Identification of Surgical Uterine Prolapse in Premenopausal Patients With Clinical or Ultrasound Criteria? A Multicenter Comparative Study

Influence of Transperineal Ultrasound on the POP-Q System in the Surgical Indication of Symptomatic Pelvic Organ Prolapse

Background/Objectives: The diagnostic capacity of the preoperative pelvic organ prolapse quantification (POP-Q) system to define surgical pelvic organ prolapse (POP) is sometimes limited. On the other hand, pelvic floor ultrasound can influence the surgical indication for patients with symptomatic POP. Therefore, our objective is to determine how transperineal ultrasound can influence the surgical indication for symptomatic POP. Methods: This is a prospective observational study conducted over two years including patients who underwent corrective surgery for symptomatic POP. All patients underwent a preoperative examination using the POP-Q system to assess POP. Patients in whom the pelvic floor specialist had diagnostic doubts about the stage of POP underwent an ultrasound examination of the POP. Before the surgical procedure and with the patient anesthetized, a new clinical examination was performed using the POP-Q system and surgical correction of the POP was executed when the patient had a decline to stage II or higher. Cohen's kappa coefficient of agreement was used to assess the agreement. Results: Of the 180 patients who met the inclusion criteria, 167 were included (99 with preoperative clinical examination and 68 with preoperative clinical examination and ultrasound study). The kappa index for the diagnosis of surgical uterine prolapse of the preoperative clinical examination (moderate correlation) was lower than the ultrasound examination (very good correlation) (0.493 p < 0.001 and 0.924 p < 0.001). The kappa index for the diagnosis of cervical elongation without surgical uterine prolapse also showed differences between the preoperative clinical examination (good correlation) and the ultrasound examination (very good correlation) (0.749 p < 0.001 and 0.853 p < 0.001). Conclusions: Transperineal ultrasound has a higher concordance than presurgical clinical examination, based on the POP-Q system, for detecting POP with central compartment surgical indication.

The Application of Shear Wave Elastography to Determine the Elasticity of the Levator Ani Muscle and Vaginal Tissue in Patients With Pelvic Organ Prolapse

OBJECTIVES

The changes of the extracellular matrix of the connective tissue have significantly contributed to the incidence of pelvic organ prolapse (POP). It seems reasonable that sonoelastography could be a useful tool to evaluate the elasticity of pelvic floor tissue in patients with POP and compare it to those without POP. The main aim of this pilot study was to determine if there are differences in the elasticity of the levator ani muscle (LAM) and vaginal tissue between patients with and without POP.

METHODS

Prospective observation study, including 60 patients (30 with POP and 30 without POP). Sonoelastography was performed to evaluate the elasticity (in kilopascals, kPa) of the following regions of interest: vagina at the level of middle third of the urethra; vagina at the level of the bladder trigone; vagina in the anterior and posterior fornix; vagina at the level of middle third of the anorectal canal; posterior third of the LAM.

RESULTS

A total of 60 patients completed the study (30 with POP, 30 without POP). In the POP group, 18/30 (60%) had an anterior vaginal wall prolapse, 3/30 (10%) a uterine prolapse, 15/30 (50%) a rectocele, and 6/30 (20%) a enterocele. Patients with POP had higher elasticity in all anatomical study areas, with statistically significant differences in the anterior fornix (13.6 vs 11.2 kPa; P: .012). A multiple regression (controlling age, menopausal stage, and parity) allowed to detect statistically significant differences in the elasticity of the middle third of the urethra (P: .03) and the middle third of the anorectal canal (P: .019).

CONCLUSION

It is possible to evaluate the elasticity of the LAM and vaginal tissue using sonoelastography, detecting a higher elasticity in patients with POP than in those without POP.

Is the Presence of Levator Ani Muscle Avulsion Relevant for the Diagnosis of Uterine Prolapse?

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.