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Murdoch-Ward J, Nahon I, De-Vitry Smith S, Bernardi E, Woods T. Assessment of the bearing-down manoeuvre in pregnancy and detection of paradoxical levator ani muscle contraction using 2D transperineal ultrasound and vaginal palpation: a concurrent validity and inter-rater reliability study. BJOG 2024; 131:843-847. [PMID: 37846213 DOI: 10.1111/1471-0528.17694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 10/01/2023] [Accepted: 10/03/2023] [Indexed: 10/18/2023]
Abstract
OBJECTIVE To examine the concurrent validity and inter-rater reliability of vaginal palpation as a measure of the quality of the bearing-down manoeuvre (BDM) and the detection of a paradoxical levator ani muscle contraction (LAM) in pregnant women, compared with 2D transperineal ultrasound (TPUS). DESIGN Concurrent validity and inter-rater reliability study. SETTING Physiotherapy clinic. POPULATION Twenty pregnant women in their third trimester. METHODS The anterior posterior diameter (APD) was measured during the BDM using TPUS by one experienced physiotherapist. An APD that shortened by >2 mm from rest was described as LAM shortening, an APD that moved by 0-2 mm was described as no change and an APD that lengthened by >2 mm was described as LAM lengthening. Vaginal palpation described the LAM during the BDM as no movement, shortening or lengthening. Participants were allowed two attempts and the best attempt was measured. MAIN OUTCOME MEASURES APD using TPUS and the assessor's subjective description of LAM during the BDM using vaginal palpation. RESULTS TPUS detected more paradoxical LAM contractions during the BDM than palpation. Agreement between vaginal palpation and TPUS assessment for BDM was poor. The Fleiss kappa coefficients were 0.457 (90% CI 0.16-0.71) between TPUS and one assessor and 0.326 (90% CI 0.01-0.6) between TPUS and the other assessor. In addition, inter-rater reliability was poor between observers palpating the BDM, with a Fleiss kappa coefficient of 0.375 (90% CI 0.13-0.64). CONCLUSIONS This study did not find vaginal palpation of the BDM in pregnant women to have concurrent validity or inter-rater reliability. Clinicians should be aware of potential inaccuracies when palpating the BDM, and, where possible, seek an assessment via TPUS.
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Affiliation(s)
- Joelene Murdoch-Ward
- Faculty of Health, University of Canberra, Canberra, Australian Capital Territory, Australia
- The Physiotherapy Clinic, Sydney, New South Wales, Australia
| | - Irmina Nahon
- Faculty of Health, University of Canberra, Canberra, Australian Capital Territory, Australia
| | - Sally De-Vitry Smith
- Faculty of Health, University of Canberra, Canberra, Australian Capital Territory, Australia
| | - Eliza Bernardi
- The Physiotherapy Clinic, Sydney, New South Wales, Australia
| | - Tamara Woods
- The Physiotherapy Clinic, Sydney, New South Wales, Australia
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García-Mejido JA, Martín-Martinez A, García-Jimenez R, González-Diaz E, Núñez-Matas MJ, Fernández-Palacín F, Carballo-Rastrilla S, Fernández-Fernández C, Sainz-Bueno JA. Is the Presence of Levator Ani Muscle Avulsion Relevant for the Diagnosis of Uterine Prolapse? JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2024; 43:265-272. [PMID: 37853913 DOI: 10.1002/jum.16356] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 09/23/2023] [Accepted: 10/01/2023] [Indexed: 10/20/2023]
Abstract
OBJECTIVE To determine if the addition of the assessment of levator ani muscle (LAM) avulsion to the measurement of the difference in the pubis-uterine fundus distance between rest and with the Valsalva maneuver could increase the diagnostic capacity of ultrasound for uterine prolapse (UP). METHODS This multicenter, observational and prospective study included 145 patients. Ultrasound assessment was performed, establishing the diagnosis of UP as a difference between the pubic-uterine fundus distance at rest and during the Valsalva maneuver ≥15 mm (standard technique), while LAM avulsion was defined as an abnormal LAM insertion in three central slices using multislice ultrasound. A binary multivariate logistic regression model was made using nonautomated methods to predict surgical UP (general population, premenopausal, and postmenopausal patients), including the difference between the pubis-uterine fundus distance at rest and with the Valsalva maneuver as well as LAM avulsion. RESULTS A total of 143 patients completed the study. The addition of LAM avulsion criteria to the standard dynamic distance-based protocol for the diagnosis of UP resulted in a higher sensitivity for the general population (79.7 vs 68.1%) as well as for premenopausal (89.3 vs 79.9%) and postmenopausal patients (76 vs 66.1%). In contrast, the standard technique showed a higher specificity than the model based on the standard technique associated with LAM avulsion for the general population (89.2 vs 74.3%) and premenopausal women (91.7 vs 63.2%). For postmenopausal patients, the model based on the standard technique associated with LAM avulsion had a higher sensitivity (76 vs 66.1%) and specificity (91.7 vs 86.8%) than the ultrasound diagnosis of UP. CONCLUSION The implementation of the assessment of LAM avulsion in the ultrasound diagnosis of UP is useful in postmenopausal patients, increasing sensitivity and specificity relative to the ultrasound assessment based only on the difference between the pubis-uterine fundus distance at rest and with the Valsalva maneuver.
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Affiliation(s)
- José Antonio García-Mejido
- Department of Obstetrics and Gynecology, Valme University Hospital, Seville, Spain
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Seville, Seville, Spain
| | - Alicia Martín-Martinez
- Department of Obstetrics and Gynecology, University Healthcare Complex of Gran Canaria, Gran Canaria, Spain
| | - Rocío García-Jimenez
- Obstetrics and Gynecology Department, Juan Ramon Jiménez Hospital, Huelva, Spain
| | - Enrique González-Diaz
- Department of Obstetrics and Gynecology, University Healthcare Complex of Leon (CAULE), Leon, Spain
| | - María José Núñez-Matas
- Department of Obstetrics and Gynecology, Virgen de la Victoria University Hospital of Malaga, Malaga, Spain
| | | | - Sonia Carballo-Rastrilla
- Department of Obstetrics and Gynecology, University Healthcare Complex of Gran Canaria, Gran Canaria, Spain
| | | | - José Antonio Sainz-Bueno
- Department of Obstetrics and Gynecology, Valme University Hospital, Seville, Spain
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Seville, Seville, Spain
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Okada Y, Nakagawa C, Shigeta M, Nomura Y, Inoue E, Ichizuka K, Yoshimura Y. Evaluation of levator ani muscle elasticity after vaginal delivery and cesarean section using shear wave elastography. J Med Ultrason (2001) 2024; 51:95-101. [PMID: 37740863 PMCID: PMC10904486 DOI: 10.1007/s10396-023-01369-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 08/30/2023] [Indexed: 09/25/2023]
Abstract
PURPOSE The risk of pelvic floor muscle injury is commonly considered to be higher in vaginal than in cesarean delivery. This study aimed to compare levator ani muscle (LAM) elasticity after vaginal and cesarean delivery using shear wave elastography (SWE). METHODS Postpartum women who underwent a single SWE evaluation 1 month after their first delivery were divided into vaginal and cesarean delivery groups. The elastic moduli of both sides of the LAM were measured in a horizontal section and compared between the groups. In addition, a subgroup analysis was performed to compare LAM elasticity according to the delivery method within the vaginal delivery group-normal vaginal delivery, episiotomy, and operative vaginal delivery. RESULTS Sixty-two women were included (vaginal delivery, n = 47; elective cesarean section, n = 15). Multiple regression analysis revealed that the LAM elastic modulus was significantly lower in the vaginal delivery group than in the cesarean delivery group (right LAM: 44.2 vs. 72.7 kPa, p = 0.0036; left LAM 40.4 vs. 82.7 kPa, p < 0.0001). In the subgroup analysis, the right LAM elastic modulus was significantly lower in the operative vaginal delivery subgroup than in the normal vaginal delivery subgroup (p = 0.0131). However, there was no significant difference in the left LAM elastic modulus between the three subgroups. CONCLUSION LAM elasticity was significantly lower after vaginal delivery than after cesarean delivery. Furthermore, the elasticity of the right LAM was lower after operative vaginal delivery than after normal vaginal delivery. SWE has the potential to provide an objective quantitative assessment of postpartum pelvic floor muscle recovery.
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Affiliation(s)
- Yoshiyuki Okada
- Department of Female Pelvic Health Center, Showa University Northern Yokohama Hospital, 35-1 Chigasaki-Chuo, Tsuzuki-Ku, Yokohama City, Kanagawa, 224-8503, Japan.
- Department of Obstetrics and Gynecology, Showa University Northern Yokohama Hospital, Kanagawa, Japan.
| | - Chie Nakagawa
- Department of Female Pelvic Health Center, Showa University Northern Yokohama Hospital, 35-1 Chigasaki-Chuo, Tsuzuki-Ku, Yokohama City, Kanagawa, 224-8503, Japan
- Department of Obstetrics and Gynecology, Showa University Northern Yokohama Hospital, Kanagawa, Japan
| | - Miwa Shigeta
- Department of Female Pelvic Health Center, Showa University Northern Yokohama Hospital, 35-1 Chigasaki-Chuo, Tsuzuki-Ku, Yokohama City, Kanagawa, 224-8503, Japan
| | - Yukiko Nomura
- Department of Female Pelvic Health Center, Showa University Northern Yokohama Hospital, 35-1 Chigasaki-Chuo, Tsuzuki-Ku, Yokohama City, Kanagawa, 224-8503, Japan
- Department of Obstetrics and Gynecology, Showa University Northern Yokohama Hospital, Kanagawa, Japan
| | - Eisuke Inoue
- Showa University Research Administration Center, Tokyo, Japan
| | - Kiyotake Ichizuka
- Department of Obstetrics and Gynecology, Showa University Northern Yokohama Hospital, Kanagawa, Japan
| | - Yasukuni Yoshimura
- Department of Female Pelvic Health Center, Showa University Northern Yokohama Hospital, 35-1 Chigasaki-Chuo, Tsuzuki-Ku, Yokohama City, Kanagawa, 224-8503, Japan
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Zhao Y, Zhang C, Cui C, Zhang X, Zhao Q, Shen W. Longitudinal changes in pelvic organ support among primiparas with postpartum pelvic organ prolapse: A follow-up magnetic resonance imaging study. Int J Gynaecol Obstet 2023. [PMID: 36811173 DOI: 10.1002/ijgo.14718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 12/26/2022] [Accepted: 02/02/2023] [Indexed: 02/24/2023]
Abstract
OBJECTIVE To quantify morphological changes of pelvic floor in primiparas with postpartum pelvic organ prolapse (POP) during the early postpartum period. METHODS A total of 309 primiparas underwent pelvic floor magnetic resonance imaging (MRI) at 6 weeks postpartum. Those primiparas diagnosed with postpartum POP by MRI criterion were followed up at 3 and 6 months postpartum. Normal primiparas were enrolled in the control group. The puborectal hiatus line, muscular pelvic floor relaxation line, levator hiatus area, iliococcygeus angle, levator plate angle, uterus-pubococcygeal line, and bladder-pubococcygeal line were assessed on MRI. Longitudinal changes in pelvic floor measurements between the two groups were compared by repeated-measures analysis of variance. RESULTS Compared with the control group, enlarged puborectal hiatus line, levator hiatus area, and RICA and decreased uterus-pubococcygeal line were observed at rest in the POP group (all P < 0.05). All of the pelvic floor measurements were significantly different in the POP group compared with the control group at the maximum Valsalva maneuver (all P < 0.05). All of the pelvic floor measurements showed no significant change over time in both the POP and control groups (all P > 0.05). CONCLUSIONS Postpartum POP accompanied by poor pelvic floor support will persist in the early postpartum period.
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Affiliation(s)
- Yujiao Zhao
- Department of Radiology, The First Central Clinical College, Tianjin Medical University, Tianjin, China.,Department of Radiology, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin, China
| | - Cheng Zhang
- Department of Radiology, The First Central Clinical College, Tianjin Medical University, Tianjin, China
| | - Can Cui
- Department of Radiology, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, Zhejiang, China
| | - Xiaodong Zhang
- Department of Radiology, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin, China
| | - Qian Zhao
- Department of Obstetrics and Gynaecology, Tianjin First Central Hospital, Tianjin, China
| | - Wen Shen
- Department of Radiology, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin, China
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Wang Y, Wang H. Transvaginal Two-Dimensional Ultrasound Evaluation as a Screening Tool for Levator ani Muscle Avulsion in Postpartum Women. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2023; 42:161-169. [PMID: 35670590 DOI: 10.1002/jum.16037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 03/28/2022] [Accepted: 05/22/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES To evaluate the agreement between two-dimensional transvaginal ultrasound (2D-TVUS) and transperineal tomographic ultrasound imaging on three-dimensional (3D) volume in diagnosing levator ani muscle (LAM) avulsion of postpartum women. Furthermore, we tested the repeatability of the 2D-TVUS in measuring the LAM thickness. METHODS A retrospective study was performed using the data sets from postpartum women. One doctor measured the thickness of the LAM on the images at the attachment to the arcus tendinous levator ani and the middle part using the 2D-TVUS ultrasound data sets of postpartum women. These women were examined twice, at 42-56 days and 3-6 months postpartum. Intra-observer repeatability was expressed using intraclass correlation coefficients (ICCs). The other doctor judged whether there was avulsion in the LAM on the 2D-TVUS and transperineal tomography imaging on the 3D volume. The inter-method agreement was determined using Cohen's kappa coefficient (k). RESULTS Thickness measurements of the middle part and attachment of the LAM by 2D-TVUS showed excellent and good intra-observer repeatability (ICC 0.84; 95% CI, 0.76-0.88, and ICC 0.74; 95% CI, 0.67-0.84, respectively). The overall agreement was 92% (Cohen's kappa was 0.79) between 2D-TVUS and transperineal tomographic imaging. Compared to transperineal tomographic imaging in the diagnosis of LAM avulsion, the diagnostic sensitivity of 2D-TVUS was 91.7%, the specificity was 92.1%. CONCLUSIONS The 2D-TVUS technique, a simple and reproducible method for assessing LAM avulsion, may be helpful as a screening tool for LAM avulsion of postpartum women.
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Affiliation(s)
- Yue Wang
- Department of Ultrasound, Peking University Shenzhen Hospital, Shenzhen, China
| | - HuiFang Wang
- Department of Ultrasound, Peking University Shenzhen Hospital, Shenzhen, China
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Abstract
This article discusses various pelvic floor ultrasonographic modalities and the clinical applications of ultrasonography of the pelvic floor. Ultrasonography provides a detailed anatomic assessment of the muscles and surrounding organs of the pelvic floor. Different anatomic variabilities and pathologic conditions, such as prolapse, fecal incontinence, urinary symptoms, vaginal wall cysts, synthetic implanted material, and pelvic pain, are assessed with pelvic floor ultrasonography. This imaging modality is an important adjunct to the evaluation and diagnosis of pelvic floor disorders.
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Affiliation(s)
- Trang X Pham
- Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences, 800 Stanton L. Young Boulevard, Suite 2400, Oklahoma City, OK 73104, USA
| | - Lieschen H Quiroz
- Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences, 800 Stanton L. Young Boulevard, Suite 2400, Oklahoma City, OK 73104, USA.
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English EM, Chen L, Sammarco AG, Kolenic GE, Cheng W, Ashton-Miller JA, DeLancey JO. Mechanisms of hiatus failure in prolapse: a multifaceted evaluation. Int Urogynecol J 2021; 32:1545-1553. [PMID: 33399905 DOI: 10.1007/s00192-020-04651-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 12/10/2020] [Indexed: 12/26/2022]
Abstract
INTRODUCTION AND HYPOTHESIS We investigated whether factors influencing pelvic floor hiatal closure are inter-related or independent, hypothesizing that (1) hiatus size is moderately correlated with levator defect, pelvic floor muscle strength, and change in hiatus size with contraction and (2) urogenital hiatus (UGH) and levator hiatus (LH) measures are similar in patients with anterior wall (AW) and posterior wall (PW) prolapse. METHODS This cross-sectional case-control study included subjects with AW prolapse (n = 50), PW prolapse (n = 50), and normal support (n = 50). Hiatus measurements and levator defects were assessed on MRI, and vaginal closure force was measured with an instrumented speculum. Pearson correlation coefficients and simple and multivariable linear regression models were performed. RESULTS During contraction, LH narrowed 47% more in the PW compared to AW group (p = 0.001). With straining, LH lengthened 34% more in the PW than AW group (p < 0.001). With straining, UGH and LH lengthening was greater by 72% and 44% in those with major compared to no/minor defect (p < 0.001 and p = 0.004). Contraction strength explained, at most, 4% of UGH (r = 0.17) or LH (r = 0.20) shortening during contraction (r = 0.17 and r = 0.20, respectively), indicating that these factors are largely independent. After controlling for prolapse size, resting UGH and levator defect status were associated with straining UGH (p < 0.001, p = 0.004), but muscle strength and resting tone were not. CONCLUSIONS Hiatus measures are complex and differ according to prolapse occurrence and type. They are, at best, only weakly correlated with pelvic floor muscle strength and movement during contraction.
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Affiliation(s)
- Emily M English
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - Luyun Chen
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA.,Department of Mechanical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Anne G Sammarco
- Department of Obstetrics and Gynecology, Rush University Medical Center, Chicago, IL, USA
| | - Giselle E Kolenic
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - Wenjin Cheng
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA.,Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing, China
| | | | - John O DeLancey
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA. .,L4000 University Hospital South, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109, USA.
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Randomized controlled trial for improved recovery of the pelvic floor after vaginal delivery with a specially formulated postpartum supplement. Obstet Gynecol Sci 2020; 63:305-314. [PMID: 32489975 PMCID: PMC7231945 DOI: 10.5468/ogs.2020.63.3.305] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 11/07/2019] [Accepted: 11/26/2019] [Indexed: 11/12/2022] Open
Abstract
Objective To improve pelvic floor recovery after vaginal delivery with daily supplementation of a specially formulated postpartum recovery supplement. Methods Within 48 hours of vaginal delivery, primipara women were randomized in a 1:1 ratio to receive daily oral supplementation for 6 weeks with either a combination of regular prenatal vitamin (PNV), leucine (4 g/day), zinc (30 mg/day) and omega-3 fatty acid (900 mg/day) (treatment group), or only a PNV daily (control group). Co-primary outcomes were vaginal squeeze pressure as measured by perineometer and levator muscle injury as measured by transperineal 3-dimensional tomographic ultrasound at 6 weeks postpartum. Results Twenty-six women in the control group and 27 in the treatment group completed the trial. Weak pelvic floor muscle strength was significantly less frequent in the treatment group compared to the control group at 6 weeks after delivery (28% vs. 58%, P=0.03). Both right and left-sided levator-urethra gap was significantly larger in the control group compared to the treatment group indicating more levator injury being present in the control group at 6 weeks after delivery. Anterior vaginal wall prolapse at or beyond the hymenal ring was significantly more common in the control group compared to the treatment group (19% vs. 0%, P=0.02). Significantly more women reported bothersome bulge symptoms in the control group compared to the treatment group at 6 weeks postpartum (19% vs. 0%, P=0.02). Conclusion Postpartum women who received a specially formulated postpartum recovery supplement had improved recovery of the pelvic floor after vaginal delivery.
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Ultrasound imaging of the perineal body: a useful clinical tool. Int Urogynecol J 2019; 31:1197-1202. [PMID: 31828399 PMCID: PMC7270988 DOI: 10.1007/s00192-019-04166-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 10/25/2019] [Indexed: 11/30/2022]
Abstract
Introduction and hypothesis The perineal body is a fibromuscular pyramidal structure located between the vagina and the anus. It has been difficult to image because of its small size and anatomical location. This study used 2D transperineal ultrasound to measure the perineal body and assess whether there is an association with prolapse. Methods An observational, cross-sectional study was carried out in a tertiary level Urogynaecology department and included prolapse patients and healthy nulliparous volunteers (control group). This was a clinical assessment, including POP-Q and trans-perineal 2D ultrasound measurement of the perineal body height, length, perimeter, and area. Parametric tests were used, as the data were normally distributed. Results are reported as mean and 95% confidence interval (±95% CI). Results A total of 101 participants were recruited of which 22 were nulliparous healthy volunteers. Mean perineal body measurements in controls were height 22.5 ± 3.3 mm, length 17.4 ± 2.7 mm, perimeter 7.5 ± 0.9 mm, and area 2.8 ± 0.38 cm2. Perineal body measurements in 79 prolapse patients: height 16.9 ± 1.7 mm, length 16.0 ± 1.4 mm, perimeter 6.5 ± 0.5 mm and area 2.1 ± 0.5 cm2. A small perineal body was strongly associated with posterior compartment prolapse (paired t test, p < 0.0001) and wider POP-Q GH (paired t test, p = 0.0003). Surprisingly, Pelvic Organ Prolapse Quantification Perineal Body (POP-Q PB) of the two groups was not significantly different. A perineal body mid-sagittal area of less than 2.4 cm2 has been shown to be associated strongly with posterior compartment prolapse. Conclusions It is possible to measure the perineal body on 2D ultrasound. This technique facilitates the objective diagnosis of perineal deficiency. POP-Q PB does not predict the length or area of the perineal body.
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