the different articles. Conclusions: Intervention programs through electromagnetic therapy, on their own or with other therapies, can be effective in patients with CPP.