Pelvic floor muscle biometry and pelvic organ mobility in East Asian and Caucasian nulliparae

Current status of the position on labor progress prediction for contemporary pregnant women using Friedman curves: An updated review

AIM

Prediction of labor progression is important for maternal and fetal health, as improved accuracy can lead to more timely intervention and improved outcomes. This review aims to outline the importance of predicting the progression of spontaneous parturition, detail the various methods employed to enhance this prediction and provide recommendations for future research.

METHODS

We searched articles relating to labor progression and systematic review articles on Artificial Inteligence (AI) in childbirth management using PubMed. To supplement, Google Scholar was used to find recent guidelines and related documents.

RESULTS

Traditional methods like vaginal examinations, criticized for subjectivity and inaccuracy, are gradually being replaced by ultrasound, considered a more objective and accurate approach. Further advancements have been observed with machine learning and artificial intelligence techniques, which promise to surpass the accuracies of conventional methods. The Friedman curve, developed in 1954, is the standard for assessing labor progress, but its application to Asian women, in particular, remains controversial, and various studies have reported that the actual rate of labor was slower than that indicated by the Friedman curve.

CONCLUSION

There is a need to innovate methodologies for predicting delivery tailored to modern pregnant women, especially when they have different genetic and cultural backgrounds than their Western counterparts, such as Asians. Future research should develop predictive models of labor progression that aim to enhance medical intervention and improve the safety and well-being of both mother and child.

Prevalence of Pelvic Floor Disorders in Parous Women from the Tibet Autonomous Region: A Cross-Sectional Study

Purpose

Pelvic floor disorder (PFD) seriously affects the everyday life of women. This cross-sectional study aimed to evaluate the prevalence and risk factors for postpartum PFD in women living in the Tibet Autonomous Region (TAR).

Methods

Parous women who attended the outpatient gynaecology clinic at our hospital between June 2022 and August 2022 were screened in this study. The demographic and clinical data of these women were collected. Their pelvic floor functions were evaluated via a pelvic organ prolapse (POP) quantification examination, the Pelvic Floor Distress Inventory Questionnaire-20 (PFDI-20) and the Overactive Bladder Symptom Score (OABSS).

Results

A total of 201 women were included in this study, of whom 81.09% (163/201) were Tibetan. Twenty-seven women (13.43%) were diagnosed with POP stage ≥2 and 27 women (13.43%) with an OABSS score ≥3. The median PFDI-20 total score was 4.17 (range 0-43.75). Han women (n = 38) in the TAR had much lower PFDI-20 total scores, compared with Tibetan women (n = 163) (p < 0.05). The results of the multiple linear regression models showed that the PFDI-20 scores obtained from women living in the TAR were closely related to parity, history of heavy weight lifting, age, history of instrumental deliveries, ethnicity and number of caesarean sections.

Conclusion

Pelvic floor disorder is common among parous women living in the TAR. Ethnicity, parity, history of heavy weight lifting, age, history of instrumental deliveries and number of caesarean sections are the factors closely related to the PFDI-20 scores.

Restoration of bladder neck activity and levator hiatus dimensions in Asian primipara: a prospective study

Pelvic floor muscle training (PFMT) reduces the symptoms in women with pelvic floor dysfunction (PFD); however, the optimal initial timing for secondary prevention of PFD by PFMT is not clear. To identify the optimal timing in Asian primiparas with vaginal delivery, bladder neck descent (BND), levator hiatus areas, and levator hiatus distensibility and contractility were assessed in 26 nulliparous women at 36 weeks of gestation and at 2, 4, 6, and 12 weeks postpartum. We found that BND increased significantly from 2 weeks onwards until 6 weeks postpartum (p = 0.004); the levator hiatus area at rest and contraction both showed the largest value at 2 weeks postpartum (p = 0.005 and p < 0.005 respectively), followed by a continuous decrease; the hiatus area during Valsalva manoeuvre, and the levator hiatus distensibility and contractility showed the lowest value at 2 weeks postpartum, followed by a continuous increase; the changes in BND showed no correlation with the changes in distensibility or hiatus area during Valsalva manoeuvre (p = 0.073 and 0.590 respectively). In Asian primiparas with vaginal delivery, the recovery of levator hiatus and bladder neck mobility begins at 2 and 6 weeks, respectively. This information could be useful in defining the best time to begin PFMT for secondary prevention of postpartum PFD in Asian primiparous women.IMPACT STATEMENTWhat is already known on this subject? Pelvic floor muscle training (PFMT) helps to reduce symptoms of pelvic floor dysfunction (PFD), however, there are no clear time strategies for the secondary prevention of PFD by PFMT in Asian primiparas with vaginal delivery.What do the results of this study add? This study was the first longitudinal study in Asian primipara to investigate the natural regeneration of pelvic floor functions in the early postpartum period by intensively monitoring the bladder neck mobility and levator hiatus dimensions at multiple time points. We found that bladder neck descent (BND) increased significantly from 2 weeks onwards until 6 weeks postpartum; the levator hiatus area at rest and contraction both showed the largest value at 2 weeks postpartum, followed by a continuous decrease; the hiatus area during Valsalva manoeuvre, and the levator hiatus distensibility and contractility showed the lowest value at 2 weeks postpartum, followed by a continuous increase; the changes in BND showed no correlation with the changes in distensibility or hiatus area during Valsalva manoeuvre.What are the implications of these findings for clinical practice and/or further research? Our study suggested that in Asian primipara, the recovery of bladder neck mobility after vaginal delivery begins at 6 weeks postpartum, while the levator hiatus muscle begins to recover within the first 2 weeks postpartum. Therefore, it could be useful in deciding the best time to start PFMT for secondary prevention of postpartum PFD in Asian primiparous women.

Correlation between clinical examination and perineal ultrasound in women treated for pelvic organ prolapse

INTRODUCTION

Lifetime risk of surgery for female pelvic organ prolapse (FPOP) is estimated at 10 to 20%. Prolapse assessment is mostly done by clinical examination. Perineal ultrasound is easily available and performed to evaluate and stage FPOP. This study's aim is to evaluate the agreement between clinical examination by POP-Q and perineal sonography in women presenting pelvic organ prolapse.

MATERIALS AND METHODS

We carried out a prospective study from December 2015 to March 2018 in the gynecologic department of a teaching hospital. Consecutive woman requiring a surgery for pelvic organ prolapse were included. All women underwent clinical examination by POP-Q, perineal ultrasound with measurements of each compartment descent, levator hiatus area and posterior perineal angle. They also answered several functional questionnaires (PFDI 20, PFIQ7, EQ-5D and PISQ12) before and after surgery. Data for clinical and sonographic assessments were compared with Spearman's test and correlation with functional questionnaires was tested.

RESULTS

82 women were included. We found no significant agreement between POP-Q and sonographic measures of bladder prolapse, surface of the perineal hiatus or perineal posterior angle. There was a significant improvement of most of the functional scores after surgery.

DISCUSSION

Our study does not suggest correlation between clinical POP-Q and sonographic assessment of bladder prolapse, hiatus surface or perineal posterior angle. Ultrasound datasets were limited by an important number of missing data resulting in a lack of power.

Assessing Obstetric Anal Sphincter Injuries: A Comparison of Exoanal and Endoanal Ultrasound

OBJECTIVES

To explore the differences in assessing obstetric anal sphincter injuries (OASI) between transperineal ultrasound (TPUS) and endoanal ultrasound (EAUS) and test relationships between ultrasound findings and anal incontinence (AI) symptoms.

METHODS

A group of 196 women with a history of vaginal delivery was recruited. OASI was detected in a set of 5 slices by EAUS and 8 slices by TPUS. OASI grading was performed on TPUS rules and EAUS rules. A "significant sphincter defect" was diagnosed by TPUS and EAUS using "2/3 rules." Symptoms of AI were determined using the St Mark's Incontinence Score (SMIS). Ultrasound findings were compared between the two methods and correlated with symptoms.

RESULTS

Of 196 women, 29 (14.8%) suffered from AI with a mean SMIS of 12.1 ± 4.5, and 70 (35.7%) women with a mean age of 57 years had suspected OASI on imaging. Twenty-one (10.7%) "significant defects" were diagnosed by TPUS and 24 (12.2%) by EAUS. OASI Grades on TPUS had good agreement with EAUS rules (k = 0.70, P < .001). Logistic regression analysis showed that OASI Grade on imaging and "significant sphincter defects" seen on both forms of imaging were associated with AI symptoms. The odds ratio was 46 and 38 for "significant defects" on TPUS and EAUS, and 14 and 7 for OASI 3b+ on TPUS and EAUS in predicting AI, respectively.

CONCLUSIONS

"Significant defects" diagnosed by EAUS or TPUS and OASI Grade 3b+ predict AI symptoms. The diagnostic performance of endoanal and exoanal ultrasound (EAUS and TPUS) appear to be very similar.

Fractional CO2 Laser Treatment Is Safe and Effective for the Management of Genitourinary Syndrome of Menopause in Korean Women

This study evaluates the efficacy and safety of fractional CO₂ lasers for treating genitourinary syndrome of menopause (GSM) in Korean women. The patients received three laser applications at an interval of 4 weeks each. The severity of GSM symptoms was assessed using a visual analog scale (VAS) at baseline and at every visit. The objective scale was measured using the vaginal health index score (VHIS) and Vaginal Maturation Index (VMI) after completion of the laser procedure. During each procedure, the patients' pain in the VAS score was recorded. In the last visit, patients evaluated their satisfaction with the laser therapy using a 5-point Likert scale. Thirty women completed all the study protocols. After two sessions of laser therapy, some GSM symptoms (vaginal dryness and urgency) and VHIS improved significantly. After completion of the treatment, all GSM symptoms improved (p < 0.05), and the VHIS further increased significantly (VHIS at baseline, 8.86 ± 3.2 vs. V3, 16.83 ± 3.15, p < 0.001). The average satisfaction was 4.3. This study shows that fractional CO₂ laser treatment is effective and safe for Korean women with GSM. Further studies are needed to confirm these results and assess the long-term effects of laser therapy.

Morphological differences in the female anal sphincter complex between endoanal and exoanal ultrasound

INTRODUCTION AND HYPOTHESIS

This study was aimed at describing the morphological characteristics of the normal female anal sphincter complex (ASC) by high-resolution transperineal ultrasound (TPUS) and endoanal ultrasound (EAUS).

METHODS

Thirty volunteers, including 19 nulliparous and 11 women who had only given birth by Cesarean section, were recruited. The ASC was shown in a set of five slices by EAUS and 8 slices by TPUS. EAUS slices 1 and 5 matched TPUS slices 1 and 8; EAUS slices 2, 3, and 4 were approximately at the levels of TPUS slices 3, 5, and 7. The anterior and lateral EAS and IAS thicknesses were measured and the two methods were compared.

RESULTS

The median age was 29 years. The mean body mass index (BMI) was 20.6 kg/m². All measured values obtained by TPUS were normally distributed. The EAS thickness on EAUS slice 2 and the IAS thickness on EAUS slices 2 and 3 were not normally distributed. The mean anterior EAS thickness was 2.51 mm, 2.96 mm, and 3.53 mm in slices 3, 5, and 7 on TPUS and was significantly thinner than that in slices 2 (2.62 mm), 3 (3.77 mm), and 4 (4.62 mm) on EAUS. In contrast, the IAS was markedly thicker on TPUS. The ratio of sphincter thickness anteriorly to laterally was similar using the two methods.

CONCLUSIONS

The morphological characteristics of EAS shown by TPUS and EAUS were similar. EAS was thinner, and IAS was thicker on TPUS. The IAS seems to be distorted on endoanal imaging.

Hiatal failure: effects of pregnancy, delivery, and pelvic floor disorders on level III factors

INTRODUCTION AND HYPOTHESIS

The failure of the levator hiatus (LH) and urogenital hiatus (UGH) to remain closed is not only associated with pelvic floor disorders, but also contributes to recurrence after surgical repair. Pregnancy and vaginal birth are key events affecting this closure. An understanding of normal and failed hiatal closure is necessary to understand, manage, and prevent pelvic floor disorders.

METHODS

This narrative review was conducted by applying the keywords "levator hiatus" OR "genital hiatus" OR "urogenital hiatus" in PubMed. Articles that reported hiatal size related to pelvic floor disorders and pregnancy were chosen. Weighted averages for hiatal size were calculated for each clinical situation.

RESULTS

Women with prolapse have a 22% and 30% larger LH area measured by ultrasound at rest and during Valsalva than parous women with normal support. Women with persistently enlarged UGH have 2-3 times higher postoperative failure rates after surgery for prolapse. During pregnancy, the LH area at Valsalva increases by 29% from the first to the third trimester in preparation for childbirth. The enlarged postpartum hiatus recovers over time, but does not return to nulliparous size after vaginal birth. Levator muscle injury during vaginal birth, especially forceps-assisted, is associated with increases in hiatal size; however, it only explains a portion of hiatus variation-the rest can be explained by pelvic muscle function and possibly injury to other level III structures.

CONCLUSIONS

Failed hiatal closure is strongly related to pelvic floor disorders. Vaginal birth and levator injury are primary factors affecting this important mechanism.

High Incidence of Obstetric Anal Sphincter Injuries among Immigrant Women of Asian Ethnicity

(1) Background: Obstetric anal sphincter injuries (OASI) may complicate vaginal deliveries. The aim of the present study was to explore the incidence and clinical characteristics of OASI among Asian women living in a Western country compared to local Caucasian women. (2) Methods: A retrospective cohort study of 380 women diagnosed with OASI, following singleton vaginal deliveries, during a 10-year period (January 2011 to December 2020). Exclusion criteria: age < 18 years, stillbirth, and breech presentation. Demographic, clinical, and obstetrical data were obtained, and a comparison between Asian and Caucasian women was performed. (3) Results: There were 35 cases of OASI among 997 women of Asian ethnicity compared to 345 cases of OASI among 86,250 Caucasian women (3.5% vs. 0.4%, respectively, p < 0.001). Asian women endured a significantly higher rate of fourth-degree OASI (17.1%) even though they bore smaller newborns (3318 g vs. 3501 g, p = 0.004), and birth weights rarely exceeded 3800 g (2.8% vs. 25.8%, p < 0.001). Asian ethnicity was also associated with a significantly higher risk for blood transfusion following OASI and a lower tendency for postpartum follow up. (4) Conclusions: Immigrant women of Asian ethnicity had a nine-fold higher rate of OASI, much higher than previously reported. Furthermore, Asian women had higher rates of fourth-degree OASI.

Are levator hiatal dimensions in mid-pregnancy associated with mode of delivery?

INTRODUCTION AND HYPOTHESIS

Slow progress of labour is a risk for operative delivery. Smaller levator hiatal dimensions are possible risk factors for slow progress and operative delivery. Our aim was to explore associations between hiatal dimensions antenatally, duration of second stage of labour and mode of delivery.

METHODS

Prospective cohort study of 65 nullipara examined at 20 weeks gestation and 6 months postpartum. Levator hiatal anteroposterior diameter and area were measured using 2D/3D transperineal ultrasound and compared between women with normal vaginal delivery and operative delivery (vacuum or caesarean) using t-test and with Spearman's rank to explore correlations with duration of second stage. ROC analysis established a cut-off for high risk of operative delivery.

RESULTS

Two-dimensional anteroposterior diameter and 3D hiatal area at rest were smaller in women with operative delivery than with normal delivery, 5.0 cm vs. 5.7 cm, p = 0.007 and 18.5 cm² vs. 14.9 cm², p < 0.001. From the ROC curve for 2D anteroposterior diameter, a cut-off of 5.6 cm, (sensitivity = 0.94, specificity = 0.63) and for 3D hiatal area a cut-off of 17.6 cm² (sensitivity = 0.94, specificity = 0.65) predicted operative delivery. We found inverse correlations between second stage of labour and anteroposterior diameter at rest, r = -0.330, contraction, r = -0.365, area at rest, r = -0.324, and contraction, r = -0.521, all p < 0.05.

CONCLUSIONS

Smaller hiatal dimensions at 20 weeks gestation were associated with longer second stage of labour and increased risk of operative delivery in nullipara. A 2D anteroposterior hiatal diameter < 5.6 cm and 3D hiatal area < 17.6 cm² at rest imply increased risk of operative delivery.

Application of Transperineal Pelvic Floor Ultrasound in Changes of Pelvic Floor Structure and Function Between Pregnant and Non-Pregnant Women

Objective

To evaluate the changes of pelvic floor tissue structure and function between pregnant and non-pregnant women from the view of transperineal pelvic floor ultrasound.

Methods

Thirty-eight cases of women with a second singleton pregnancy and thirty-two cases of women with a first singleton pregnancy underwent transperineal pelvic floor ultrasound, and their results were compared with forty-two cases of healthy non-pregnant women.

Results

The differences of bladder neck descent (BND), rectal ampulla distance and levator hiatus area (LHA) among the three groups were statistically significant (P<0.05), and the differences of BND, rectal ampulla distance, LHA between the women with a second singleton pregnancy group and non-pragnent group were statistically significant (P<0.05). The BND, retrovesical angle at rest (RVA-R) and retrovesical angle underwent Valsalva maneuver (RVA-V) in the group of stress urinary incontinence (SUI) during pregnancy were larger than those in non-SUI group, with significant difference (P<0.05), especially BND and RVA-V (P = 0.00).

Conclusion

Transperineal pelvic floor ultrasound has a high resolution of pelvic floor structure and function changes during pregnancy, and can dynamically evaluate pelvic floor function, providing a theoretical basis for early diagnosis and prevention of female pelvic floor dysfunction (FPFD) in subsequent pregnancies.

Pelvic organ prolapse in nulliparae

Background

Pregnancy and childbirth are thought to be the strongest environmental risk factors for pelvic organ prolapse, but prolapse does occur in nulliparae.

Aim

To characterise prolapse in vaginal nulliparae.

Material and methods

This was a retrospective study using archived clinical and imaging data of 368 vaginally nulliparous women seen between 2006 and 2017 at two tertiary urogynaecological centres. Patients underwent a standardised interview, clinical examination and 3D/4D translabial ultrasound. Volume datasets were analysed by the second author, blinded against all clinical data, using post‐processing software on a personal computer. Significant prolapse was defined as Pelvic Organ Prolapse Quantification system stage ≥2 for the anterior and posterior compartment, and stage ≥1 for the central compartment. On imaging, significant prolapse was defined as previously described.

Results

Of 4297 women seen during the inclusion period, 409 were vaginally nulliparous, for whom 368 volume data sets could be retrieved. Mean age was 50 years (17–89) and mean body mass index 29 (16–64). Eighty‐one (22%) presented with prolapse symptoms. On clinical examination, 106 women (29%) had significant prolapse, mostly of the posterior compartment (n = 70, 19%). On imaging 64 women showed evidence of significant prolapse (17%), again mostly posterior (n = 47, 13%). Rectovaginal septal defects were even more common in 69 (19%). On multivariate analysis we found no differences between true nulliparae (n = 184) and women delivered exclusively by caesarean section (n = 184).

Conclusions

Prolapse occurs in vaginal nulliparae, but it has distinct characteristics. Rectocele predominates, while cystocele and uterine prolapse are uncommon. Pregnancy and caesarean delivery seem to have little effect.

Longitudinal Study of Pelvic Floor Characteristics Before, During, and After Pregnancy in Nulliparous Women

OBJECTIVES

To investigate the changes in the pelvic floor before, during, and after pregnancy in the same collective of nulliparous women.

METHODS

In a prospective observational pilot study between April 2015 and June 2019 in nulliparous women with planned pregnancy, we used the pelvic organ prolapse quantification (POP-Q) system; a 2-dimensional (2D) sonography to investigate the bladder neck, cervix, and anorectal junction positions; and a 3D/4D sonography to measure the hiatus of the levator ani muscle (LH area) during Valsalva maneuver. Five visits were planned: 1 before, 3 during, and 1 visit after pregnancy.

RESULTS

Twenty-four women participated in the study. We achieved a minimum of 2 visit measurements from 10 women who became pregnant. The LH area decreased during the first trimester and then increased until the third trimester. Postpartum, the LH area reached the prepregnancy state. We observed changes in the bladder neck mobility, bladder neck position, cervix, and anorectal junction from the first trimester. Postpartum, the bladder neck mobility was higher, and the position of the bladder neck and anorectal junction was lower than before pregnancy. We observed no remarkable changes in the POP-Q state during pregnancy.

CONCLUSION

This was the first study to investigate pelvic floor characteristics in the same collective before, during, and after pregnancy. We observed pelvic floor changes from the prepregnancy state to the first trimester to postpartum. The study results need to be confirmed in a larger study.

Cut-offs for defining uterine prolapse using transperineal ultrasound in Chinese women: prospective multicenter study

OBJECTIVE

Transperineal ultrasound is a simple and highly repeatable method that has been used increasingly in the quantification of pelvic organ prolapse, but abnormal uterine descent on ultrasound in Chinese women is still poorly defined. We aimed to determine the optimal cut-off to define abnormal uterine descent on transperineal ultrasound in Chinese women.

METHODS

This prospective multicenter study recruited women who were examined in tertiary-level gynecological centers, due to symptoms of lower urinary tract and/or pelvic floor dysfunction, between February 2017 and September 2018. All recruited women underwent a standardized interview, pelvic organ prolapse quantification (POP-Q) examination, and four-dimensional transperineal ultrasound examination. On ultrasound, uterine descent was measured relative to the posteroinferior margin of the symphysis pubis during maximum Valsalva maneuver. The optimal cut-off value for definition of abnormal uterine descent was selected as the value with the highest Youden index and the diagnostic performance of this cut-off for the prediction of prolapse symptoms and POP-Q stage was assessed and compared by means of the area under the receiver-operating-characteristics curve (AUC).

RESULTS

In total, 538 Chinese women, with a mean age of 39.4 (range, 18-81) years, were enrolled into the study. Both uterine descent on transperineal ultrasound (P < 0.001) and POP-Q stage (P < 0.001) were associated strongly with presence of prolapse symptoms. Uterine descent on ultrasound was associated significantly with POP-Q stage for apical compartment prolapse (P < 0.001). The optimal cut-off value for the definition of abnormal uterine descent on transperineal ultrasound during maximum Valsalva maneuver in the prediction of prolapse symptoms was 4.79 mm above the symphysis pubis (AUC, 0.75 (95% CI, 0.71-0.78)), while the optimal cut-off values in the prediction of prolapse of POP-Q Stage ≥ 1 and POP-Q Stage ≥ 2 were 6.63 mm above the symphysis pubis (AUC, 0.83 (95% CI, 0.80-0.86)) and 8.42 mm below the symphysis pubis (AUC, 0.85 (95% CI, 0.82-0.88)), respectively.

CONCLUSIONS

The optimal cut-off value to define abnormal uterine descent on transperineal ultrasound during maximum Valsalva maneuver for the prediction of prolapse symptoms in this population of Chinese women was 4.79 mm above the symphysis pubis, close to that for predicting apical compartment prolapse of POP-Q Stage ≥ 1 (6.63 mm above the symphysis pubis). These are somewhat different from values described previously in mainly Caucasian populations. Ethnic differences should be taken into account in the evaluation of pelvic organ prolapse using transperineal ultrasound. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Women with advanced pelvic organ prolapse and levator ani muscle avulsion would significantly benefit from mesh repair surgery

OBJECTIVES

Mesh repair surgery for pelvic organ prolapse (POP) has been suspended in some countries owing to concerns about its associated complications. However, mesh repair has been shown to reduce the risk of prolapse recurrence after surgery. In view of this controversy, our aim was to assess the incidence of subjective and objective recurrence of POP following mesh repair surgery vs native-tissue repair in women with Stage-III or Stage-IV POP.

METHODS

This was a prospective observational study of women who presented with Stage-III or Stage-IV POP and received primary prolapse surgery between 2013 and 2018. Transperineal ultrasound was performed before the operation and volumes were analyzed offline to assess the presence of levator ani muscle (LAM) avulsion. All women were counseled on either mesh repair or native-tissue reconstruction. The mesh-repair group was followed up for up to 5 years and the native-tissue-repair group for up to 2 years after the operation. Prolapse symptoms and POP quantification (POP-Q) staging were assessed at follow-up. Subjective recurrence of POP was defined as symptoms of prolapse (vaginal bulge sensation or dragging sensation) reported by the patient. Objective recurrence was defined as POP-Q ≥ Stage II. The subjective and objective recurrences of prolapse were compared between women with and those without mesh use. Multivariate regression analysis was used to identify risk factors for the recurrence of POP.

RESULTS

A total of 154 Chinese women with Stage-III or Stage-IV prolapse were recruited. Of these, 104 (67.5%) underwent mesh repair (transabdominal in 57 women and transvaginal in 47 women) and 50 (32.5%) had native-tissue repair surgery. Ninety-five (61.7%) women had LAM avulsion. Both the subjective POP recurrence rate (4.8% vs 20.0%; P = 0.003) and the objective recurrence rate (20.2% vs 46.0%; P = 0.001) were significantly lower in the mesh-repair group than in the native-tissue-repair group. On multivariate logistic regression analysis, mesh repair was associated significantly with a reduced risk of subjective recurrence (odds ratio (OR), 0.20 (95% CI, 0.07-0.63)) and of objective recurrence (OR, 0.16 (95% CI, 0.07-0.55)) of prolapse. On subgroup analysis of women with LAM avulsion, mesh repair significantly reduced the risk of subjective recurrence (OR, 0.24 (95% CI, 0.07-0.87)) and objective recurrence (OR, 0.23 (95% CI, 0.09-0.57)) of POP. The incidence of mesh-related complications was low, and mesh exposure could be treated conservatively or by minor surgery.

CONCLUSIONS

Mesh repair surgery, compared with native-tissue repair, was associated with a 5-fold reduction in the risk of subjective recurrence and a 6-fold reduction in the risk of objective recurrence of prolapse in women with Stage-III or Stage-IV POP. In women with concomitant LAM avulsion, mesh repair surgery was associated with a 4-fold reduction in both objective and subjective recurrence of POP. The rate of mesh-related complications was low, and mesh exposure could be treated conservatively or by minor surgery. The benefit of mesh surgery for these high-risk women appears to outweigh the risks of mesh complications, and it could be a treatment option for this group of women. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Pregnancy, labour and delivery as risk factors for pelvic organ prolapse: a systematic review

INTRODUCTION

Pregnancy and childbirth are considered risk factors for pelvic organ prolapse (POP). The long latency between obstetric events and morbidity hinders the establishment of cause-effect relationships. Recently, intermediate outcomes such as organ descent and levator avulsion (LA) have been identified. We aimed to assess the effect of obstetric events on symptoms and signs of POP and on LA.

METHODS

We systematically reviewed the literature by searching PubMed/MEDLINE, Embase and Cochrane Library. We included studies in women examining associations between obstetric events and symptoms and signs of POP and LA, assessed through questionnaires, clinical examination and pelvic floor imaging. Two reviewers evaluated the studies for eligibility and for methodological quality/susceptibility to bias. We extracted study results and clustered them by outcome: symptoms of POP (sPOP), clinical findings of POP (cPOP) and LA. When appropriate, we performed a random-effect meta-analysis and reported the summary odds ratios (OR) with 95% confidence intervals. Heterogeneity across studies was assessed using the I² statistic.

RESULTS

The first vaginal delivery was a risk factor for POP as measured by sPOP (OR: 2.65 [1.81-3.88]), cPOP (OR: 4.85 [2.15-10.94]) and in association with LA (OR: 41.6 [4.13- 419.41]). Forceps delivery was a risk factor for POP as measured by sPOP (OR: 2.51 [1.34-4.69]), cPOP (OR: 1.68 [1.21-2.34]) and in association with LA (OR: 5.92 [3.75-9.34]). Birth exclusively by caesarean was protective for sPOP (OR: 0.38 [0.29-0.51]) and for cPOP (OR: 0.29 [0.20-0.41]) and it did not confer any additional risk compared to nulliparity.

CONCLUSIONS

This review confirms a strong aetiological link between vaginal birth and POP, with the first vaginal and forceps delivery being the main determinants.

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

BACKGROUND

Pelvic floor muscle function has been shown to be inversely associated with pelvic organ prolapse in Western women, however differences have been documented between ethnic groups.

OBJECTIVE

To determine if pelvic floor muscle strength and thickness and hiatal area are associated with pelvic organ prolapse in Nepali women.

METHODS

This cross-sectional study included non-pregnant Nepali women ≥18 years attending an outpatient gynecology clinic in Kathmandu, Nepal. A clinical examination included the pelvic organ prolapse quantification (POP-Q)- system examination and Modified Oxford Scale. Puborectalis muscle thickness and hiatal area were assessed using 3D/4D translabial ultrasound. Statistical analysis included Pearson's correlation and multiple regression (p<0.05).

RESULTS

Of the 123 women; 14 (11%) had POP-Q stage 0 prolapse, 29 (24%) stage I, 69 (56%) stage II, 8 (7%) stage III, and 3 (2%) stage IV. Mean±SD Modified Oxford Scale was 3.37±0.48 and muscle thickness was 1.14±0.21cm, hiatal area at rest was 14.67±3.11cm² and on contraction was 11.29±2.51cm². No associations were found between pelvic floor muscle strength or thickness and POP-Q stages 0-IV. There was a positive correlation found between hiatal area at rest and pelvic organ prolapse stage (r=0.34, p<0.001)and hiatal area on contraction and prolapse stage (r=0.30, p<0.001) and a negative correlation between pelvic floor muscle strength and hiatal area on contraction (r=-0.36, p<0.001).

CONCLUSION

In contrast to previous findings, pelvic floor muscle strength and thickness are not associated with pelvic organ prolapse in this sample of Nepali women. It is important to consider these findings when developing pelvic organ prolapse treatment and management strategies in this population.

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

PURPOSE

To explore the value of high-frequency two-dimensional (2D) ultrasound on demonstrating the morphology of puborectalis muscle and detect muscle avulsion.

METHODS

High-frequency 2D ultrasound and tomographic ultrasound image (TUI) were peformed to demonstrate puborectalis muscle and detect muscle avulsion respectively among 158 women with or without significant pelvic organ prolapse (POP) (POP quantification grade 2 or higher). Mean values were compared using student's t test between women with or without avulsion defects. We performed Cohen's Kappa analysis to examine the test agreement between high-frequency 2D ultrasound and TUI mode. Pearson correlation analysis was performed to explore the relationship between the thickness of puborectalis muscle and the measurements of levator-urethra gap (LUG).

RESULTS

The result of high-frequency 2D ultrasound in detecting muscle avulsion agreed well with TUI mode (Kappa 0.88, P < 0.05). Women with muscle avulsion had thinner muscles and larger LUG measurements than those with normal muscle insertion (P < 0.05). Pearson correlation analysis revealed the negative relationship between the thickness of puborectalis muscle and LUG measurements (r = - 0.73).

CONCLUSION

The study confirmed that it was feasible to observe the morphology of puborectalis muscle and detect muscle avulsion by high-frequency 2D ultrasound.

Can Stress Urinary Incontinence Be Predicted by Ultrasound?

OBJECTIVE. The purpose of this study is to determine the value of translabial real-time 3D ultrasound for predicting stress urinary incontinence (SUI). SUBJECTS AND METHODS. From December 2012 to August 2016, women with or without SUI diagnosed by urologists via urodynamics were prospectively recruited. All subjects underwent translabial real-time 3D ultrasound at one institution. Volume data were analyzed offline by a radiologist who was blinded to the diagnosis and who evaluated the bladder neck position on maximal Valsalva maneuver, the levator hiatus area on maximum Valsalva maneuver, bladder neck descent, and the urethral rotation angle. Combinations of two, three, and four parameters were analyzed using Fisher linear discriminant analysis. ROC curves were constructed to determine the optimal cutoff values of the four parameters and all combinations of parameters to predict SUI. RESULTS. A total of 321 women with SUI (mean [± SD] age, 35 ± 11 years) and 90 women without SUI (mean age, 31 ± 8 years) were included. Only 337 women were included in the final study, to eliminate the confounder of age. The cutoff values for the bladder neck position on maximal Valsalva maneuver, the levator hiatus area on maximum Valsalva maneuver, bladder neck descent, and the urethral rotation angle as parameters predicting SUI were 1 mm, 19 cm², 24 mm, and 45°, respectively. For all combinations of parameters, the negative predictive values were more than 90%, although none of the combinations had a sensitivity higher than 70%. The specificities were approximately 95% when three or four parameters were included. The positive predictive value of the combinations ranged from 49.2% to 84.8%. CONCLUSION. Translabial real-time 3D ultrasound is insufficient for predicting SUI, but it can be used to identify women without the condition.

Pelvic organ prolapse in Caucasian and East Asian women: a comparative study

OBJECTIVE

Ethnicity has been suggested to be a significant risk factor for pelvic organ prolapse (POP); yet, pelvic organ descent in different ethnic groups, especially in Asian populations, is not well studied. The aim of this study was to compare prolapse stages, pelvic organ descent and hiatal dimensions between East Asian and Caucasian women presenting with symptoms of POP.

METHODS

This was a prospective observational study of East Asian and Caucasian women presenting with symptoms of POP to a tertiary urogynecology clinic in, respectively, Hong Kong and Sydney. Demographic data, prolapse symptoms and prolapse stage were assessed. Physical examination was performed using the pelvic organ prolapse quantification (POP-Q) system. All women underwent transperineal ultrasound using Voluson systems. Offline analysis of four-dimensional ultrasound volume data was performed at a later date, by one operator blinded to all clinical data, to ascertain pelvic organ descent and hiatal dimensions on Valsalva maneuver. Levator muscle avulsion was assessed in volumes obtained on pelvic floor muscle contraction. Multiple logistic regression analysis was performed to assess factors associated with prolapse on clinical and ultrasound examinations.

RESULTS

A total of 225 East Asian women were included between July 2012 and February 2014 from the Hong Kong clinic and 206 Caucasian women between January 2015 and July 2016 from the Sydney clinic. There was no significant difference in the overall staging of prolapse. However, in East Asian women, compared with Caucasians, apical compartment prolapse was more common (99.6% vs 71.8%, P < 0.001) and posterior compartment prolapse less common (16.9% vs 48.5%, P < 0.001) on POP-Q examination. On Valsalva maneuver, the position of the uterus was lower in East Asian than in Caucasian women (-11.3 vs 1.35 mm, P < 0.001), while the rectal ampulla position was lower in Caucasians than in East Asians (-10.6 vs - 4.1 mm, P < 0.001). On multiple regression analysis, Caucasian ethnicity was a significant factor for lower risk of apical compartment prolapse on clinical assessment (odds ratio (OR), 0.01; P < 0.001) and on ultrasound (OR, 0.13; P < 0.001), and for a higher risk of posterior compartment prolapse on clinical assessment (OR, 4.36; P < 0.001) and of true rectocele on ultrasound (OR, 8.14; P < 0.001).

CONCLUSIONS

East Asian women present more commonly with uterine prolapse while Caucasians show more often posterior compartment prolapse. Ethnicity was a significant predictor of type of prolapse on multivariate analysis. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Does Patient Posture Affect the Ultrasound Evaluation of Pelvic Organ Prolapse?

OBJECTIVES

Translabial ultrasound (US) imaging is an emerging method for the evaluation of pelvic organ prolapse (POP). Normative data to date are limited to imaging in the supine position. The purpose of this study was to evaluate the effect of posture changes on US pelvic organ mobility.

METHODS

This work was a retrospective study of 175 women seen in a tertiary urogynecologic center for symptoms of lower urinary tract and pelvic floor dysfunction. All underwent a standardized interview, POP quantification prolapse assessment, and 4-dimensional translabial US examination in supine and standing positions. Offline measurement of organ descent on the Valsalva maneuver was undertaken at a later date and was blinded against all other data.

RESULTS

The mean age was 58 (SD, 13.5; range, 17 to 89) years, with a mean body mass index of 29 (SD, 6.1; range, 18 to 53) kg/m² . In total, 58.9% (n = 103) presented with symptoms of prolapse. Clinically, 82.8% (n = 145) had substantial prolapse on the POP quantification assessment. On imaging, bladder, uterine, and rectal ampulla positions were significantly lower, and the hiatal area on the Valsalva maneuver was larger in the standing position (P < .03). On receiver operating characteristic statistics assessing correlations between POP symptoms and US pelvic organ descent, the area under the curve was higher in the standing position, but the difference was not statistically significant.

CONCLUSIONS

Measurements of organ descent and hiatal dimensions are generally higher in the standing position. However, they are not reflected in a stronger association between symptoms and organ descent. Hence, imaging in the standing position can be limited to those patients in whom a false-negative assessment result is suspected.

2D USS of the pelvic floor in the 3rd trimester versus mode of delivery

OBJECTIVE

Biomechanics of pelvic floor muscles is becoming an important field of research in understanding a complex process of labour. Current evidence indicates that the levator ani stretches to allow passage of the fetus through the birth canal. We sought to identify properties of the functional female pelvic floor during pregnancy that could help to predict the mode of delivery, especially in women who underwent caesarean section in the past.

METHODS

A single centre prospective cohort study of pregnant women in the 3rd trimester attending antenatal clinic. Participants were categorised into three groups: 1. nulliparous, 2. previous one vaginal delivery and 3. previous one caesarean section who chose a trial of labour in their current pregnancy. All women underwent ultrasonographic evaluation of their pelvic floor muscles. Distensibility and the mode of delivery were assessed in participants' current pregnancies. The primary outcome was the mode of delivery. ANOVA test was used for statistical analysis.

RESULTS

133 women were included: 55 nulliparous, 52 primiparous (previous one vaginal birth), and 26 primiparous (previous one LSCS and planned for vaginal delivery after caesarean (VBAC)). Participants were scanned at an average gestation of 32 weeks. The inter-observer reliability test for puborectalis distensibility was good (kappa 0.75). Overall, women who delivered vaginally had a more distensible puborectalis muscle than those who delivered by emergency LSCS regardless of their previous type of delivery. Women who underwent a successful VBAC had less distensible pelvic floor muscles compared to their nulliparous and primiparous counterparts (who delivered vaginally in the past).

CONCLUSION

These results support our basic conceptual theory of puborectalis muscle distensibility influencing the mode of delivery and endorse application of dynamic pelvic floor ultrasound in future studies. We identified measurable differences in the functional female pelvic anatomy aiding a better understanding of physiology of the labour. There are trends towards lesser distensibility in women who delivered by LSCS.

Prospective comparison of obstetric anal sphincter injury incidence between an Asian and Western hospital

INTRODUCTION AND HYPOTHESIS

Obstetric anal sphincter injury (OASIS) rates are reported to be higher in Asian women living in Western countries than in those living in Asia, but the reasons for the differences remain unclear. The objectives of this study were for a single examiner to prospectively compare OASIS rates in primiparous Asian women in an Asian and Western birth unit and determine potential birth factors that may influence the possible difference in OASIS incidence.

METHODS

This was a prospective observational study based in Hong Kong, China, and Sydney, Australia, involving primiparous women > 36 weeks gestation of Asian descent undergoing vaginal delivery. A single examiner recorded basic patient demographics, observed all the deliveries at both sites, noting birthing techniques, and then examined the women, including a rectal examination, to determine OASIS incidence.

RESULTS

Seventy births in Hong Kong and 66 in Sydney were studied. The incidence of OASIS was 34% in Sydney and 10% in Hong Kong (p = 0.001). Birthweight, epidural rate, body mass index, and instrumental delivery were higher in Sydney. Episiotomy rates were higher in Hong Kong (59.2% vs. 82.9%; p = 0.007). When comparing OASIS with no-OASIS, perineal length (OR = 0.36, 95% CI 0.17 to 0.76, p = 0.004) and birthweight (OR = 1.14, 95% CI 1.00 to 1.30, p = 0.039) were independent risk factors for OASIS.

CONCLUSIONS

The incidence of OASIS in Asian women is significantly higher in a Western than in an Asian setting. In Asian women, perineal length and birthweight can affect the risk of OASIS at the time of vaginal delivery.

Can We Evaluate Hiatal Ballooning by Measuring the Anteroposterior Diameter With 2-Dimensional Translabial Ultrasonography?

OBJECTIVES

To analyze the association between the anteroposterior hiatal diameter and pelvic organ prolapse and to determine whether 2-dimensional translabial ultrasonography can evaluate hiatal ballooning by measuring the anteroposterior diameter.

METHODS

This study was a retrospective analysis of 312 women seen for lower urinary tract symptoms or pelvic organ prolapse between December 2014 and July 2016. All women had an International Continence Society (ICS) Pelvic Organ Prolapse Quantification (POP-Q) system examination and 4-dimensional translabial ultrasonography. The anteroposterior hiatal diameter was measured in the midsagittal plane, and the hiatal area was measured in the minimal axial plane during the maximal Valsalva maneuver.

RESULTS

Valid data from 294 patients were analyzed. International Continence Society POP-Q stage 0 was found in 121 women, stage 1 in 49, stage 2 in 78, stage 3 in 42, and stage 4 in 4. The anteroposterior diameter had an excellent linear correlation (r = 0.814; P < .001) with the hiatal area during the Valsalva maneuver and was strongly related to ICS POP-Q stages (P < .01). A receiver operating characteristic curve analysis proposed a cutoff of 6.0 cm for the anteroposterior diameter against ICS POP-Q stage 2 and higher (sensitivity, 73%; specificity, 52%) and prolapse symptoms (sensitivity, 74%; specificity, 64%).

CONCLUSIONS

The anteroposterior hiatal diameter, which represents hiatal distensibility in the midsagittal plane, can be used to evaluate hiatal ballooning. "Mild" ballooning was defined as an anteroposterior diameter measurement of 6.0 to less than 6.5 cm, "moderate" ballooning as 6.5 to less than 7.0 cm, and "marked" ballooning as 7.0 cm or greater.

Functional pelvic floor anatomy in Nepali women attending a general gynaecology clinic

INTRODUCTION AND HYPOTHESIS

Limited existing evidence suggests that there is a high prevalence of female pelvic organ prolapse (POP) amongst Nepali women. However, to date, no comprehensive assessment of pelvic floor functional anatomy has been undertaken in this population. Our study aimed to determine functional pelvic floor anatomy in Nepali women attending a general gynaecology clinic.

METHODS

One hundred and twenty-nine consecutive women attending the clinic were offered an interview, clinical examination [International Continence Society Pelvic Organ Prolapse Quantification system (ICS/POP-Q)] and 4D translabial ultrasound (TLUS). Most presented with general gynaecological complaints. Five were excluded due to previous pelvic surgery, leaving 124.

RESULTS

A POP-Q exam was possible in 123 women, of whom 29 (24%) were diagnosed with a significant cystocele, 50 (41%) significant uterine prolapse and seven (6%) significant posterior compartment prolapse. Evaluation of 4D TLUS data sets was possible in 120 women, of whom 25 (21%) had a significant cystocele, 45 (38%) significant uterine prolapse and ten (8%) significant descent of the rectal ampulla. In 13 cases, there was a rectocele with a mean depth of 14 (10-28) mm. Of 114 women in whom uterine position could be determined, 68 (60%) had a retroverted uterus associated with significant uterine prolapse (P 0.038).

CONCLUSIONS

POP is common in Nepali women attending a general gynaecology clinic, with a high prevalence of uterine prolapse (40%). Uterine retroversion was seen in 60% and was associated with uterine prolapse. Patterns of POP in Nepal seem to be different from patterns observed in Western populations.

Levator ani muscle avulsion is a risk factor for expulsion within 1 year of vaginal pessary placed for pelvic organ prolapse

OBJECTIVE

The aim of this study was to investigate whether the presence of levator ani muscle (LAM) avulsion is associated with expulsion within 1 year of a vaginal pessary placed for pelvic organ prolapse (POP).

METHODS

This was a prospective observational study of consecutive women with symptomatic POP, who had not received treatment for the condition before the consultation and opted for vaginal pessary placement in our center. Volume acquisition was performed before pessary insertion and offline analysis of the 3D/4D transperineal ultrasound volume data was performed. LAM was assessed on maximum pelvic floor muscle contraction (PFMC) and hiatal dimensions were assessed at rest, on PFMC and on maximum Valsalva. Results were compared between women in whom the pessary was retained for 1 year and those in whom the pessary was expelled within 1 year.

RESULTS

The datasets of 255 women were analyzed including 147 (57.6%) women who had a vaginal pessary continuously in place over 1 year and 108 (42.4%) with pessary expulsion. Mean age was 63.2 (SD, 9.9) years and median parity was 3 (2-4). Eighteen (7.1%) had Stage I, 164 (64.3%) Stage II, 67 (26.3%) Stage III and six (2.4%) Stage IV POP. Women with vaginal pessary expulsion within 1 year had significantly larger hiatal dimensions at rest and on Valsalva, larger hiatal area during rest, PFMC and Valsalva and higher rate of LAM avulsion (53.7% vs 27.2%, P < 0.01) compared with women in whom the pessary was retained for 1 year. After controlling for potential confounders, LAM avulsion remained a risk factor (OR, 3.18, P < 0.01) of vaginal pessary expulsion within 1 year.

CONCLUSIONS

Women in whom a vaginal pessary was expelled within 1 year of placement for POP had a larger hiatus. Presence of LAM avulsion was associated with a three-fold increase in the risk of expulsion of a vaginal pessary within 1 year. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Longitudinal follow-up of levator ani muscle avulsion: does a second delivery affect it?

OBJECTIVES

To evaluate the morphological outcome of levator ani muscle (LAM) avulsion 3-5 years after a first delivery and to assess the effect of a second delivery on this condition. The impact of LAM avulsion on pelvic floor disorders was also studied.

METHODS

Six hundred and sixty-six women who had been assessed for LAM avulsion 8 weeks after their first delivery were invited for a follow-up examination 3-5 years later. Women completed the Pelvic Floor Distress Inventory including the Urinary Distress Inventory (UDI) and Pelvic Organ Prolapse Distress Inventory (POPDI) questionnaires to explore symptoms of pelvic floor disorders, and the pelvic floor was examined using three-dimensional translabial ultrasound and assessed using the pelvic organ prolapse quantification system.

RESULTS

Three hundred and ninety-nine women completed the study, of whom 151 were multiparous. Mean interval between first delivery and follow-up was 42.3 ± 7.6 months. Among 69 women who had LAM avulsion 8 weeks after their first delivery, nine (13.0%) had no LAM avulsion at follow-up. One (0.9%) woman had a new LAM avulsion after her second vaginal delivery. A greater proportion of women with LAM avulsion reported symptoms of stress urinary incontinence (SUI) (adjusted odds ratio, 2.09 (95% CI, 1.18-3.70); P = 0.01) and symptoms of prolapse than did women without avulsion; however, this difference did not reach statistical significance (P = 0.61). Women with LAM avulsion had higher UDI and POPDI scores than did women without avulsion (median UDI score, 17.7 (interquartile range (IQR), 5.0-32.4) vs 9.2 (IQR, 0.0-22.1); P = 0.045 and median POPDI score, 20.8 (IQR, 8.8-40.5) vs 10.7 (IQR, 0.0-32.8); P = 0.021).

CONCLUSIONS

The risk of developing new LAM avulsion after a second vaginal delivery is low (0.9%). Healing of LAM avulsion was observed in 13% of women who had at least one vaginal delivery. At 3-5 years after delivery, women with LAM avulsion reported symptoms of SUI more often than did those without, and had higher UDI and POPDI scores, implying more bothersome symptoms. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Vaginal Pessary in Women With Symptomatic Pelvic Organ Prolapse: A Randomized Controlled Trial

OBJECTIVE

To compare pelvic floor symptoms, quality of life, and complications in women with symptomatic pelvic organ prolapse (POP) with or without vaginal pessaries in addition to those who do pelvic floor exercises for 12 months.

METHODS

This was a parallel-group, single-blind, randomized controlled trial with 12 months of follow-up. Women with symptomatic stage I to stage III POP were randomized to either pelvic floor exercises training (control group) or pelvic floor exercises training and insertion of a vaginal pessary (pessary group). The primary outcome was the change of prolapse symptoms and quality of life by using the Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaires. Secondary outcomes included bothersome of prolapse symptoms, desired treatment, and any complications.

RESULTS

From December 2011 through November 2014, 311 women were screened and 276 were randomized as follows: 137 to the control and 139 to the pessary group. One hundred thirty-two (95.0%) women in the pessary group and 128 (93.4%) in the control group completed the study. The Pelvic Organ Prolapse Distress Inventory of Pelvic Floor Distress Inventory and the Pelvic Organ Prolapse Impact Questionnaire of Pelvic Floor Impact Questionnaire scores decreased in both groups after 12 months, but the mean score differences were higher in the pessary group (Pelvic Organ Prolapse Distress Inventory: -29.7 compared with -4.7, P<.01; Pelvic Organ Prolapse Impact Questionnaire: -29.0 compared with 3.5, P<.01). Complication rates were low and similar in both groups.

CONCLUSION

We provided further evidence in nonsurgical treatment for POP. Prolapse symptoms and quality of life were improved in women using a vaginal pessary in addition to pelvic floor exercises.

CLINICAL TRIAL REGISTRATION

Centre for Clinical Research and Biostatistics-Clinical Trials Registry, https://www2.ccrb.cuhk.edu.hk/web/?page_id=746, ChiCTR-TRC-11001796.

Antenatal pelvic floor biometry is related to levator ani muscle injury

OBJECTIVE

To evaluate the relationship between antenatal pelvic floor biometry and levator ani muscle (LAM) injury in Chinese women.

METHODS

Three-dimensional transperineal ultrasound was performed in nulliparous Chinese women with a singleton pregnancy at 9-12 weeks, 26-28 weeks and 36-38 weeks of gestation and again at 12 months after delivery. Hiatal anteroposterior (AP) diameter, transverse diameter and area were measured on the antenatal ultrasound volumes obtained at rest, on Valsalva maneuver and during pelvic floor muscle contraction (PFMC). LAM injury was evaluated using ultrasound volumes obtained during PFMC at 12 months after delivery.

RESULTS

In total, 328 women completed the study. At 12 months after delivery, 38 (14.8% of those who delivered vaginally) women had LAM injury; 28 were unilateral (14 right- and 14 left-sided) and 10 were bilateral. In all three trimesters there was smaller hiatal AP diameter and hiatal area in women with LAM injury when compared with women without injury. On multivariable analysis of the three factors, hiatal AP diameter at rest, hiatal area at rest and operative vaginal delivery, only hiatal AP diameter at rest in all three trimesters was an independent factor of LAM injury. A larger hiatal AP diameter at rest in the first, second and third trimesters reduced the likelihood of LAM injury with odds ratios of 0.21, 0.15 and 0.21, respectively.

CONCLUSIONS

A smaller antenatal hiatal AP diameter at rest is a risk factor for LAM injury. The hiatal AP diameter is relatively simple to measure and the error in measurement is relatively small. A prospective study to confirm this relationship and to explore whether this measurement, performed in the midsagittal plane, is repeatable should be performed. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

The association between maternal age at first delivery and risk of obstetric trauma

BACKGROUND

There are a number of poor birth outcomes with advancing maternal age. Although there is some evidence of a higher risk of trauma to obstetric anal sphincter and the levator ani muscle with advancing age, findings to date are inconclusive.

OBJECTIVE

The aim of this study was to assess the risk of pelvic floor injury using translabial 3- and 4-dimensional ultrasound relative to advancing maternal age in primiparous women after a singleton vaginal delivery at term and to determine any association between maternal age and obstetric trauma, including obstetric anal sphincter injuries, levator avulsion, and irreversible overdistension of the levator hiatus.

STUDY DESIGN

This is a subanalysis of a perinatal intervention trial conducted in a specialist urogynecology referral unit at 2 tertiary units. All primiparous women with singleton birth at term underwent 3- and 4-dimensional translabial pelvic floor ultrasound both ante- and postnatally for the assessment of the obstetric trauma including levator ani muscle avulsion, hiatal overdistension to 25 cm(2) or more, and obstetric anal sphincter injuries. A multivariate logistic regression analysis was performed to examine the association between maternal age and obstetric trauma diagnosed on 3- and 4-dimensional translabial ultrasound. Multiple confounders were included, and the most significant (forceps and vacuum delivery) were used for probability modeling.

RESULTS

Of 660 women recruited for the original study, a total of 375 women who had a vaginal delivery with complete data sets were analyzed. A total of 174 women (46.4%) showed evidence of at least 1 form of major pelvic floor trauma. Advancing maternal age at first delivery carries with it a significant incremental risk of major pelvic floor trauma with an odds ratio of 1.064 for overall risk of injury for each increasing year of age past age 18 years (P = .003). The probability of any type of trauma appears to be substantially higher for forceps delivery. Vacuum delivery appears to increase the risk of obstetric anal sphincter injuries but not of levator avulsion.

CONCLUSION

There is a significant association between the risk of major pelvic floor injury and increasing maternal age at first delivery.

Agreement and reliability of pelvic floor measurements during rest and on maximum Valsalva maneuver using three-dimensional translabial ultrasound and virtual reality imaging

OBJECTIVES

Imaging of the levator ani hiatus provides valuable information for the diagnosis and follow-up of patients with pelvic organ prolapse (POP). This study compared measurements of levator ani hiatal volume during rest and on maximum Valsalva, obtained using conventional three-dimensional (3D) translabial ultrasound and virtual reality imaging. Our objectives were to establish their agreement and reliability, and their relationship with prolapse symptoms and POP quantification (POP-Q) stage.

METHODS

One hundred women with an intact levator ani were selected from our tertiary clinic database. Information on clinical symptoms were obtained using standardized questionnaires. Ultrasound datasets were analyzed using a rendered volume with a slice thickness of 1.5 cm, at the level of minimal hiatal dimensions, during rest and on maximum Valsalva. The levator area (in cm(2) ) was measured and multiplied by 1.5 to obtain the levator ani hiatal volume (in cm(3) ) on conventional 3D ultrasound. Levator ani hiatal volume (in cm(3) ) was measured semi-automatically by virtual reality imaging using a segmentation algorithm. Twenty patients were chosen randomly to analyze intra- and interobserver agreement.

RESULTS

The mean difference between levator hiatal volume measurements on 3D ultrasound and by virtual reality was 1.52 cm(3) (95% CI, 1.00-2.04 cm(3) ) at rest and 1.16 cm(3) (95% CI, 0.56-1.76 cm(3) ) during maximum Valsalva (P < 0.001). Both intra- and interobserver intraclass correlation coefficients were ≥ 0.96 for conventional 3D ultrasound and > 0.99 for virtual reality. Patients with prolapse symptoms or POP-Q Stage ≥ 2 had significantly larger hiatal measurements than those without symptoms or POP-Q Stage < 2.

CONCLUSIONS

Levator ani hiatal volume at rest and on maximum Valsalva is significantly smaller when using virtual reality compared with conventional 3D ultrasound; however, this difference does not seem clinically important. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Is pelvic organ support different between young nulliparous African and Caucasian women?

OBJECTIVE

There seems to be substantial variation in the prevalence of pelvic floor disorders between different ethnic groups. This may be due partially to differences in pelvic floor structure and functional anatomy. To date, data on this issue are sparse. The aim of this study was to compare hiatal dimensions, pelvic organ descent and levator biometry in young, healthy nulliparous Caucasian and African women.

METHODS

Healthy nulliparous non-pregnant volunteers attending a local nursing school in Uganda were invited to participate in this study during two fistula camps. All volunteers underwent a simple physician-administered questionnaire and a four-dimensional translabial ultrasound examination. Offline analysis was performed to assess hiatal dimensions, pelvic organ descent, levator muscle thickness and area. To compare findings with those obtained in nulliparous non-pregnant Caucasians, we retrieved the three-dimensional/four-dimensional ultrasound volume datasets of a previously published study.

RESULTS

The dataset of 76 Ugandan and 49 Caucasian women was analyzed. The two groups were not matched but they were comparable in age and body mass index. All measurements of hiatal dimensions and pelvic organ descent were significantly higher among the Ugandans (all P ≤ 0.01); however, muscle thickness and area were not significantly different between the two groups.

CONCLUSIONS

Substantial differences between Caucasian and Ugandan non-pregnant nulliparae were identified in this study comparing functional pelvic floor anatomy. It appears likely that these differences in functional anatomy are at least partly genetic in nature. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Correlations of third-trimester hiatal biometry obtained using four-dimensional translabial ultrasonography with the delivery route in nulliparous pregnant women

Purpose:

The goal of this study was to evaluate normal hiatal dimensions in the third trimester in nulliparous Thai pregnant women and to establish which biometric factors were associated with various pregnancy outcomes.

Methods:

Fifty-seven consecutive nulliparous pregnant Thai women in their third trimester were recruited on a voluntary basis from April to October 2014. All subjects underwent four-dimensional (4D) translabial ultrasonography. Hiatal biometric parameters were measured at rest, while performing a Valsalva maneuver, and during contraction. Information about the patients’ eventual deliveries was obtained from their medical records.

Results:

The mean values of the patients’ age, body mass index, and gestational age at the time of examination were 27.4±5.47 years, 26.7±3.48 kg/m², and 36.6±1.49 weeks, respectively. No subjects had vaginal lumps or experienced prolapse greater than stage 1 of the Pelvic Organ Prolapse Quantification system. Ultrasonography showed that the mean values of the hiatal area at rest, while performing a Valsalva maneuver, and during contraction were 13.10±2.92 cm², 17.50±4.81 cm², and 9.69±2.09 cm², respectively. The hiatal area at rest, the axial measurement at rest, and the axial measurement while performing a Valsalva maneuver were significantly associated with the route of delivery (P=0.02, P=0.04, and P=0.03, respectively).

Conclusion:

The route of delivery was associated with hiatal biometric values measured using 4D translabial ultrasonography, based on the results of nulliparous Thai women in the third trimester.