Ultrasound imaging of the pelvic floor. Part II: three-dimensional or volume imaging

Prevalence of levator ani muscle injuries in primiparous women after delivery and their influence on pelvic floor disorders-systematic review

BACKGROUND

Studies show a significant association between the first vaginal delivery and injuries of the levator ani muscle (LAM), which can cause pelvic floor disorders (PFDs).

OBJECTIVES

This study aims to identify the prevalence of short and long-term LAM injuries after vaginal delivery in primiparous women and its influence on PFDs.

METHOD

A systematic review was conducted according to the PRISMA methodology. The databases used were Pubmed, Cochrane, and PEDro. The quality assessment of the evidence was carried out using the Critical Appraisal Skills Programme (CASP). Both the selection of studies and their evaluation were done by two researchers and a third reviewer in cases of disagreement.

RESULTS

From the search, 57 articles were gathered, and 19 were included to match the eligibility criteria. The prevalence of avulsion of the LAM was found in association with vaginal delivery between 13% and 28% ≤ 1 year after delivery and between 16% and 29% > 1 year after delivery. Ballooning was detected between 20% and 37% ≤ 1 year, and 33% of women > 1 year after delivery, appearing to be more common when compared to avulsion. Pelvic organ prolapse (POP) was considered the most common disorder associated with injuries of the LAM, and there seems to be some connection with sexual dysfunction.

CONCLUSION

Avulsion of the LAM and ballooning of the hiatal area have a high prevalence in primiparous women after vaginal delivery and have a strong direct relation to the development of POP.

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.

Coronal Plane Assessment for Levator Trauma

OBJECTIVE

Levator avulsion is a major etiological factor of pelvic organ prolapse (POP) and is primarily diagnosed on tomographic axial plane imaging. Two-dimensional imaging can also image the levator. The objective was to test reproducibility and validity of coronal plane assessment for diagnosis of levator trauma by assessing the coronal plane obtained on tomographic ultrasound imaging.

METHODS

A retrospective study of women who had undergone an interview, POPQ and four-dimensional translabial ultrasound at a tertiary urogynecological unit. Post-processing of archived volume data was performed for assessment; and levator muscle area and estimate of remnant muscle mass in the coronal plane. Interobserver reproducibility of the latter two measures and associations between various measures of levator trauma and POP were tested.

RESULTS

Interobserver agreement was good for percentage estimates (ICC 0.743), but fair for area measurements (ICC 0.482). Six hundred and twenty four women were seen, 468 (75%) had significant clinical prolapse. Full levator avulsions were diagnosed in 137 (22%). Mean TTS was 2.7 (range 0-12). On coronal plane assessment average muscle area was 1.47 (SD 0.76) cm2 and 1.55 (SD 0.74) cm2 on the right and left, respectively (P = .005). It was 76% and 79% for average estimates of muscle mass (P = .021). Both measures were strongly associated with POP; however, they were not superior to TTS in predicting POP.

CONCLUSION

Coronal plane assessment in volume data is reproducible and valid for evaluation of levator trauma. Muscle mass estimate may be a better measure than muscle area.

Reliability and Reproducibility of Analyzing 3D Transperineal Ultrasound Volumes Obtained in the First Phase of Labor - A Pilot Study

PURPOSE

The aim of this study was to investigate the reliability and reproducibility of transperineal ultrasound (TPUS) in the initial phase of labor. As TPUS is a common method, it could supplement vaginal palpation and even replace it in certain situations. In addition, we used a 4-dimensional method for the assessment of cervical effacement.

MATERIALS AND METHODS

54 women in labor were included and underwent TPUS. The resulting images from the acquired 4D volumes were evaluated after the examination for the first time and a second time after 21 days. The measured values were cervical length, dilatation and effacement, the angle of progression (AoP), and head-perineum distance.

RESULTS

54 patients were examined. TPUS images were unable to be evaluated in 12 patients because of cervical dilatation of more than 5 cm or poor image quality. Thus, 42 measurements were included. The concordance correlation coefficients according to Lin are satisfactory overall, with one exception for cervical effacement. The accuracy component of cervical length (CCCLin: 0.93; accuracy: 1.00), dilatation (CCCLin: 0.93; accuracy: 1.00), and AoP (CCCLin: 0.87; accuracy: 1.00) is excellent and still high for the head-perineum distance (CCCLin: 0.89; accuracy: 0.96) and cervical effacement (CCCLin: 0.77; accuracy: 0.97).

CONCLUSION

TPUS is a valuable noninvasive tool with good diagnostic accuracy for the AoP, cervical length, and dilatation. Our study provides support for the use of TPUS to complement a vaginal examination. It should not replace a digital examination but should serve as a suitable alternative method for monitoring labor progression in the future.

Automated segmentation and measurement of the female pelvic floor from the mid-sagittal plane of 3D ultrasound volumes

BACKGROUND

Transperineal ultrasound (TPUS) is a valuable imaging tool for evaluating patients with pelvic floor disorders, including pelvic organ prolapse (POP). Currently, measurements of anatomical structures in the mid-sagittal plane of 2D and 3D US volumes are obtained manually, which is time-consuming, has high intra-rater variability, and requires an expert in pelvic floor US interpretation. Manual segmentation and biometric measurement can take 15 min per 2D mid-sagittal image by an expert operator. An automated segmentation method would provide quantitative data relevant to pelvic floor disorders and improve the efficiency and reproducibility of segmentation-based biometric methods.

PURPOSE

Develop a fast, reproducible, and automated method of acquiring biometric measurements and organ segmentations from the mid-sagittal plane of female 3D TPUS volumes.

METHODS

Our method used a nnU-Net segmentation model to segment the pubis symphysis, urethra, bladder, rectum, rectal ampulla, and anorectal angle in the mid-sagittal plane of female 3D TPUS volumes. We developed an algorithm to extract relevant biometrics from the segmentations. Our dataset included 248 3D TPUS volumes, 126/122 rest/Valsalva split, from 135 patients. System performance was assessed by comparing the automated results with manual ground truth data using the Dice similarity coefficient (DSC) and average absolute difference (AD). Intra-class correlation coefficient (ICC) and time difference were used to compare reproducibility and efficiency between manual and automated methods respectively. High ICC, low AD and reduction in time indicated an accurate and reliable automated system, making TPUS an efficient alternative for POP assessment. Paired t-test and non-parametric Wilcoxon signed-rank test were conducted, with p < 0.05 determining significance.

RESULTS

The nnU-Net segmentation model reported average DSC and p values (in brackets), compared to the next best tested model, of 87.4% (<0.0001), 68.5% (<0.0001), 61.0% (0.1), 54.6% (0.04), 49.2% (<0.0001) and 33.7% (0.02) for bladder, rectum, urethra, pubic symphysis, anorectal angle, and rectal ampulla respectively. The average ADs for the bladder neck position, bladder descent, rectal ampulla descent and retrovesical angle were 3.2 mm, 4.5 mm, 5.3 mm and 27.3°, respectively. The biometric algorithm had an ICC > 0.80 for the bladder neck position, bladder descent and rectal ampulla descent when compared to manual measurements, indicating high reproducibility. The proposed algorithms required approximately 1.27 s to analyze one image. The manual ground truths were performed by a single expert operator. In addition, due to high operator dependency for TPUS image collection, we would need to pursue further studies with images collected from multiple operators.

CONCLUSIONS

Based on our search in scientific databases (i.e., Web of Science, IEEE Xplore Digital Library, Elsevier ScienceDirect and PubMed), this is the first reported work of an automated segmentation and biometric measurement system for the mid-sagittal plane of 3D TPUS volumes. The proposed algorithm pipeline can improve the efficiency (1.27 s compared to 15 min manually) and has high reproducibility (high ICC values) compared to manual TPUS analysis for pelvic floor disorder diagnosis. Further studies are needed to verify this system's viability using multiple TPUS operators and multiple experts for performing manual segmentation and extracting biometrics from the images.

The role of Gestational Diabetes Mellitus and pelvic floor 3D-ultrasound assessment during pregnancy predicting urinary incontinence: a prospective cohort study

Postpartum urinary incontinence may have a severe impact on women's health. Despite pregnancy and parturition being the most recognized risk factors, methods to identify new pregnant predictor risk factors are needed. Our study investigated the Gestational Diabetes Mellitus, clinical and pelvic floor 3D-ultrasound markers in pregnant women as predictors for 6-18 months of urinary incontinence. This prospective cohort study included nulliparous pregnant women submitted to Gestational Diabetes Mellitus screening in the second trimester. Pelvic floor 3D Ultrasound was performed at the second and third trimesters of gestation to evaluate the pelvic floor muscles and functions. Clinical data, the ICIQ-SF, and ISI questionnaires for urinary incontinence were applied in the third trimester and 6-18 months postpartum. Univariate analysis (P < .20) to extract risk factors variables and multivariate logistic regression analysis (P < .05) to obtain the adjusted relative ratio for urinary incontinence were performed. A total of 93 participants concluded the follow-up. Using the variables obtained by univariate analysis and after adjustments for potential confounders, multivariate analysis revealed that Gestational Diabetes Mellitus exposure was a solid and independent risk factor for 6-18 months of urinary incontinence (Adjusted RR 8.08; 95%CI 1.17-55.87; P:0.034). In addition, a higher Hiatal area observed in distension maneuver from the second to third trimester was negatively associated (Adjusted RR 0.96; 95%CI 0.93-0.99; P:0.023). In conclusion, Gestational Diabetes Mellitus was positively associated with 6-18 months of urinary incontinence, and higher Hiatal area distension was negatively associated.

Factors involved in changes in the levator ani during pregnancy

INTRODUCTION AND HYPOTHESIS

Levator ani muscle (LAM) dimensions increase during pregnancy to allow the delivery of the fetus. The objective was to investigate which factors are involved in LAM modifications during pregnancy.

METHODS

A prospective longitudinal observational study was conducted between July 2015 and March 2018. Ninety-nine nulliparous pregnant women were included. Data on the physical examination, 4D transperineal ultrasound and hormonal concentrations (progesterone, oestradiol and relaxin) were collected during the first and third trimesters.

RESULTS

We found higher hiatal dimensions at the beginning of pregnancy than in other studies with nonpregnant women. Increases in the levator ani hiatal (LH) dimensions were observed at contraction (1.01 ±1.96 cm2), rest (0.82 ± 2.51 cm2) and on Valsalva (2.36 ± 3.64 cm2) throughout pregnancy. The distensibility in the third trimester was higher than in the first trimester (5.79 vs 4.24 cm2; p=0); however, the contractility was lower (-3.32 vs -3.5 cm2; p=0.04). Women with lower scores on the Modified Oxford Grading Scale in the third trimester presented with lower contractility in the LAM. A larger LH at the end of pregnancy was associated with age and body mass index. Eleven women developed ballooning during pregnancy; in these women, relaxin was higher in both trimesters than in women without ballooning, but these results were not statistically significant. The linear models to predict third-trimester Valsalva LH, distensibility and contractility were not conclusive and did not show any factors to predict LAM modifications during pregnancy.

CONCLUSIONS

Hormones could play a role in modifying the muscle properties of LAM from the beginning of pregnancy, but we did not find an association between LAM measurements and hormone concentration in this study.

A Qualitative and Quantitative Study to Evaluate the Effectiveness and Safety of Magnetic Stimulation in Women with Urinary Incontinence Symptoms and Pelvic Floor Disorders

Background and objectives: Involuntary loss of urine owed to dysfunction of the detrusor muscle or muscles of the pelvic floor is known as urinary incontinence (UI). In this study, ultrasound monitoring was employed for the first time to measure the usefulness and safety of electromagnetic stimulation for women with Stress or Urge UI. Materials and Methods: A total of 62 women were enrolled, with a mean age of 55.1 (±14.5); 60% of them were menopausal and presented with urinary incontinence (UI). Eight validated questionnaires were used to evaluate Stress UI, prolapse, overactive bladder urge, faecal incontinence, and quality of life, and the whole study population was tested with ultrasounds at the beginning and at the end of the treatment cycle. The device used was a non-invasive electromagnetic therapeutic system composed of a main unit and an adjustable chair applicator shaped for deep pelvic floor area stimulation. Results: Ultrasound measurements and validated questionnaires revealed a consistent and statistically significant (p < 0.01) improvement of the mean scores when pre- and post-treatment data were considered. Conclusions: Study results showed that the proposed treatment strategy led to a significant improvement in Pelvic Floor Muscle (PFM) tone and strength in patients with UI and pelvic floor disorders, without discomfort or side effects. The demonstration was qualitatively carried out with validated questionnaires and quantitatively with ultrasounds exams. Thus, the "chair" device we used represents valuable and effective support that could be widely employed in the gynaecological field for patients affected by different pathologies.

Diagnosis of maternal birth trauma by pelvic floor ultrasound

BRIEF SUMMARY

Maternal somatic birth trauma due to vaginal delivery is more common than generally assumed and an important cause of future morbidity. Maternal birth trauma may involve both psychological and somatic morbidity, some of it long-term and permanent. Somatic birth trauma is now understood to encompass not just episiotomy, perineal tears and obstetric anal sphincter injuries (OASI), but also trauma to the levator ani muscle, termed 'avulsion'. This review will focus on recent developments in the imaging diagnosis of maternal birth trauma, discuss the most important risk factors and strategies for primary and secondary prevention. Translabial and exo-anal ultrasound allow the assessment of maternal birth trauma in routine clinical practice and enable the use of levator avulsion and anal sphincter trauma as key performance indicators of maternity services. This is likely to lead to a greater awareness of maternal birth trauma amongst maternity caregivers and improved outcomes for patients, not the least due to an increasing emphasis on patient autonomy and informed consent in antenatal and intrapartum care.

Reducing pelvic floor injury by induction of labor

INTRODUCTION AND HYPOTHESIS

We hypothesized that elective induction of labor (eIOL) at 39 weeks is protective of levator ani muscle injury (LAMI) and is associated with decreased pelvic symptoms at 6 weeks postpartum compared to expectant management of labor.

METHODS

Prospective cohort pilot study of uncomplicated, primiparous women with a singleton, vertex gestation enrolled immediately post-vaginal delivery (VD). Subjects were dichotomized into two groups based on labor management: eIOL without complication defined by the ARRIVE trial versus spontaneous VD between 39 weeks0/7 and 42 weeks5/7 or no indication for IOL prior to 40 weeks5/7. The primary outcome was LAMI at 6 weeks postpartum as evidenced by any of the following ultrasound measures: (1) increased levator hiatal area (LHA) > 2500 mm2, (2) increased elasticity index (EI, > 75th quartile) or (3) levator enthesis avulsion.

RESULTS

Analysis represents 45/102 consented women from July 2019-October 2020 (eIOL n = 22 and spontaneous VD, n = 23). Neither maternal, clinical, sociodemographic characteristics nor pelvic symptoms differed between groups. Fewer women had LAMI as defined by the primary outcome with eIOL (n = 5, 23.8%) compared to spontaneous VD (n = 15, 65.2%), p = 0.008. Levator enthesis was more deformable (increased EI) with spontaneous VD as compared to the eIOL [10.66 (8.99) vs. 5.68 (2.93), p = 0.046]. On univariate logistic regression women undergoing spontaneous VD had unadjusted OR of 6.0 (1.6-22.5, p = 0.008) of sustaining LAMI compared to those undergoing eIOL.

CONCLUSIONS

Composite measures of LAMI though not pelvic floor symptoms were markedly increased in women undergoing spontaneous VD compared to those undergoing eIOL at 39 weeks.

All or nothing? A second look at partial levator avulsion

OBJECTIVE

To define associations between partial levator trauma and symptoms and signs of pelvic organ prolapse (POP).

METHODS

This was a retrospective study of 3484 women attending a tertiary urogynecology unit for symptoms of pelvic floor dysfunction between January 2012 and February 2020. All women underwent a standardized interview, clinical pelvic organ prolapse quantification (POP-Q) examination and tomographic ultrasound imaging of the pelvic floor. Women with full levator avulsion were excluded from analysis. Partial levator avulsion was quantified using the tomographic trauma score (TTS), in which slices 3-8 are scored bilaterally for abnormal insertions. Binomial multiple logistic regression was analyzed independently for the outcome variables prolapse symptoms, symptom bother and objective prolapse on clinical examination and imaging, with age and body mass index as covariates. Two continuous outcome variables, prolapse bother score and hiatal area on Valsalva, were analyzed using multiple linear regression.

RESULTS

Of the 3484 women, ultrasound data were missing or incomplete in 164 due to lack of equipment, clerical error and/or inadequate image quality. Full levator avulsion was diagnosed in 807 women, leaving 2513 for analysis. TTS ranged from 0-10, with a median of 0. Partial trauma (TTS > 0) was observed in 667/2513 (26.5%) women. All subjective and objective measures of POP were associated significantly with TTS, most strongly for cystocele. Associations were broadly linear and similar for all slice locations but disappeared after accounting for hiatal area on Valsalva.

CONCLUSION

Partial avulsion is associated with POP and prolapse symptoms. This association was strongest for cystocele, both on POP-Q and ultrasound imaging. The effect of partial avulsion on POP and prolapse symptoms is explained fully by its effect on hiatal area. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Associations of Maternal Complaints to Levator Ani Muscle Trauma within 9 Months after Vaginal Birth: A Prospective Observational Cohort Study

Introduction. Pelvic floor trauma in the form of partial or complete avulsions of the levator ani muscle (LAM) affects 6-42% of women after vaginal birth and can cause tremendous long-term morbidity. Many studies assessed morphological pelvic floor trauma after childbirth but lacked to evaluate women’s associated short-term complaints. A proper assessment of trauma and subjective complaints after birth could help to assess possible associations between them and their relevance to women’s daily life. Therefore, we aimed to assess women’s complaints within the first months after birth in association to their LAM trauma. Materials and Methods. Between 3/2017 and 4/2019, we prospectively evaluated vaginal births of 212 primiparous women with singletons in $\text{vertex}\text{presentation}\ge 36+0$ gestational weeks for levator ani muscle (LAM) trauma by translabial ultrasound, for pelvic organ prolapse by clinical examination, and for urogynecological complaints using questionnaires 1-4 days (P1), 6-10 weeks (P2), and 6-9 months (P3) after birth. The questionnaires were self-designed but oriented to and modified from validated questionnaires. Women’s complaints were evaluated for P1-P3 according to their LAM trauma state. Results. At P1, 67% of women showed an intact LAM, whereas 14.6% presented a hematoma, 6.6% a partial avulsion (PAV), and 11.8% a complete avulsion (CAV). At P2, 75.9% showed an intact LAM, 9.9% a PAV, and 14.2% a CAV. At P3, 72.9% of women with a LAM trauma in P1 and/or P2 were assessed with 21.6% being intact and 39.2% having a PAV and CAV, respectively. Obstetrical and baseline characteristics differed slightly between the groups. When comparing the time before and during pregnancy with the time after childbirth, birth itself affected women’s complaints in all LAM state groups, but the presence of a LAM trauma, especially a CAV, had more negative effects. Conclusions. Vaginal birth changes the anatomical structure of the maternal birth canal and genital tract, and it alters women’s perceptions and body function. In our study, LAM trauma did not change these effects tremendously within the first months. Therefore, other maternal, fetal, and obstetrical factors need consideration for the explanation of maternal complaints, in addition to long-term effects of trauma and dysfunction of the LAM and other birth canal structures.

Is age at menarche a predictor of maternal birth trauma?

OBJECTIVE

Age at menarche and the interval between menarche and age at first vaginal birth have been shown to be associated with reproductive performance; however, their association with maternal birth trauma has not been studied. We aimed to determine whether age at menarche, age at first vaginal birth and their interval are associated independently with levator ani muscle (LAM) avulsion and external anal sphincter (EAS) defect.

METHODS

This was a retrospective analysis of the ultrasound volume datasets of 466 vaginally parous patients attending one of two tertiary urogynecological units in Australia. All patients had undergone a standardized interview and clinical examination using the pelvic organ prolapse quantification staging system, followed by four-dimensional translabial ultrasound. Tomographic ultrasound imaging was used to evaluate the LAM for avulsion and the EAS for significant defect.

RESULTS

Of the 466 women analyzed, LAM avulsion was diagnosed in 121 (26.0%) and significant EAS defect in 55 (11.8%). Logistic regression analysis showed no association between age at menarche and LAM avulsion (P = 0.67). Weak but significant associations were noted between LAM avulsion and age at first vaginal birth (odds ratio (OR), 1.070 (95% CI, 1.03-1.11); P = 0.0007) and between LAM avulsion and menarche-to-first-vaginal-birth interval (OR, 1.064 (95% CI, 1.02-1.11); P = 0.0018). No significant associations were noted between significant EAS defect and any of the evaluated variables (all P ≥ 0.49).

CONCLUSIONS

Age at menarche is not predictive of maternal birth trauma i.e. LAM avulsion and EAS residual defect. There was a statistically significant association between LAM avulsion and menarche-to-first-vaginal-birth interval; however, this was not stronger than the previously established association between LAM avulsion and age at first vaginal birth, arguing against any distinct effect of prolonged prepregnancy hormonal stimulation on the biomechanical properties of the pelvic floor. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Ultrasound assessment of bladder descent and its correlation with prolapse severity in Chinese women: a prospective multicenter study

INTRODUCTION AND HYPOTHESIS

Translabial ultrasound is currently regarded as one of the most promising modalities in the evaluation of female pelvic organ prolapse. However, abnormal bladder descent on pelvic floor ultrasound has not been established among Chinese women. This study aimed to establish optimal cutoffs for defining bladder prolapse among Chinese women using translabial ultrasound.

METHODS

In this prospective multicenter study, 674 women with symptoms of lower urinary tract dysfunction and/or pelvic floor dysfunction were finally included and underwent interview, Pelvic Organ Prolapse Quantification (POP-Q) examinations and 4D translabial ultrasound. The receiver-operating characteristic (ROC) statistic was used to assess accuracy and define the optimal cutoffs.

RESULTS

The mean patient age was 42.6 (range, 19-82) years. Multivariable analysis showed that both POP-Q assessment and translabial ultrasound findings for anterior compartment were significantly associated with prolapse symptoms. The ROC statistics suggested an optimal cutoff value of 10 mm below the symphysis pubis of bladder position on Valsalva for predicting prolapse symptoms, with an area under the curve (AUC) of 0.73. Compared to translabial ultrasound, POP-Q stage showed similar accuracy for predicting prolapse symptoms (AUC: 0.74; P = 0.79), with an optimal cutoff of POP-Q stage ≥ 2.

CONCLUSIONS

This study proposed that the descent of the bladder to ≥ 10 mm below the symphysis pubis on Valsalva should be proposed as an optimal cutoff value for defining abnormal bladder prolapse on translabial ultrasound among the Chinese population. These cutoff values are nearly identical to those previously established in mainly Caucasian women.

Pelvic floor muscle dysfunction at 3D transperineal ultrasound in maternal exposure to gestational diabetes mellitus: A prospective cohort study during pregnancy

AIM

This study aimed to assess, for the first time, the dynamic morphometry of pelvic floor muscles (PFM) using three-dimensional transperineal ultrasound (3D-TPUS) and its progression at two-time points of gestation between women with and without gestational diabetes mellitus (GDM), and whether the PFM dysfunction is connected to GDM.

METHODS

The study comprised 83 consecutive pregnant women with (n = 38) and without (n = 45) GDM screened at 24-30 and 38-40 weeks of gestation. 3D-TPUS and a mobility test were used to quantify PFM dynamic morphometry during maximum contraction and the Valsalva maneuver.

RESULTS

When compared to the control group, GDM women had no significant variations in all levator hiatal dimensions at 24-30 weeks of gestation. Meanwhile, women with GDM experienced an increase in levator hiatal area (LHa) (p < 0.000) during PFM contraction and enlargement in LHa (p < 0.001) during Valsalva maneuver (p = 0.010) at 38-40 weeks of gestation. As a result, the mobility index among GDM women had a lower value (p = 0.000). The dynamic morphometry development of PFM in GDM women at two stages during pregnancy revealed a substantial decrease (p = 0.000) in all LHa dimensions of contraction, distension, and mobility.

CONCLUSIONS

Using 3D-TPUS, we found that GDM women had a specific pattern of PFM functional changes in the third trimester of pregnancy. These initial findings revealed alterations in PFM functionality, such as decreased contractility, distensibility, or mobility. This dysfunctional PFM could contribute to the long-term development of pelvic floor dysfunction years after a GDM pregnancy.

The impact of levator ani muscle trauma and contraction on recurrence after prolapse surgery

Introduction and hypothesis

The objective was to explore the impact of levator ani muscle (LAM) trauma and pelvic floor contraction on symptoms and anatomy after pelvic organ prolapse (POP) surgery.

Methods

Prospective study including 200 women with symptomatic POP ≥ grade 2 examined 3 months prior to and 6 months after surgery. Prolapse in each compartment was graded using the Pelvic Organ Prolapse Quantification (POP-Q) system, and women answered yes/no to a question about bulge sensation. Pelvic floor muscle contraction was assessed with transperineal ultrasound measuring proportional change in levator hiatal anteroposterior diameter from rest to contraction. LAM trauma was diagnosed using tomographic ultrasound imaging. Statistical analysis was performed using multivariate logistic regression analysis.

Results

A total of 183 women (92%) completed the study. Anatomical recurrence (POP ≥ grade 2) was found in 76 women (42%), and a bulge sensation was reported by 35 (19%). Ninety-two women (50%) had LAM trauma, and this was associated with increased risk of anatomical recurrence (OR 2.1 (95% CI 1.1–4.1), p = 0.022), but not bulge sensation (OR 1.1 (95% CI 0.5–2.4), p = 0.809). We found a reduced risk of bulge sensation for women with absent to weak contraction compared with normal to strong contraction (OR 0.4 (95% CI 0.1–0.9), p = 0.031), but no difference in risk for POP ≥ 2 after surgery (OR 1.5 (95% CI 0.8–2.9), p = 0.223).

Conclusions

Levator ani muscle trauma was associated with increased risk of anatomical failure 6 months after POP surgery. Absent to weak pelvic floor muscle contraction was associated with reduced risk of bulge sensation after surgery.

Four-dimensional ultrasound biometry following botulinum toxin type A injection to the pelvic floor

AIMS

The objective of this study was to provide follow-up data on four-dimensional ultrasound (4DUS) morphometry for women having botulinum toxin type A (BoNT-A) treatment of pelvic floor tension myalgia (PFTM).

MATERIALS AND METHODS

A prospective cohort study was performed from October 2013 to June 2018, recruiting women scheduled for BoNT-A injection in the pelvic floor musculature. Translabial 4DUS, vaginal pressure assessment by manometry and pain visual analog scales (VAS) were performed on all women before injection and again at 4, 12, and 26 weeks. The BoNT-A injection was performed under 4DUS guidance.

RESULTS

Twenty-nine women had 44 injections over the course of the study. Although improvements were seen in VAS scores for dysmenorrhea, nonmenstrual pelvic pain, and dyspareunia, there were no significant differences in ultrasound biometry at either rest, Valsalva, or on contraction when comparing postinjection measurements at 4, 12, and 26 weeks with pre-injection baseline. Similarly, vaginal pressure readings at rest demonstrated a significant improvement throughout the 4, 12, and 26 week follow-up, with a reduction in maximal contraction at 4 and 12 but not 26 weeks.

CONCLUSIONS

This study demonstrates that 4DUS biometry of the pelvic floor does not correlate with clinical pain and vaginal pressure outcomes for BoNT-A injection in the context of PFTM.

Importance of Translabial Ultrasound for the Diagnosis of Pelvic Organ Prolapse and Its Correlation with the POP-Q Examination: Analysis of 363 Cases

The incidence of pelvic organ prolapse (POP) is increasing in our aging society. We aimed to evaluate the clinical usefulness of translabial ultrasound (TLUS) by comparing the findings of POP-Q examination and TLUS in advanced POP patients and we also aimed to evaluate the prevalence of rectocele and enterocele on the TLUS. We analyzed the TLUS and POP-Q exam findings of 363 symptomatic POP patients who visited our clinic from March 2019 to April 2021. We excluded three patients who had conditions mimicking POP, as revealed by the TLUS. The most common POP type was anterior compartment POP (68.61%), followed by apical compartment (38.61%) and posterior compartment (16.11%) POP. Agreement between the POP-Q exam and TLUS was tested using Cohen’s kappa (κ). p values < 0.05 were considered statistically significant. The incidence of rectocele or enterocele was only 1.67% (6/360) and there was no rectocele or enterocele in most patients (246/252, 96.63%) when the POP-Q exam revealed posterior compartment POP, suggesting that they only had posterior vaginal wall relaxation. The positive predictive value of the POP-Q exam for detecting rectocele or enterocele (as revealed by TLUS) was only 2.38%, whereas the negative predictive value was 100%. In conclusion, the application of TLUS is useful in the diagnosis of POP, especially for differentiation of true POP from conditions mimicking POP. The correlation between the POP-Q exam and TLUS is low, especially in posterior compartment POP, and therefore, patients with POP-Q exam findings suggesting posterior compartment POP should undergo TLUS to check for rectocele or enterocele. The use of TLUS in the diagnosis of POP patients can improve the accuracy of the diagnosis of POP patients in conjunction with a POP-Q exam.

Levator plate descent angle in pelvic floor disorders

BACKGROUND

The levator plate descent angle (LPDA) quantifies the levator plate position with reference to the pubic bone and perineal body at rest. Unfortunately, research on this notable new parameter is lacking, but it is clear that levator ani deficiency (LAD) will undermine the fundamental role of the levator ani muscle (LAM) in organ support. The aim of this study was to establish the relationship between the LPDA and LAD in patients with pelvic floor disorders.

METHODS

This retrospective study was conducted at Seoul Songdo Hospital, Korea between August 2019 and August 2020 on women with symptoms of pelvic floor disorder such as urinary incontinence, constipation, and fecal incontinence. In all cases, three-dimensional pelvic floor ultrasound was performed for LAD scoring, minimal levator hiatus, and LPDA evaluation. We evaluated LAD using a scoring system that graded levator injury according to the insertion point of each subdivision scored unilaterally. For the entire LAM group, a cumulative LAD score that ranged between 0 and 18 was possible. Scores were categorized as mild (0-6 points), moderate (7-12 points), and severe (13-18 points) deficiency RESULTS: A total of 93 patients were included in the study (mean age 65.89 ± 11.12 [range, 34-86] years). Thirteen participants had mild LAD scores (14.0%), 42 had moderate LAD scores (45.2%), and 38 had severe LAD scores (40.9%). There was a significant difference in mean age (59.23 ± 12.55 years vs. 64.43 ± 10.03 vs. 69.79 ± 10.55 years, p = 0.005) and mean parity (1.85 ± 0.90 vs 2.48 ± 1.15 vs 2.76 ± 1.10, p = 0.038) of patients between groups. There was also a significant difference in the mean Wexner incontinence score (7.14 ± 3.63 vs 7.24 ± 5.76 vs 11.41 ± 5.54, p = 0.028) and in the mean fecal incontinence quality of life (FIQOL) score (12.91 ± 3.11 vs 14.10 ± 3.87 vs 10.41 ± 3.65, p = 0.014). The mean value of the LPDA in the group with mild LAD scores was 14.65° (SD ± 3.54) and in the group with moderate LAD scores was 9.66° (SD ± 3.36). In the group with severe LAD scores, the mean LPDA was 1.83° (SD ± 4.71). The mean value for minimal levator hiatus (MLH) area in the mild LAD score group was 14.16cm² (SD ± 2.72), that in the moderate LAD score group was 15.82cm² (SD ± 2.30), and that in the severe LAD score group was 17.99cm² (SD ± 2.81). There were significant differences between the three groups both in decreasing LPDA (p < 0.001) and increasing MLH (p < 0.001). There was a negative correlation between the LAD score and LPDA and the Pearson correlation coefficient was -0.528 (moderate correlation). There was a positive correlation between the LAD score and MLH, and the Pearson correlation coefficient was 0.303 (weak correlation).

CONCLUSIONS

The LAD score and LPDA have a moderate negative correlation. In patients with severe pelvic floor symptoms and extensive LAM injury, high LAD scores and low LPDA results were confirmed. In the treatment of patients with pelvic floor disorders, the LPDA seems to be a very useful parameter in determining the severity of structural defects.

Has the prevalence of levator avulsion after forceps delivery changed over the last six decades? A retrospective study in a urogynaecological population

OBJECTIVE

Forceps delivery is associated with a higher risk of maternal birth trauma. It is speculated that it is due to sub-optimal use of forceps in inexperienced hands. The aim of this study was to determine the association between time of forceps birth and prevalence of levator avulsion over the last six decades.

STUDY DESIGN

This was a retrospective analysis of datasets of women with a history of forceps delivery, seen at a tertiary urogynaecological centre between January 2014 and August 2018. They had undergone a standardized interview, clinical examination and four-dimensional translabial ultrasound. Archived imaging data was reviewed for levator avulsion offline at a later date, blinded against all clinical data. Associations between levator avulsion, maternal age at first vaginal birth, the weight of the first vaginally born baby, and time since forceps delivery categorised by decade were tested by univariable analysis. Factors found to be significant on univariable analysis were included in a multivariable logistic regression model to test the association between prevalence of levator avulsion and time of forceps delivery while controlling for confounders.

RESULTS

In total, 2026 patients were seen during the study period. Among them 511 (25.2%) had a history of forceps delivery. Fourteen volume datasets were incomplete or missing, leaving 497 complete datasets for analysis. Mean age at presentation was 58 ± 12 years (23-91). Mean body mass index was 29 ± 6 kg/m². Mean age at first delivery was 25 ± 5 years. Mean birth weight of the first vaginal birth was 3454 ± 557 g. 457 women (92%) had had one forceps delivery, 31 had two forceps deliveries (6%) and 9 had three forceps deliveries (2%). Mean time interval between forceps delivery and assessment was 32 ± 13 years (0.3-64.8). 229 women (46%) were diagnosed with levator avulsion. The prevalence of avulsion after forceps increased significantly from 34% to 56% between 1950 and 2017 (P = 0.04). However this difference became insignificant when controlling for maternal age at 1st vaginal delivery and birth weight.

CONCLUSIONS

We found no evidence of a changed prevalence of levator avulsion at forceps delivery over the last 67 years.

Transperineal pelvic floor ultrasound for analyzing the outcomes of pelvic floor surgery for the treatment of anterior compartment prolapse: A comparative study of transvaginal mesh and native-tissue repair

OBJECTIVE

To compare the outcomes of transvaginal mesh (TVM) and native-tissue repair (NTR) for the repair of anterior compartment prolapse.

METHODS

This retrospective study involved 90 patients with anterior compartment prolapse who underwent pelvic organ prolapse surgery between January 2018 and October 2020. A TVM was used to treat 53 patients and 37 underwent NTR. All patients underwent a standardized interview, clinical examination, and four-dimensional pelvic floor ultrasound (PFUS) before and after the surgery. The primary outcome was anatomic recurrence evaluated by ultrasonic parameters. The secondary outcomes were subjective recurrence and complications.

RESULTS

Subjective recurrence was 9.43% (5/53) for TVM and 16.22% (6/37) for NTR (P = .522). Significant recurrence of prolapse on ultrasound occurred in five patients (9.43%) after TVM and 12 (32.43%) after NTR; there was a significant difference between the TVM and NTR groups (P = .006). In the TVM group, the mesh was visible on ultrasound in each patient. The mesh exposure rate was 1.89% (1/53). The postoperative hiatal area reduction in the TVM group, compared with the NTR group, was statistically significant (5.55 ± 4.71 cm² vs 3.09 ± 5.61 cm² , P = .027). The incidence of de novo stress urinary incontinence was higher in the TVM group (20.75% vs 2.70%, P = .03). After surgery, there were significant differences between the two groups based on bladder descent (12.02 ± 8.64 mm vs 22.41 ± 13.95 mm, P = .000) and urethral rotation angle (25.26 ± 13.92° vs 40.27 ± 23.72°, P = .001).

CONCLUSION

PFUS is effective for evaluating postoperative outcomes. TVM facilitates a better anatomic cure than NTR for anterior compartment prolapse.

Transperineal and endovaginal ultrasound for evaluating suburethral masses: comparison with magnetic resonance imaging

OBJECTIVE

To evaluate the utility of pelvic floor ultrasound (US) in the detection and evaluation of suburethral masses, using magnetic resonance imaging (MRI) as the reference standard.

METHODS

This was a retrospective analysis of US and MRI scans of all women with a suburethral mass on clinical examination at a single urogynecology clinic over a 13-year period (February 2007 to March 2020). All women were examined using two-dimensional transperineal US (2D-TPUS) with or without three-dimensional endovaginal US (3D-EVUS). All patients underwent unenhanced T1-weighted and T2-weighted MRI, which was considered the reference standard in this study. Presence of a suburethral mass and its size, location, connection with the urethral lumen and characteristics were evaluated on both pelvic floor US and MRI. Agreement between pelvic floor US and MRI was assessed using intraclass correlation coefficients (ICC; 3,1).

RESULTS

Forty women suspected of having a suburethral mass on clinical examination underwent both MRI and US (2D-TPUS with or without 3D-EVUS). MRI detected a suburethral mass in 34 women, which was also detected by US. However, US also identified a suburethral mass in the remaining six women. Thus, the agreement between US and MRI for detecting a suburethral mass was 85% (95% CI, 70.2-94.3%). The ICC analysis showed good agreement between MRI and 2D-TPUS for the measured distance between the suburethral mass and the bladder neck (ICC, 0.89; standard error of measurement (SEM), 3.64 mm) and excellent agreement for measurement of the largest diameter of the mass (ICC, 0.93; SEM, 4.31 mm). Good agreement was observed between MRI and 3D-EVUS for the measured distance from the suburethral mass to the bladder neck (ICC, 0.88; SEM, 3.48 mm) and excellent agreement for the largest diameter of the suburethral mass (ICC, 0.94; SEM, 4.68 mm).

CONCLUSIONS

2D-TPUS and 3D-EVUS are useful in the imaging of suburethral masses. US shows good-to-excellent agreement with MRI in identifying and measuring suburethral masses; therefore, the two modalities can be used interchangeably depending on availability of equipment and expertise. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology. - Legal Statement: This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

Levator Morphology and Strength After Obstetric Avulsion of the Levator Ani Muscle

OBJECTIVES

Obstetric levator avulsion may be an important risk factor for prolapse. This study compares the size of the levator hiatus, the width of the genital hiatus, and pelvic muscle strength between vaginally parous women with or without levator avulsion, 5 to 15 years after delivery.

METHODS

Parous women were assessed for levator ani avulsion, using 3-dimensional transperineal ultrasound. Women with and without levator ani avulsion were compared with respect to levator hiatus areas (measured on ultrasound), genital hiatus (measured on examination), and pelvic muscle strength (measured with perineometry). Further analysis also considered the association of forceps-assisted birth.

RESULTS

At a median interval of 11 years from first delivery, levator avulsion was identified in 15% (66/453). A history of forceps-assisted delivery was strongly associated with levator avulsion (45% vs 8%; P < 0.001). Levator avulsion was also associated with a larger levator hiatus area (+7.3 cm; 95% confidence interval [CI], 4.1-10.4, with Valsalva), wider genital hiatus (+0.6 cm; 95% CI, 0.3-0.9, with Valsalva), and poorer muscle strength (-14.5 cm H2O; 95% CI, -20.4 to -8.7, peak pressure). Among those with levator avulsion, forceps-assisted birth was associated with a marginal increase in levator hiatus size but not genital hiatus size or muscle strength.

CONCLUSIONS

Obstetric levator avulsion is associated with a larger levator hiatus, wider genital hiatus, and poorer pelvic muscle strength. Forceps-assisted birth is an important marker for levator avulsion but may not be an independent risk factor for the development of pelvic muscle weakness or changes in hiatus size in the absence of levator avulsion.

Ultrasonographic evaluation of pelvic floor structure at antepartum and postpartum periods using three-dimensional transperineal ultrasound

PURPOSE

To examine the changes in the pelvic floor structure caused by pregnancy and delivery.

METHODS

A total of 141 nulliparous women were examined with three-dimensional transperineal ultrasound (3D-TPU) at the 24th and 34th weeks of gestation, 5th day postpartum, and 1 month postpartum. Puborectalis muscle trauma was diagnosed and the area of levator hiatus (ALH) was measured.

RESULTS

One hundred and five normal vaginal deliveries, 19 vacuum/forceps deliveries, and 17 cesarean deliveries were included. In the normal delivery group, the rate of puborectalis muscle trauma was low and showed no significant change between the 24th and 34th weeks of gestation (12.5% vs. 17.2%, p = 0.42). The rate of trauma significantly increased to 70.2% at the 5th day postpartum (p < 0.001). There was no significant difference between the rates at the 5th day postpartum and 1 month postpartum (73.7%, p = 0.60). The same trend was found in the vacuum/forceps group. In the cesarean section group, no significant change was observed throughout pregnancy and postpartum periods. In the normal delivery group, ALH significantly increased between the 24th and 34th week (14.1 ± 2.6 cm² vs. 14.6 ± 3.4 cm², p = 0.007). ALH markedly increased to 20.9 ± 4.8 cm² at the 5th day postpartum (p < 0.001). ALH at 1 month postpartum decreased to 17.0 ± 4.3 cm² (p < 0.001), but did not return to the value at the 24th week (p < 0.001).

CONCLUSIONS

Vaginal childbirth results in enlargement of the levator hiatus. Pelvic floor muscles in pregnant women are affected not only by mechanical damage associated with delivery but also by physiologic changes during pregnancy. The effects of pregnancy and delivery on pelvic floor muscles may persist after delivery.

Abdominal pressure and pelvic organ prolapse: is there an association?

INTRODUCTION AND HYPOTHESIS

The primary aim of this study was to assess for an association between maximal intra-abdominal pressure reached on Valsalva (MAP) and pelvic organ prolapse (POP) on subjective, clinical and sonographic evaluation. Another objective was to test for association between MAP and body mass index (BMI).

METHODS

A retrospective cross-sectional study was carried out on 504 archived datasets of women seen for pelvic floor dysfunction symptoms between January 2017 to September 2019 at a tertiary urogynaecology clinic. Patients underwent a standardized interview including use of visual analogue scores (VAS) to evaluate bother of pelvic floor symptoms, examination using the International Continence Society Pelvic Organ Prolapse Quantification (ICS POP-Q), dual-channel filling and voiding cystometry, test for MAP as well as four-dimensional (4D) transperineal ultrasound. Analysis of ultrasound volumes for pelvic organ descent was performed blinded against all other data.

RESULTS

There was a weak but significant association between MAP and sonographic rectal ampulla descent (p = 0.0275). There was also a significant association between MAP and bother of obstructed defecation symptoms (p = 0.0065). Symptomatic, clinical and sonographic POP in the anterior or the apical compartments was not significantly associated with MAP. On multivariate analysis, the association between MAP and rectal descent remained significant (p = 0.01). There was no significant association between BMI and MAP.

CONCLUSIONS

This cross-sectional study showed an association between MAP and posterior compartment prolapse on imaging as well as between MAP and the bother score of obstructed defecation symptoms. There was no association between BMI and MAP.

Levator ani muscle avulsion: Digital palpation versus tomographic ultrasound imaging

OBJECTIVE

To determine the diagnostic performance of digital palpation of levator ani muscle (LAM) avulsion compared with translabial tomographic ultrasound imaging (TUI).

METHODS

A cross-sectional study, incorporating 195 women involved in a longitudinal cohort study. Palpation for levator integrity was performed, followed by a four-dimensional translabial ultrasound. LAM avulsion defects were diagnosed in the presence of puborectalis muscle detachment from its insertion. Post-processing analysis of ultrasound volumes for LAM integrity on TUI was performed blinded against palpation findings. Agreement between methods was assessed using Cohen's κ.

RESULTS

In all, 388 paired assessments of LAM bilaterally, were available. Sixteen (8.2%) unilateral avulsion defects were detected on palpation. Sonographically, 31 (16%) were diagnosed with avulsions: 4.6% bilateral and 11.3% unilateral. An overall agreement of 91% was observed between digital palpation and TUI, yielding a Cohen's κ of 0.32 (95% confidence interval 0.15-0.48) demonstrating "fair agreement": and implying 25% sensitivity, 98% specificity, 63% positive predictive value, and 92% negative predictive value. Analysis of the first and last 20 palpations showed no change in performance during the 13-day study period.

CONCLUSION

Assessment of LAM avulsion defects by digital palpation is feasible but may require substantial training. Confirmation by imaging is crucial, especially if the diagnosis of avulsion may influence clinical management.

Urogynecology in obstetrics: impact of pregnancy and delivery on pelvic floor disorders, a prospective longitudinal observational pilot study

Purpose

To assess changes in the pelvic floor anatomy that cause pelvic floor disorders (PFDs) in primigravidae during and after pregnancy and to evaluate their impact on women’s quality of life (QoL).

Methods

POP-Q and translabial ultrasound examination was performed in the third trimester and 3 months after delivery in a cohort of primigravidae with singleton pregnancy delivering in a tertiary center. Results were analyzed regarding mode of delivery and other pre- and peripartal factors. Two individualized detailed questionnaires were distributed at 3 months and at 12 months after childbirth to determinate QoL.

Results

We recruited 45 women, of whom 17 delivered vaginally (VD), 11 received a vacuum extraction delivery (VE) and 17 a Cesarean section in labor (CS). When comparing third-trimester sonography to 3 months after delivery, bladder neck mobility increased significantly in each delivery group and hiatal area increased significantly in the VD group. A LAM avulsion was found in two women after VE. Connective tissue weakness (p = 0.0483) and fetal weight at birth (p = 0.0384) were identified as significant risk factors for the occurrence of PFDs in a multivariant regression analysis. Urinary incontinence was most common with 15% and 11% of cases at 3, respectively, 12 months after delivery. 42% of women reported discomfort during sexual intercourse, 3 months after delivery and 24% 12 months postpartum. Although 93% of women engage a midwife after delivery, only 56% participated in pelvic floor muscle training.

Conclusion

Connective tissue weakness and high fetal weight at birth are important risk factors for the occurrence of PFDs. Nevertheless, more parturients should participate in postpartal care services to prevent future PFDs.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00404-021-06022-w.

Ultrasound imaging of maternal birth trauma

INTRODUCTION AND HYPOTHESIS

The term 'maternal birth trauma' has undergone substantial changes in meaning over the last 2 decades. Leaving aside psychological morbidity, somatic trauma is now understood to encompass not just episiotomy, perineal tears and obstetric anal sphincter injuries (OASI), but also trauma to the levator ani muscle. This review covers diagnosis of maternal birth trauma by translabial ultrasound imaging.

METHODS

Narrative review.

RESULTS

Tomographic imaging of pelvic structures with the help of 4D ultrasound, used since 2007, has allowed international standardization and seems to be highly reproducible and valid for the diagnosis of OASI and levator avulsion.

CONCLUSIONS

Translabial and exo-anal ultrasound allows the assessment of maternal birth trauma in routine clinical practice and the utilization of avulsion and sphincter trauma as key performance indicators of maternity services. It is hoped that this will lead to a greater awareness of maternal birth trauma among maternity caregivers and improved outcomes for patients, both in the short term and in the decades to come.

Does pregnancy affect pelvic floor functional anatomy? A retrospective study

OBJECTIVE

Vaginal childbirth is an established main aetiological factor in the pathogenesis of female pelvic floor dysfunction. However, pregnancy itself is also likely to have an effect. This study investigated the effect of pregnancy on pelvic floor functional anatomy.

STUDY DESIGN

This was a retrospective observational study involving vaginally nulliparous women who presented to a tertiary urogynaecology unit with symptoms and signs of pelvic floor dysfunction between 2006 and 2014. Nulliparous women were compared with those who delivered exclusively by Caesarean Section (CS). All had undergone a standardised clinical interview, ICS POP-Q assessment and 3D/4D translabial pelvic floor ultrasound. Main outcome measures included sonographically determined pelvic organ position and hiatal dimensions on Valsalva and pelvic floor muscle contraction (PFMC).

RESULTS

Of 2930 women seen during the study period, 242 had never given birth vaginally. One hundred and twenty-nine (53 %) were nulliparous, and 113 (47 %) were delivered by CS only. The CS group demonstrated significantly higher pelvic organ mobility in the anterior compartment (all P < 0.05) and a larger hiatal area on Valsalva (P = 0.004). All sonographic measures of pelvic floor muscle function demonstrated greater tissue displacement on PFMC in the CS group (all P < 0.05).

CONCLUSIONS

Compared to nulliparas, women who delivered exclusively by CS showed increased pelvic organ descent on Valsalva and tissue displacement on PFMC, implying increased tissue elasticity/ compliance or reduced stiffness, consistent with a small permanent hormonal and/or mechanical effect of pregnancy.

The relationship between diastasis rectus abdominus, pelvic floor trauma and function in primiparous women postpartum

INTRODUCTION AND HYPOTHESIS

A functional interaction exists between the pelvic floor and the abdominal wall. The study was aimed at investigating the clinical and morphological relationships between diastasis rectus abdominus (DRA) and pelvic floor trauma in primiparous women.

METHODS

Eighteen women suffering from DRA and 18 women without DRA (non-DRA group), all primiparous with pelvic floor trauma, were enrolled in the study. Ultrasound was performed on the 36 women examining the inter-rectus distance, pelvic floor morphology, abdominal muscle force (MMT), Static Abdominal Flexion Endurance Test (SFET), and Dynamic Abdominal Flexion Endurance Test (DFET), abdominal circumference, visual analog scale, and responses to the Oswestry Low Back Pain Questionnaire and the Pelvic Floor Distress Inventory questionnaire (PFDI).

RESULTS

A significant increase in the urinary symptoms portion of the in PFDI-20 questionnaire was found in the DRA group (non-DRA = 12.5 ± 22.8, DRA = 26.8 ± 18.2, p = 0.01). A significant reduction in abdominal force and endurance was observed in the DRA2-3 group compared with the DRA0-1 group (0.025 < p < 0.04). DFET (average repetitions) in the DRA0-1 group measured 13.4 ± 11.8 and 6.46 ± 4.59 in the DRA2-3 group (p = 0.025). SFET was 20.48 ± 14.46 s in the DRA0-1 group and 10.62 ± 10.6 s in the DRA2-3 group (p = 0.031). MMT was 4 in the DRA0-1 group and 3 in the DRA2-3 group (p = 0.04).

CONCLUSIONS

Diastasis rectus abdominus does not correlate with morphological changes in the pelvic floor, but does correlate with higher scores in the urinary symptoms portion of the PFDI-20. Women suffering from DRA do not endure more pain or greater lumbar disability than non-DRA women. In extended DRA, the abdominal muscles are significantly compromised and weaker.

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

INTRODUCTION AND HYPOTHESIS

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.

METHODS

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.

RESULTS

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).

CONCLUSIONS

Anatomical changes in the puborectalis muscle during PFM contraction were detected by 4D TLUS within gynecological cancer patients after pelvic RT.

Three-dimensional ultrasound evaluation of the pelvic floor in postmenopausal women using hormone therapy

OBJECTIVE

To evaluate the three-dimensional (3D) ultrasound characteristics of the pelvic floor muscles (PFM) in two groups of postmenopausal women: users and nonusers of menopausal hormone therapy (MHT).

STUDY DESIGN

Observational, cross-sectional cohort study.

MAIN OUTCOME MEASURES

In this study 226 sexually active heterosexual women, aged 45-60 years with amenorrhea >12 months and without clinical pelvic floor disorders or urinary incontinence were included. Women using MHT ≥ 6 months were classified as systemic users. PFM strength was assessed by digital vaginal palpation and scored on the Modified Oxford Scale. Biometry of the PFM was performed by 3D transperineal ultrasound for evaluation of total urogenital hiatus area, transverse and anteroposterior diameters, and levator ani muscle thickness.

RESULTS

The participants were divided into users (n = 78) and nonusers (n = 148) of MHT. There were no differences in clinical or anthropometric parameters between groups. The mean age was 55 years and the time since menopause was six years in both groups. The mean duration of MHT use was 43.4 ± 33.3 months. Users of MHT had greater levator ani muscle thickness (p = 0.001) and higher PFM strength (p = 0.029) than nonusers. Risk analysis adjusted for age, time since menopause, BMI, parity, and type of delivery showed an association of MHT use with greater levator ani muscle thickness (OR = 2.69; 95% CI 1.42-5.11, p = 0.029), and higher PFM strength (OR = 1.78; 95% CI1.01-3.29, p = 0.046). There was a weak positive correlation between levator ani muscle thickness and duration of MHT use (r = 0.25, p = 0.0002) and PFM strength (r = 0.12, p = 0.043).

CONCLUSIONS

Postmenopausal women using MHT had a greater levator ani muscle thickness associated with higher PFM strength than nonusers.

Is vaginal flatus related to pelvic floor functional anatomy?

INTRODUCTION AND HYPOTHESIS

Vaginal flatus is an embarrassing condition that can impair women's quality of life. The underlying pathophysiology is unclear. We aimed to evaluate the association between vaginal flatus and pelvic floor anatomy.

METHODS

Retrospective observational study on women seen in a tertiary urogynaecological service. All had undergone a standardised interview, clinical examination and four-dimensional transperineal ultrasound. Offline analysis of volume data was performed blinded against clinical data.

RESULTS

Datasets of 570 women were analysed. Five hundred twelve (90%) were vaginally parous. Vaginal flatus was reported by 190 (33%). Mean bother score was 4.2 (SD 3.4, range 0-10). One hundred eighty-five reported frequency of vaginal flatus: it occurred < once a month in 25 (14%), once a month in 70 (38%), once a week in 47 (25%), once daily in 28 (15%) and > once daily in 15 (8%). One hundred two women identified the following precipitating factors: intercourse in 72 (71%), postural change in 22 (22%) and physical activities in 9 (9%). Vaginal birth, central and posterior compartment prolapse, anal incontinence, higher levator resting tone and younger age were associated with vaginal flatus. The latter was moderately correlated with symptom bother (correlation coefficient - 0.21).

CONCLUSIONS

Vaginal flatus is a prevalent and bothersome condition affecting one-third of our study population. The condition is associated with pelvic floor functional anatomy. A higher resting tone may confer a higher resistance against which trapped air is expelled during physical activities. Younger age was moderately correlated with symptom bother.

The effect of replacing vacuum with forceps in operative vaginal delivery: an observational study

INTRODUCTION AND HYPOTHESIS

An increase in vaginal delivery with forceps may increase rates of pelvic floor trauma. This study was designed to predict trauma rates resulting from policies preferencing forceps.

METHODS

This is an observational cohort study utilizing data from 660 primiparae enrolled in an RCT in two tertiary obstetric units in Sydney, Australia. Participants were assessed clinically and with 4D translabial ultrasound in the late third trimester and again at 3-6 months postpartum. Incidence of trauma associated with mode of delivery was adjusted to reflect change associated with a conversion of vacuum to forceps delivery. Primary outcome measures were third-/fourth-degree tear, levator avulsion (LA) and external anal sphincter (EAS) trauma diagnosed sonographically.

RESULTS

Five hundred four women were seen at a mean of 5.1 (2.3-24.3) months postpartum. After exclusion of 21 because of missing data, 483 women were analysed: 112 (23%) had a CS, 268 (55%) a normal vaginal delivery (NVD), 69 (14%) a vacuum (VD) and 34 (7%) a forceps (FD). One hundred fifty-two women had EAS trauma and/or LA; 17 sustained both. After VD, 32/69 (46%) women suffered LA and/or EAS trauma; after FD, it was 33/34 (97%). Converting VD to FD was estimated to result in an increase in trauma from 152/483 (31%) to 187/483 (39%). A formula can be generated based on local obstetric and ultrasound data to estimate trauma incidence.

CONCLUSIONS

A change in obstetric practice resulting in the conversion of primary VD to primary FD would be expected to substantially increase the likelihood of pelvic floor trauma.

Accuracy of clinical diagnosis of anal sphincter defect: clinical evaluation versus 3D-transperineal ultrasound

BACKGROUND

Obstetric anal sphincter injuries (OASIS) are common and an important factor in the etiology of anal incontinence. The objective of this study was to evaluate, classify and compare the agreement of clinically diagnosed third-degree sphincter tears with 3D-transperineal ultrasound (3D-TPUS) realized within 3-7 days post-delivery.

METHODS

This is a retrospective observational study were 119 patients with third-degree obstetric anal sphincter tears were diagnosed and treated, 85 of those underwent a 3D-TPUS examination 3-7 days postpartum. We compared the proportion of third-degree perineal tears, classified with the clinical examination as grade 3a+b and grade 3c, with the 3D-TPUS.

RESULTS

In 16 patients with clinically diagnosed third-degree perineal tears grade a and b, the ultrasound examination confirmed the lesion of the external anal sphincter (EAS) muscle, but in nine patients (56% of the cases) we found a lesion of the internal anal sphincter (IAS) muscle, missed by clinical examination. In the remaining 69 patients with the third-degree perineal tears grade c, the ultrasound examination confirmed both lesions (EAS and IAS muscles) in 56 women, but in 13 patients (19% of the cases) defects of the IAS muscle could not be confirmed by the ultrasound.

CONCLUSIONS

There was moderate agreement regarding diagnosis of grade 3a+b and grade c perineal tears between ultrasound and clinical examination, so a combined use of clinical and ultrasound knowledge can improve the possibility to find a gold standard in the diagnosis of OASIS.

Association between the side of levator Ani muscle trauma and fetal position at birth - a prospective observational study

INTRODUCTION

Trauma of the levator ani muscle (LAM) is common after vaginal birth and can most reliably be diagnosed by 3-dimensional (3D) translabial ultrasound (TLUS). Multiple risk factors are known in general, but not in association to a specific side of the body. Therefore, our aim was to evaluate different impact factors which cause LAM trauma on either side of the body or bilateral by focusing on the fetal position at birth.

MATERIAL AND METHODS

As part of a prospective cohort study between 3/2017 and 4/2019, we analyzed vaginal births of nulliparous women with singletons in vertex presentation≥36+0 gestational weeks. We evaluated their pelvic floor for hematomas, partial and complete LAM avulsions by 3D TLUS 2-4 days postpartum and searched for an association between the affected body side and different fetal, maternal and obstetrical factors.

RESULTS

71 out of 213 women (33.3%) suffered from LAM trauma - 17 (23.9%) on the right side, 20 (28.2%) on the left side and 34 (47.9%) bilateral. No association between the different evaluated factors and the affected body side could be identified, except for the quality of fetal heart rate tracing.

CONCLUSIONS

No significant impact factors of LAM trauma could be associated with a specific side of the body. Other possible mechanisms need investigation in the future, such as the time of the birth canal and the fetus to adapt to each other, including adequate time for the tissue to stretch and the fetus to rotate into the ideal position within the LAM hiatus.

EINLEITUNG

Levatormuskelverletzungen sind häufig nach Vaginalgeburten und können zuverlässig mittels translabialem 3D-Ultraschall diagnostiziert werden. Diverse Risikofaktoren sind hierfür bekannt, allerdings keine hinsichtlich der Assoziation zu einer der beiden Körperseiten. Daher war das Ziel dieser Arbeit, verschiedene Einflussfaktoren im Rahmen vaginaler Geburten zu evaluieren, welche eine Levatorverletzung auf einer der beiden Körperseiten bzw. beidseitig begünstigen, v. a. hinsichtlich der Kindsposition im Geburtskanal.

MATERIAL UND METHODIK

In einer prospektiven Kohortenstudie analysierten wir von 3/2017-4/2019 Erstgebärende mit vaginalen Einlingsgeburten aus Schädellage≥36+0 SSW. Wir evaluierten 2-4 Tage postpartal ihren Beckenboden mittels 3D-Ultraschall hinsichtlich Hämatomen sowie partiellen und kompletten Levatoravulsionen und suchten nach Assoziationen zwischen der betroffenen Körperseite und fetalen, maternalen und geburtshilflichen Einflussfaktoren.

ERGEBNISSE

Von 213 Frauen erlitten 71 (33.3%) eine Levatorverletzung - 17 (23.9%) rechtsseitig, 20 (28.2%) linksseitig und 34 (47.9%) beidseitig. Es wurden keine Assoziationen zwischen den untersuchten Einflussfaktoren und der betroffenen Körperseite gefunden, bis auf die Qualität der fetalen Herzfrequenz.

DISKUSSION

Es konnten keine signifikanten Einflussfaktoren für das Auftreten einer Levatorverletzung einer spezifischen Körperseite eruiert werden. Daher bedarf es in Zukunft der Untersuchung weiterer Mechanismen, wie der Adaptationsvorgänge von Geburtskanal und Fet und der adäquaten Zeit für das Gewebe zur notwendigen Dehnung, v. a. im Bereich der Levatoröffnung.

Prediction of levator ani muscle avulsion by genital tears after vaginal birth-a prospective observational cohort study

INTRODUCTION

Visible birth tears and levator ani muscle (LAM) trauma are common after birth. For the diagnosis of LAM trauma ultrasound evaluation is advisable. As ultrasound equipment and trained personnel are not available everywhere at all times, we aimed to evaluate whether specific overt birth tears are an indicator for LAM trauma.

METHODS

In a prospective cohort study at our center from March 2017-April 2019, we evaluated vaginal births of nulliparous women with singletons in vertex presentation ≥ 36 + 0 gestational weeks for LAM trauma by translabial ultrasound and for overt birth tears by inspection. We then calculated the association of overt birth tears with complete LAM avulsion.

RESULTS

Of 213 women, 23.9% had any kind of LAM trauma, with 14.1% being complete avulsions. In univariate analysis, solely high-grade perineal tears (OASIS) were significantly associated with complete LAM avulsions.

CONCLUSIONS

Fourteen percent of women suffered a complete LAM avulsion after vaginal birth, with OASIS being the only associated parameter of significance. The occurrence of such trauma might be an indicator for a mismatch between the size of the fetus and the structures of the birth canal, leading to birth trauma. Assessing for LAM trauma by translabial ultrasound in women with OASIS might be worthwhile.

Postpartum sexual function; the importance of the levator ani muscle

Introduction and hypothesis

Pelvic floor muscle function plays an important role in female sexual functioning. Smaller genital hiatal dimensions have been associated with sexual dysfunction, mainly dyspareunia. On the other hand, trauma of the levator ani muscle sustained during childbirth is associated with increased genital hiatus, which potentially can affect sexual functioning by causing vaginal laxity. This study aims to determine the association between levator hiatal dimensions and female sexual dysfunction after first vaginal delivery.

Methods

This is a secondary analysis of a prospective observational study. Two hundred four women who had a first, spontaneous vaginal delivery at term between 2012 and 2015 were recruited at a minimum of 6 months postpartum. Thirteen pregnant women were excluded. We analyzed the association of total PISQ-12 score, as well as individual sexual complaints (desire, arousal, orgasm and dyspareunia), with levator hiatal dimensions at rest, with maximum Valsalva and during pelvic floor muscle contraction as measured by 4D transperineal ultrasound. Statistical analysis was performed using linear regression analysis and Mann-Whitney U test.

Results

One hundred ninety-one women were evaluated at a median of 11 months postpartum. There was no significant association between total PISQ-12 score and levator hiatal dimensions. Looking at individual sexual complaints, women with dyspareunia had significantly smaller levator hiatal area and anterior-posterior diameter on maximum Valsalva. By using multivariate logistic regression analysis however we found dyspareunia was not independently associated with levator hiatal dimensions.

Conclusions

After first vaginal delivery sexual dysfunction is not associated with levator hiatal dimensions as measured by 4D transperineal ultrasound.

The importance of using 3D ultrasound during pelvic organ prolapse surgery in relation to pre- and post-operative quality of life questionnaires

AIM

The main aim of this study is to evaluate the interest of three-dimensional ultrasound perineal in the measurement of the levator hiatus area as an objective reflection of the surgical correction of pelvic organ prolapse (POP). Our hypothesis is that POP surgery decreases the size of the levator hiatus area.

MATERIALS AND METHODS

A longitudinal and prospective study was conducted between April and July 2017 in the Department of Gynaecology & Obstetrics at University Hospital of Angers. Surgery was performed either by laparoscopy (sacrocolpopexy) or vaginal surgery (with or without the use of mesh). All patients were handed an information letter and signed an informed consent before being included in the study. A questionnaire was fullfilled before and one month after surgery. A clinical evaluation using the simplified POP-Q classification and a perineal 3D ultrasound were carried out before and after surgery by the same professional. The levator hiatus area was assessed before and after surgery in order to evaluate the impact of surgery on the levator hiatus area. Simplified POP-Q measurements and responses to PFDI-20 and PFDI-7 questionnaires were also collected.

RESULTS

A total of 18 patients were included in the study and four were excluded. Seven underwent laparoscopic surgery and seven underwent vaginal surgery. The levator hiatus area decreased substantially from 20.87 to 16.55cm² on mean (p=0.0001) at rest. Regarding patient satisfaction, the PFDI-20 score improved after surgery from 89.36 to 37.87 on mean (p=0.006), but the PFIQ-7 score did not reveal any significant changes (p=0.096). For the clinical examination, we used the simplified POP-Q with Ba measurement from 2.3 to -1.92cm (p=0.005) or Bp from -1.5 to -2.46cm, which is not a significant change (p=0.14). Points C (or D in cases with a history of hysterectomy) changed from -3.1 to -6.15cm (p=0.03).

CONCLUSION

The levator hiatus area seems to decrease after POP surgery. 3D ultrasound seems a new and complementary procedure that allowed to evaluate objectively the levator hiatus area and thus the clinical findings of the surgery.

Painful Love: Superficial Dyspareunia and Three Dimensional Transperineal Ultrasound Evaluation of Pelvic Floor Muscle in Women with Endometriosis

We conducted an observational study between March 2015 and March 2018 in our academic center. Symptomatic, sexually active women with clinical and sonographic diagnosis of deep infiltrating endometriosis (DIE) or isolated ovarian endometriosis were enrolled. Women were asked to rank endometriosis-related symptoms, especially superficial and deep dyspareunia. Moreover, 3D transperineal ultrasound was performed to assess the levator hiatus area (LHA) evaluating pelvic floor muscle (PFM) morphometry. Women with endometriosis seem to have a high prevalence of superficial dyspareunia and three-dimensional transperineal ultrasound seems to be a viable technique to assess PFM morphometry in these women.

Magnetic resonance imaging and 3-dimensional transperineal ultrasound evaluation of pelvic floor dysfunction in symptomatic women: a prospective comparative study

Purpose

The purpose of this study was to investigate magnetic resonance imaging (MRI) and 3-dimensional transperineal ultrasound (3D-TPUS) features of pelvic floor dysfunction (PFD) in symptomatic women in correlation with digital palpation and to define cut-offs for hiatal dimensions predictive of muscle dysfunction.

Methods

This prospective study included 73 women with symptoms suggesting PFD. 3D-TPUS, MRI, and digital palpation of the levator ani muscle were performed in all patients. Levator hiatal antero-posterior (LHap) diameter and area (LH area) were measured at rest and at maximum muscle contraction.

Results

The reduction in LHap diameter and LH area during contraction was significantly less in women with underactive pelvic floor muscle contraction (UpfmC) than in those who had normal pelvic floor muscle contraction by digital palpation (P<0.001). Statistically significant positive correlations (P<0.001) were found between the Modified Oxford Score and 3D-TPUS and MRI regarding the reduction in the LHap diameter (r=0.80 and r=0.82, respectively) and LH area (r=0.60 and r=0.70, respectively). A reduction in LHap of <6.5% on 3D-TPUS and <7.6% on MRI predicted UpfmC with sensitivities of 46.2% and 82.7%, respectively. A reduction in LH area of <3.4% on 3D-TPUS and <3.8% on MRI predicted UpfmC with sensitivities of 75.0% and 88.5%, respectively. MRI was more sensitive in detecting levator avulsion (63.4%) than 3D-TPUS (27.1%).

Conclusion

MRI and 3D-TPUS had strong positive correlations with findings on palpation, and at certain cut-offs for hiatal dimensions, they can be used as complementary and objective tools to improve the accuracy of diagnosis and management planning of PFD.