Biometry of the pubovisceral muscle and levator hiatus by three-dimensional pelvic floor ultrasound

Patient-specific surrogate model to predict pelvic floor dynamics during vaginal delivery

Childbirth is a challenging event that can lead to long-term consequences such as prolapse or incontinence. While computational models are widely used to mimic vaginal delivery, their integration into clinical practice is hindered by time constraints. The primary goal of this study is to introduce an artificial intelligence pipeline that leverages patient-specific surrogate modeling to predict pelvic floor injuries during vaginal delivery. A finite element-based machine learning approach was implemented to generate a dataset with information from finite element simulations. Thousands of childbirth simulations were conducted, varying the dimensions of the pelvic floor muscles and the mechanical properties used for their characterization. Additionally, a mesh morphing algorithm was developed to obtain patient-specific models. Machine learning models, specifically tree-based algorithms such as Random Forest (RF) and Extreme Gradient Boosting, as well as Artificial Neural Networks, were trained to predict the nodal coordinates of nodes within the pelvic floor, aiming to predict the muscle stretch during a critical interval. The results indicate that the RF model performs best, with a mean absolute error (MAE) of 0.086 mm and a mean absolute percentage error of 0.38%. Overall, more than 80% of the nodes have an error smaller than 0.1 mm. The MAE for the calculated stretch is equal to 0.0011. The implemented pipeline allows loading the trained model and making predictions in less than 11 s. This work demonstrates the feasibility of implementing a machine learning framework in clinical practice to predict potential maternal injuries and assist in medical-decision making.

Fully Automated Localization and Measurement of Levator Hiatus Dimensions Using 3-D Pelvic Floor Ultrasound

OBJECTIVE

To develop an algorithm for the automated localization and measurement of levator hiatus (LH) dimensions (AI-LH) using 3-D pelvic floor ultrasound.

METHODS

The AI-LH included a 3-D plane regression model and a 2-D segmentation model, which first achieved automated localization of the minimal LH dimension plane (C-plane) and measurement of the hiatal area (HA) on maximum Valsalva on the rendered LH images, but not on the C-plane. The dataset included 600 volumetric data. We compared AI-LH with sonographer difference (ASD) as well as the inter-sonographer differences (IESD) in the testing dataset (n = 240). The assessment encompassed the mean absolute error (MAE) for the angle and center point distance of the C-plane, along with the Dice coefficient, MAE, and intra-class correlation coefficient (ICC) for HA, and included the time consumption.

RESULTS

The MAE of the C-plane of ASD was 4.81 ± 2.47° with 1.92 ± 1.54 mm. AI-LH achieved a mean Dice coefficient of 0.93 for LH segmentation. The MAE on HA of ASD (1.44 ± 1.12 mm²) was lower than that of IESD (1.63 ± 1.58 mm²). The ICC on HA of ASD (0.964) was higher than that of IESD (0.949). The average time costs of AI-LH and manual measurement were 2.00 ± 0.22 s and 59.60 ± 2.63 s (t = 18.87, p < 0.01), respectively.

CONCLUSION

AI-LH is accurate, reliable, and robust in the localization and measurement of LH dimensions, which can shorten the time cost, simplify the operation process, and have good value in clinical applications.

Levator Ani Muscle Avulsion After Vaginal Delivery Comparing Routine Versus Restrictive Episiotomy: A Pilot Study

INTRODUCTION AND HYPOTHESIS

The objective was to compare the rate of levator ani muscle avulsion following vaginal birth after routine and restrictive episiotomy.

METHODS

This study consists of two cohorts of pregnant women prospectively enrolled between September 2015 and December 2017 at a university hospital. The pregnant women were subject to a randomized controlled trial, in which participants received a restrictive episiotomy protocol versus a routine episiotomy protocol for vaginal delivery. Levator ani avulsion was evaluated by four-dimensional ultrasound screening.

RESULTS

Sixty-one post-partum primipara women were enrolled in our study. Thirty-two women (52.5%) had undergone routine episiotomy whereas 29 women (47.5%) had gone through restrictive episiotomy. Right mediolateral episiotomies were performed in all cases. The rate of anal sphincter tear was 12.5% in the routine episiotomy group versus 13.8% in the restrictive episiotomy group (p = 1.00). Levator ani avulsion was detected in 9.4% of the routine episiotomy group (only on the right side) and in 10.3% of the restrictive episiotomy group (p = 1.00). No bilateral levator avulsion was detected in either of the groups. There were no statistical differences in the distances of the bladder neck descent, cystocele descent, uterine descent, rectocele descent, and the ballooning of the genital hiatus area between the groups.

CONCLUSIONS

In our pilot study, there was no reduction of the rate of levator ani avulsion in women with restrictive episiotomy compared with routine episiotomy. There were no differences in pelvic floor ultrasound parameters between the two groups.

Levator-urethra gap: is there a need for individualization of cut-offs?

OBJECTIVES

To determine whether height, weight and body mass index (BMI) are associated with the levator-urethra gap (LUG) measurement, and whether these factors confound the relationship between LUG and symptoms and signs of pelvic organ prolapse (POP).

METHODS

This was a retrospective study of women seen at a tertiary urogynecology unit between January 2020 and December 2021. Postprocessing of saved ultrasound volume data was used to measure the LUG, blinded against all other data. This measurement was tested for its association with organ descent and hiatal area, and height, weight and BMI were investigated for any potential confounding effect.

RESULTS

The 624 women seen during the inclusion period presented mostly with stress urinary incontinence (448/624 (72%)), urgency urinary incontinence (469/624 (75%)) and/or prolapse (338/624 (54%)). Mean age at assessment was 58 (range, 20-94) years, mean height was 163 (range, 142-182) cm, mean weight was 80 (range, 41-153) kg and mean BMI was 30 (range, 17-65) kg/m2. LUG measurements could be obtained in 613 women, resulting in 7356 (12 × 613) measurements. The average LUG in individual women measured 2.35 cm on the right and 2.32 cm on the left side (difference not significant), with a mean ± SD of 2.34 ± 0.63 cm overall. Mean LUG was associated with symptoms and signs of prolapse, both on clinical examination (POP quantification system) and on imaging, but not with height (P = 0.36), weight (P = 0.20) or BMI (P = 0.09).

CONCLUSIONS

Levator-urethra gap measurements do not seem to be significantly associated with height, weight or BMI in our population, obviating the need for individualization of LUG. However, this does not exclude interethnic variability of this biometric measure. © 2024 International Society of Ultrasound in Obstetrics and Gynecology.

In vivo measurement of the elastic properties of pelvic floor muscles in pregnancy using shear wave elastography

OBJECTIVE

We aimed to investigate changes in the elastic properties of levator ani muscle (LAM) and external anal sphincter (EAS) during pregnancy using shear wave elastography (SWE). Our secondary objective was to examine the association between the elastic properties of pelvic floor muscles (PFM) and perineal tears at childbirth.

METHODS

This was a prospective monocentric study, including nulliparous women. Three visits were planned (14-18, 24-28, and 34-38 weeks) with a SWE assessment of the LAM and EAS at rest and during Valsalva maneuver. Then, we collected data about the delivery's characteristics. Assessments were performed using an Aixplorer V12® device (SL 18-5 linear probe) using a transperineal approach, reporting the shear modulus in kPa. We looked for changes in PFM's elastic properties during pregnancy using one-way ANOVA for repeated measures. We compared the mean shear modulus in late pregnancy for each muscle and condition between women with an intact perineum at delivery and those with a perineal tear using Student's t test.

RESULTS

Forty-seven women were considered. Forty-five women had vaginal delivery of which 38 (84.4%) had perineal tears. We did not report any significant changes in the elastic properties of PFM during pregnancy. Women with an intact perineum at delivery had a stiffer EAS at Valsalva maneuver in late pregnancy (27.0 kPa vs. 18.2 kPa; p < 0.005).

CONCLUSIONS

There were no significant changes in the elastic properties of the PFM in pregnancy. Stiffer EAS in late pregnancy appears to be associated with a lower incidence of perineal tears.

Analysis of minimal levator ani hiatus area based on MRI in female adults without pelvic floor dysfunction at different age groups

PURPOSE

To investigate the association of minimal levator ani hiatus area with age in female adults without pelvic floor dysfunction.

METHODS

532 female subjects aged 18 ~ 90 years without pelvic floor dysfunction, divided into four groups (Group A, 18 ~ 29 years old; Group B, 30 ~ 39 years old; Group C, 40 ~ 49 years old; Group D, ≥ 50 years old) based on age, underwent traditional pelvic two-dimensional (2D) T2-weighted imaging (T2WI) axial to the body (AxB) for measuring the minimal levator ani hiatus area. 39 female volunteers were re-recruited to undergo both traditional pelvic 2D T2WI AxB and three-dimensional (3D) T2WI. An axial plane parallel to the direction of the puborectalis muscle (AxPRM) was acquired based on 3D T2WI. The difference of levator ani hiatus area measured on AxB and AxPRM images in 39 female volunteers was compared by one-sample t test, to verify if minimal levator ani hiatus area can be acquired on the traditional pelvic 2D T2WI AxB images. Spearman analysis evaluated the association of minimal levator ani hiatus area with age and the rank-sum test analyzed the area differences among four age groups.

RESULTS

Female age was positively correlated with minimal levator ani hiatus area (r = 0.23; p < 0.001). The minimal levator ani hiatus areas of 532 subjects were: 15.17 ± 1.77 cm2 in Group A, 15.52 ± 2.21 cm2 in Group B, 16.03 ± 2.16 cm2 in Group C, and 16.40 ± 2.10 cm2 in Group D. ANOVA showed significant statistical differences among four age groups (F = 7.519, p < 0.0001). Significant differences in minimal levator ani hiatus areas were found between Group A and Group C (p = 0.0491), Group A and Group D (p = 0.0007), and Group B and Group D (p < 0.001). There was no statistical difference in minimal levator ani hiatus areas measured on AxB and AxPRM images in 39 female volunteers (p = 0.1000). There were no statistical difference in minimal levator ani hiatus areas between nulliparous and multiparous group for each age group (all p > 0.05).

CONCLUSIONS

Based on a large sample, this study summarized the minimum levator ani hiatus area of female adults without pelvic floor dysfunction in different age groups. We found significant differences among different age groups. In addition, a positive correlation was found between age and the minimum levator ani hiatus area. These findings can provide reference criteria for diagnosing pelvic organ prolapse in female adults of different age groups.

Comparison of Cross-Sectional Area of Pubovisceral Muscle in Nulliparous and Primiparous Women

INTRODUCTION AND HYPOTHESIS

The main risk factor for pelvic floor disorders is vaginal delivery, which may cause levator ani muscle (LAM) injury and denervation. LAM includes pubovisceral muscle (PVM, pubococcygeus), puborectalis muscle (PRM), and iliococcygeus muscle. We hypothesize that primiparous women with low pelvic floor muscle contraction have a reduced PVM cross-sectional area (CSA) compared to nulliparous women.

METHODS (SAMPLE SIZE AND STATISTICAL APPROACHES)

This single-centre prospective observational study compared healthy nulliparous (n = 40) to primiparous (n = 40) women after vaginal delivery without LAM avulsion and Oxford score ≤ 3. Demographics, questionnaires (ICIQ-UI-SF, OAB-Q-SF, PISQ-12), POP-Q, Oxford score, ultrasound measurements (minimal anteroposterior and lateral diameters, hiatal area, PRM thickness, levator-urethra gap) and magnetic resonance imaging (MRI)-PVM CSA were evaluated. Normality was tested, and an appropriate test was used to compare the groups. Power calculation suggested 40 participants per group.

RESULTS

The primiparous group was older, had a higher BMI, and their hiatal area on ultrasound at contraction was larger compared to the nulliparous group. The CSA of the left-sided PVM (1.15 ± 0.50 cm2) was larger compared to the right side (1.03 ± 0.50 cm2), p = 0.02 in nulliparous women. The PVM CSA of primiparous women with low Oxford score was reduced compared to nulliparous (0.87 ± 0.30 versus 1.09 ± 0.50 cm2, p = 0.006). The intra-rater reliability for PVM CSA had an ICC of 0.90 and inter-rater ICC of 0.77.

CONCLUSIONS

Primiparous women after vaginal delivery with low pelvic floor contraction force had reduced PVM CSA on MRI images compared to nulliparous women.

Soft-tissue dystocia due to paradoxical contraction of the levator ani as a cause of prolonged second stage: concept, diagnosis, and potential treatment

Smaller pelvic floor dimensions seem to have been an evolutionary need to provide adequate support for the pelvic organs and the fetal head. Pelvic floor dimension and shape contributed to the complexity of human birth. Maternal pushing associated with pelvic floor muscle relaxation is key to vaginal birth. Using transperineal ultrasound, pelvic floor dimensions can be objectively measured in both static and dynamic conditions, such as pelvic floor muscle contraction and pushing. Several studies have evaluated the role of the pelvic floor in labor outcomes. Smaller levator hiatal dimensions seem to be associated with a longer duration of the second stage of labor and a higher risk of cesarean and operative deliveries. Furthermore, smaller levator hiatal dimensions are associated with a higher fetal head station at term of pregnancy, as assessed by transperineal ultrasound. With maternal pushing, most women can relax their pelvic floor, thus increasing their pelvic floor dimensions. Some women contract rather than relax their pelvic floor muscles under pushing, which is associated with a reduction in the anteroposterior diameter of the levator hiatus. This phenomenon is called levator ani muscle coactivation. Coactivation in nulliparous women at term of pregnancy before the onset of labor is associated with a higher fetal head station at term of pregnancy and a longer duration of the second stage of labor. In addition, levator ani muscle coactivation in nulliparous women undergoing induction of labor is associated with a longer duration of the active second stage of labor. Whether we can improve maternal pelvic floor relaxation with consequent improvement in labor outcomes remains a matter of debate. Maternal education, physiotherapy, and visual feedback are promising interventions. In particular, ultrasound visual feedback before the onset of labor can help women increase their levator hiatal dimensions and correct levator ani muscle coactivation in some cases. Ultrasound visual feedback in the second stage of labor was found to help women push more efficiently, thus obtaining a lower fetal head station at ultrasound and a shorter duration of the second stage of labor. The available evidence on the role of any intervention aimed to aid women to better relax their pelvic floor remains limited, and more studies are needed before considering its routine clinical application.

Validation of an automated software (Smartpelvic™) in assessing hiatal area from three dimensional transperineal pelvic volumes of pregnant women: comparison with manual analysis

OBJECTIVES

The aim of this investigation was to evaluate the agreement between a manual and an automatic technique in assessing levator hiatus area (LHA) during pregnancy from three-dimensional (3D) pelvic floor volumes obtained by trans-perineal ultrasound (TPUS).

METHODS

3D volumes were acquired during rest, maximum pelvic floor contraction and Valsalva maneuver from 66 pregnant women. Manual selection of LHA and automatic software (Smart Pelvic™) were applied on TPUS volume starting from a C-plane view. To evaluate intra- and inter-observer variability measurements of LHA were performed twice by the same operator and once by a second sonographer. Reference hiatal contours obtained manually by the first operator were compared with the automated ones. Reproducibility was evaluated by intraclass correlation coefficients (ICC) and Bland-Altman plots.

RESULTS

LHA measurement, using automatic software, achieved excellent intra-observer and inter-observer reproducibility in pregnant women both at rest and after dynamic analysis (ICC>0.9). Further, an excellent agreement resulted between manual selection of the LHA and automatic imaging (ICC>0.9). The average time taken to obtain LHA manually was significantly longer when compared to the automatic analysis (p≤0.0001).

CONCLUSIONS

Smart pelvic software resulted from a reliable method for automatically measuring the LHA, showing high reproducibility and accuracy.

Validation of a built-in software in automatically reconstructing the tomographic images of the levator ani muscle

INTRODUCTION AND HYPOTHESIS

Transperineal ultrasound (TPUS) is an effective tool for evaluating the integrity of the levator ani muscle (LAM). Several operating steps are required to obtain the standard multi-slice image of the LAM, which is experience dependent and time consuming. This study was aimed at evaluating the feasibility and reproducibility of the built-in software, Smart-pelvic™, in reconstructing standard tomographic images of LAM from 3D/4D TPUS volumes.

METHODS

This study was conducted at a tertiary teaching hospital, enrolling women who underwent TPUS. Tomographic images of the LAM were automatically reconstructed by Smart-pelvicTM and rated by two experienced observers as standard or nonstandard. The anteroposterior diameter (APD) of the levator hiatus was also measured on the mid-sagittal plane of the automatically and manually reconstructed images. The APD measurements of each approach were compared using Bland-Altman plots, and interclass correlation coefficient (ICC) was used to evaluate intra- and inter-observer reproducibility. Meanwhile, the time taken for the reconstruction process of both methods was also recorded.

RESULTS

The ultrasound volume of a total of 104 patients were included in this study. Using Smart-pelvicTM, the overall success rate of the tomographic image reconstruction was 98%. Regarding measurements of APD, the ICC between the automatic and manual reconstruction methods was 0.99 (0.98, 0.99). The average time taken for reconstruction per case was 2.65 ± 0.52 s and 22.08 ± 3.45 s, respectively.

CONCLUSIONS

Using Smart-pelvicTM to reconstruct tomographic images of LAM is feasible, and it can promote TPUS by reducing operator dependence and improving examination efficiency in a clinical setting.

Differences in pelvic floor muscle morphology and function between female runners with and without running-induced stress urinary incontinence

OBJECTIVE

To investigate the differences in pelvic floor muscle (PFM) morphology and function between female runners with and without running-induced stress urinary incontinence (RI-SUI).

DESIGN

This was a cross-sectional, observational study.

METHODS

Experienced female runners were recruited into two groups: runners who regularly experience RI-SUI (n = 19) and runners who do not (n = 20). Active and passive pelvic floor muscle (PFM) properties were assessed using intravaginal dynamometry during maximal voluntary contractions (MVC) and during passive tissue elongation. The morphology of the urethra and PFMs was assessed using 2D and 3D transperineal ultrasound imaging. Independent t tests or Mann-Whitney U were used as appropriate to test group differences on all study outcomes, and Cohen's d effect sizes were calculated.

RESULTS

The rate of force development during the MVC was significantly higher in participants reporting RI-SUI (p ≤ 0.05) and conversely, significantly lower during passive elongation of the PFMs (p ≤ 0.05) compared to runners with no history of leakage. Concurrently, the extent of bladder neck elevation between rest and maximum voluntary activation was significantly higher among those with RI-SUI compared to those without. Although not significant, small to moderate effect sizes were observed for other outcomes-active force outcomes measured during MVC tended to be higher in runners with RI-SUI, while passive force outcomes measured during passive tissue elongation tended to be lower. The cross-sectional area of the urethral wall and the area of the levator hiatus tended to be larger in runners with RI-SUI compared to those without.

CONCLUSION

Runners who experience RI-SUI demonstrate better PFM contractile function but lower passive support when compared to their continent counterparts.

Management of levator ani avulsion: a systematic review and narrative synthesis

PURPOSE

Levator ani muscle (LAM) avulsion affects up to 35% of women. Unlike obstetric anal sphincter injury, LAM avulsion is not diagnosed immediately after vaginal delivery, however, has a profound impact on quality of life. The management of pelvic floor disorders is in growing demand yet the significance of LAM avulsion in the context of pelvic floor dysfunction (PFD) is poorly understood. This study collates information on success of treatment for LAM avulsion to establish the best options for management of women.

METHODS

MEDLINE®, MEDLINE® In-Process, EMBASE, PubMed, CINAHL and The Cochrane Library were searched for articles that evaluated the management techniques used to treat LAM avulsion. The protocol was registered with PROSPERO (CRD42021206427).

RESULTS

Natural healing of LAM avulsion occurs in 50% of women. Conservative measures, including pelvic floor exercises and pessary use are poorly studied. Pelvic floor muscle training for major LAM avulsions was of no benefit. Post-partum pessary use was only of benefit in the first three months for women. Surgeries for LAM avulsion are poorly researched but studies suggest they may provide benefit for 76-97% of patients.

CONCLUSIONS

Whilst some women with PFD secondary to LAM avulsion improve spontaneously, 50% continue to have pelvic floor symptoms 1 year following delivery. These symptoms result in a significant negative impact on quality of life, however, it is not clear whether conservative or surgical methods are helpful. There is a pressing need for research to find effective treatments and explore appropriate surgical repair techniques for women with LAM avulsion.

A randomised interventional parallel study to evaluate the effect of different frequencies of pelvic floor muscle exercises with core stabilisation using three-dimensional ultrasound: the PELSTAB study

INTRODUCTION AND HYPOTHESIS

The primary objective was to compare high- and low-frequency pelvic floor muscle training (PFMT) with the impact on urinary incontinence episode frequency over 1 week (IEF/week). The secondary objective was to compare the two groups with regard to pelvic floor muscle function, morphometry, incontinence quality of life, and patient global impression.

METHODS

This was a randomised parallel controlled study. The setting was regional gynaecological and urological outpatient clinics. The subjects consisted of a sample of 86 women with stress urinary incontinence (SUI). Group A underwent high-frequency PFMT and group B underwent low-frequency PFMT for 12 weeks. We recorded the IEF/week. The International Consultation on Incontinence Questionnaire Urinary Incontinence Short Form (ICIQ-UI SF) was used. Pelvic floor muscle function was evaluated using a perineometer. Pelvic floor muscle morphometry was evaluated with 3D/4D ultrasound. The Urinary Incontinence Quality of Life Scale (I-QoL) was used.

RESULTS

Significant differences between group A and B after treatment (p<0.001) were noted in favour of group A in IEF/week (group A 10.2±7.0/2.3±3.0 vs group B 9.3±4.7/6.3±4.9), in the ICIQ-UI SF (group A 9.7±3.0/3.7 ± 3.6 vs group B 9.9±3.2/9.4±3.4). Significant differences between groups A and B after treatment were noted in favour of group A for pelvic floor muscle function in terms of maximal voluntary contraction and its duration, and also for pelvic floor muscle morphometry in terms of a reduction of the hiatal area during rest, contraction, and the Valsalva manoeuvre.

CONCLUSIONS

High-frequency PFMT for 12 weeks significantly decreased IEF/week in comparison with low-frequency PFMT. In the high-frequency exercise group, women had significantly better pelvic floor muscle function, morphometry and quality of life than the low-frequency exercise group.

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.

Impact of parity and delivery mode on pelvic floor function in young women: a 3D ultrasound evaluation

INTRODUCTION AND HYPOTHESIS

The objectives were to evaluate clinical and anatomical parameters assessed by three-dimensional pelvic floor ultrasound (3D ultrasound) in parous and nulliparous women of childbearing age and to assess underreported symptoms of sexual dysfunction (SD), urinary incontinence (UI) and flatus incontinence (FI).

METHODS

Women without complaints of pelvic floor dysfunction, aged 20-50 years, were eligible for this prospective cross-sectional study. They completed the King's Health Questionnaire, Female Sexual Function Index and St Mark's Incontinence Score adapted for this study. Next, a physical examination and 3D ultrasound were performed. The scores obtained in the questionnaires were compared with the 3D ultrasound data.

RESULTS

In total, 326 women were invited to participate. Of these, 203 women met the inclusion criteria, and their cases were classified as nulliparity (NU, 59), vaginal delivery (VD, 80), forceps delivery (FD, 18) and caesarean section (CS, 48). These groups were homogeneous regarding age (p=0.096), parity (p=0.051) and body mass index (p=0.06). The hiatal dimension (HD; p=0.003) and transverse diameter (TD) (p=0.001) were significantly different among the groups. Compared with the NU and CS groups, the VD and FD groups had an increased HD and TD. The frequencies of underreported symptoms identified by questionnaires were as follows: SD (46.3%), UI (35%) and FI (28%). After VD and FD, women were more likely to present UI (p<0.001), FI (p<0.001) and SD (p=0.002) than the women with NU and those who had undergone a CS. UI was related to a greater HD (p=0.002) and anteroposterior diameter (p=0.022), FI was associated with a thinner left pubovisceral muscle (p=0.013), and SD was related to a greater HD (p=0.026).

CONCLUSIONS

Three-dimensional ultrasound can identify mild morphological changes in young women with apparently normal physical examinations, mainly after VD and FD. In such individuals, these findings are associated with higher incidences of underreported sexual, urinary and anal symptoms.

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.

Association Between Urinary Stress Incontinence and Levator Avulsion Detected by 3D Transperineal Ultrasound

PURPOSE

 To determine the association between levator avulsion and urinary stress incontinence (USI) by 3/4D transperineal ultrasound.

MATERIALS AND METHODS

 842 patients who were admitted to our hospital from 2016 to 2019 were recruited for our study. 3D/4D transperineal ultrasound was performed. After standard interview and clinical evaluation, general conditions and levator hiatus data were collected and measured to compare with each group. The odds ratio (OR) of USI symptoms or ultrasound features with levator avulsion were calculated.

RESULTS

 A total of 593 women were studied: 204 suffered from levator avulsion (96 cases of left-side avulsion, 80 cases of right-side avulsion and 28 cases of bilateral avulsion) and 389 women had no avulsion. The gravidity and episiotomy conditions of the avulsion groups were significantly different from the no-avulsion group. Significant differences were found in the transverse diameters and anteroposterior diameters between the levator avulsion group and the no-avulsion group, but there was no difference among the avulsion groups, regardless of whether the patient was at rest or performing the Valsalva maneuver. Interestingly, a significant difference was found in the presence of USI symptoms between the uni-avulsion group and the no-avulsion group. The odds ratio (OR) of USI symptoms in the uni-avulsion group is 2.786 (95 %CI, 1.663-4.669), but 0.939 (95 %CI, 0.276-3.199) for the bilateral avulsion and no-avulsion groups.

CONCLUSION

 Unilateral levator avulsion may be a risk factor for urinary stress incontinence.

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.

Postpartum pelvic floor muscle training, levator ani avulsion and levator hiatus area: a randomized trial

INTRODUCTION AND HYPOTHESIS

Vaginal delivery may lead to tearing of the levator ani (LA) muscle from its bony insertions (complete LA avulsion) and increased levator hiatus (LH) area, both risk factors for pelvic floor dysfunctions. Early active rehabilitation is standard treatment after musculo-skeletal injury. We hypothesized that pelvic floor muscle training (PFMT) early postpartum would reduce the presence of LA avulsions and reduce LH area.

METHODS

We carried out a planned secondary analysis from a randomized controlled study. Primiparous women (n=175) giving birth vaginally were included 6 weeks postpartum, stratified on complete LA avulsion, and thereafter randomized to PFMT or control. The training participants (n=87) attended a supervised PFMT class once a week and performed home-based PFMT daily for 16 weeks. The control participants (n=88) received no intervention. Presence of complete LA avulsion, LH area at rest, maximal contraction, and maximal Valsalva maneuver were assessed by transperineal ultrasound. Between-group comparisons were analyzed by analysis of covariance for continuous data, and relative risk (RR) for categorical data.

RESULTS

Six months postpartum, the number of women who had complete LA avulsion was reduced from 27 to 14 within the PFMT group (44% reduction) and from 28 to 17 within the control group (39% reduction). The between-group difference was not significant, RR 0.85 (95% CI 0.53 to 1.37). Further, no significant between-group differences were found for LH area at rest, during contraction, or Valsalva.

CONCLUSIONS

Supervised PFMT class combined with home exercise early postpartum did not reduce the presence of complete LA avulsion or LH area more than natural remission.

Assessment of Pelvic Floor Disorders due to the Gestational Diabetes Mellitus Using Three-Dimensional Ultrasonography: A Narrative Review

Gestational diabetes mellitus (GDM)is an entity with evolving conceptual nuances that deserve full consideration. Gestational diabetes leads to complications and adverse effects on the mother's and infants' health during and after pregnancy. Women also have a higher prevalence of urinary incontinence (UI) related to the hyperglycemic status during pregnancy. However, the exact pathophysiological mechanism is still uncertain. We conducted a narrative review discussing the impact of GDM on the women's pelvic floor and performed image assessment using three-dimensional ultrasonography to evaluate and predict future UI.

Predictive Value of Pelvic Floor Muscle Morphometry Using 3D/4D Ultrasound in Relation to the Success of Pelvic Floor Muscle Training in Women with Stress Urinary Incontinence

The aim of our study was to establish the predictive value of pelvic floor muscle morphometry using 3D/4D ultrasound in relation to the success of pelvic floor muscle training (PFMT) for 12 weeks in women with stress urinary incontinence (SUI). A total of 86 women with SUI from regional gynaecological and urological outpatient clinics were enrolled on this cross-sectional study. SUI symptoms were assessed by the International Consultation on Incontinence Questionnaire (ICIQ-UI SF). Pelvic floor muscle function was evaluated using a perineometer. Pelvic floor muscle morphometry (PFMM) was evaluated by the size of the urogenital hiatus (HA in cm²) at rest (R), at contraction (C) and during the Valsalva manoeuvre, i.e., a strong push (V), by 3D/4D USG. The intervention was PFMT for 12 weeks. After PFMT, we noted significant improvement in SUI symptoms, pelvic floor muscle function and morphometry. Moderately significant (0.001) negative correlations were confirmed between the total ICIQ-UI SF score and strength (-0.236 **) and endurance (-0.326 **) of the maximal voluntary contraction (MvC), the number of MvC lasting 3 s (-0.406 **) and 1 s (-0.338 **). Moderately significant (0.001) positive correlations were confirmed between the total ICIQ-UI SF score and R (r = 0.453 **), C (r = 0.533 **) and V (r = 0.442 **). The predictive value of PFMM reached a positive prediction of a decrease with an ICIQ-UI SF score below 8. HA during V was most strongly associated with SUI reduction, with an area under the curve (AUC) of 0.87 (p ≤ 0.001), a positive predictive value of 83.3%, a negative predictive value of 75.0%, sensitivity of 78.9% and specificity of 80.0%. The predictive values of pelvic floor muscle morphometry using 3D/4D USG confirmed the success of PFMT in women with SUI.

Diagnostic test accuracy of magnetic resonance imaging and pelvic floor ultrasound for diagnosis of levator ani muscle avulsion

OBJECTIVE

To estimate the diagnostic test accuracy of magnetic resonance imaging (MRI) and pelvic floor ultrasound for levator ani muscle (LAM) avulsion in a general parous population, with view to establishing if ultrasound could substitute for MRI to diagnose LAM avulsion.

METHODS

This was a cross-sectional study of 135 women 4 years after their first delivery. Signs and symptoms of pelvic floor dysfunction were assessed using validated methods. All women underwent four-dimensional transperineal ultrasound (TPUS), three-dimensional endovaginal ultrasound (EVUS) and MRI. Images were acquired at rest, on pelvic floor muscle contraction (PFMC) and on maximum Valsalva maneuver, and analyzed by two blinded observers. Predefined cut-off values were used to diagnose LAM avulsion. In the absence of a reference standard, latent class analysis (LCA) was used to establish diagnostic test characteristics for LAM avulsion as the primary outcome measure. Secondary outcomes were kappa (κ) agreement between imaging techniques, intraclass correlation coefficients (ICC) for hiatal measurements at rest, on PFMC and on maximum Valsalva maneuver, and the association of LAM avulsion with signs and symptoms of pelvic floor dysfunction.

RESULTS

The prevalence of LAM avulsion was 23.0% for MRI, 11.1% for TPUS and 17.8% for EVUS. The prevalence of LAM avulsion using LCA was 15.7%. The sensitivity for LAM avulsion of TPUS (71% (95% CI, 50-90%)) and EVUS (91% (95% CI, 74-100%)) was lower than that of MRI (100% (95% CI, 84-100%)). The specificity of TPUS (100% (95% CI, 97-100%)) and EVUS (95% (95% CI, 91-99%)) was higher than that of MRI (91% (95% CI, 85-97%)). MRI and EVUS had high predictive values for the assessment of major LAM avulsion (positive predictive value (PPV), 95% and negative predictive value (NPV), 100%; PPV, 100% and NPV, 98%, respectively), while TPUS had high predictive values for minor LAM avulsion (PPV, 100% and NPV, 95%). Major LAM avulsion on MRI and EVUS was associated with anterior vaginal wall prolapse, which was not found for TPUS. The agreement in the diagnosis of LAM avulsion (κ, 0.69) and hiatal measurements (ICC, 0.60-0.81) was highest between MRI and EVUS.

CONCLUSIONS

Pelvic floor ultrasound can be implemented as a triage test to assess parous women for LAM avulsion because of its high specificity. Ultrasound cannot substitute for MRI because of its lower sensitivity. The predictive ability of ultrasound is moderate for the presence, and very good for the absence, of LAM avulsion. A positive test should be confirmed by a different observer or imaging technique. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Automatic identification and segmentation of slice of minimal hiatal dimensions in transperineal ultrasound volumes

OBJECTIVE

To develop and validate a tool for automatic selection of the slice of minimal hiatal dimensions (SMHD) and segmentation of the urogenital hiatus (UH) in transperineal ultrasound (TPUS) volumes.

METHODS

Manual selection of the SMHD and segmentation of the UH was performed in TPUS volumes of 116 women with symptomatic pelvic organ prolapse (POP). These data were used to train two deep-learning algorithms. The first algorithm was trained to provide an estimation of the position of the SMHD. Based on this estimation, a slice was selected and fed into the second algorithm, which performed automatic segmentation of the UH. From this segmentation, measurements of the UH area (UHA), anteroposterior diameter (APD) and coronal diameter (CD) were computed automatically. The mean absolute distance between manually and automatically selected SMHD, the overlap (dice similarity index (DSI)) between manual and automatic UH segmentation and the intraclass correlation coefficient (ICC) between manual and automatic UH measurements were assessed on a test set of 30 TPUS volumes.

RESULTS

The mean absolute distance between manually and automatically selected SMHD was 0.20 cm. All DSI values between manual and automatic UH segmentations were above 0.85. The ICC values between manual and automatic UH measurements were 0.94 (95% CI, 0.87-0.97) for UHA, 0.92 (95% CI, 0.78-0.97) for APD and 0.82 (95% CI, 0.66-0.91) for CD, demonstrating excellent agreement.

CONCLUSIONS

Our deep-learning algorithms allowed reliable automatic selection of the SMHD and UH segmentation in TPUS volumes of women with symptomatic POP. These algorithms can be implemented in the software of TPUS machines, thus reducing clinical analysis time and simplifying the examination of TPUS data for research and clinical purposes. © 2021 The Authors. Ultrasound in Obstetrics &amp; Gynecology published by John Wiley &amp; Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

A review of levator ani avulsion after childbirth: Incidence, imaging and management

Key Content • Levator ani muscle (LAM) avulsion injury occurs occultly during childbirth, most commonly during operative vaginal deliveries. • Injuries of levator ani have long term sequelae for pelvic floor health. As life expectancy increases the burden of disease upon urogynaecology services will need to be considered. • Diagnosis of this condition can be difficult as there is no agreed 'gold standard' imaging modality. • There is no consensus regarding surgical management of LAM avulsion. Learning objectives • Review anatomy and function of levator ani muscle • Identify the risk factors for levator ani avulsion injury • Role of imaging to appropriately identify LAM injury and current management options including appropriate follow up • Management of subsequent pregnancy following LAM avulsion Ethical issues • Is there value to the patient in diagnosing levator ani avulsion when there is no recommended treatment for these injuries?

3D Ultrasound in Pelvic Floor: Is It Useful as a Prognostic Tool in Type of Labor Development and Subsequent Pelvic Floor Diseases?

The objective of our study is to determine the thickness of the pubovisceral fasciculus of the levator ani muscle and the area of the genital hiatus by means of three-dimensional perineal ultrasound, in pregnant women in the 2nd trimester, and to analyze the related maternal, perinatal and postpartum clinical variables. Furthermore, to compare the results of our study with two similar series previously published. An observational, prospective study of pelvic floor ultrasound was carried out, performed at week 20, whose delivery was attended in the obstetrics service of the Hospital General Universitario Gregorio Marañón de Madrid (HGUGM), during the period of August from 2021 to June 2022. Maternal, ultrasound, perinatal and postpartum clinical variables were collected from each participant. During the study period, a total of 54 patients were included in it. The mean gestational age at which the ultrasound was performed was 19.81 ± 0.91 weeks. In relation to the ultrasound variables, the mean thickness of the pubovisceral muscle was 0.87 ± 0.13 cm (95% CI, 0.64-1.38 cm), while, in the plane of minimum dimension of the genital hiatus, the hiatal area at rest was 13.41 ± 3.22 (95% CI, 4.60-18.78) cm2. There is a significant correlation between the age of pregnant women (over 35 years of age) and the increase in the area of the genital hiatus (r = 0.295, p = 0.031). 3D ultrasound of the pelvic floor performed at week 20 of gestation can to be an effective, non-invasive, reproducible and cheap tool in the prognosis of the development of labor and of possible subsequent perineal dysfunctions.

Never Too Late to Train: The Effects of Pelvic Floor Muscle Training on the Shape of the Levator Hiatus in Incontinent Older Women

Pelvic floor muscle (PFM) training is the first-line treatment for women of all ages with urinary incontinence (UI), but evidence supporting its effects on the functional anatomy of the pelvic floor is scarce in older women. We aimed to evaluate the long-term (one-year) effects of PFM training on the shape of the levator hiatus (LH) in older women with UI and its association with PFM force, incontinence severity, and potential effect modifiers (age, UI severity, BMI, and UI type). This is a secondary analysis of the GROUP study, a non-inferiority RCT assessing the effects of a structured and progressive 12-week PFM training program to treat UI in older women. Data were available from 264/308 participants at the one-year follow-up. PFM training resulted in reduced LH size toward a more "circular" shape, which was consistently associated with greater PFM force and reduced UI severity. Further, no significant interactions were found between LH shape changes and any of the potential effect modifiers, suggesting that women will potentially benefit from PFM training, regardless of age, UI severity, BMI, and UI type (stress or mixed), with changes that can be observed in the functional anatomy of the pelvic floor and sustained in the long-term.

Ultrasonography Comparison of Pelvic Floor and Abdominal Wall Muscles in Women with and without Dyspareunia: A Cross-Sectional Study

Pelvic floor hypertonicity and narrowing of the levator ani hiatus is traditionally assumed in women with dyspareunia and considered a therapeutical target by physical therapists. However, accurate pre-treatment assessment of pelvic floor muscles is difficult to perform in clinical sites. In addition, the abdominal musculature has not been evaluated in this population, despite its relationship with pelvic floor disfunctions. The purpose of this study was to determine the existence of differences in the length of the anteroposterior diameter of the levator ani hiatus (APDH), the thickness of the abdominal wall musculature and the interrecti distance (IRD) in subjects with dyspareunia compared to a control group. A cross-sectional observational study was designed using ultrasound imaging to measure the APH, the thickness of the abdominal musculature—rectus abdominis (RA), transverse abdominis (TrAb), internal oblique (IO), external oblique (EO)—and IRD at rest and during contraction. Thirty-two women were recruited through advertising and social webs and divided into two groups: dyspareunia (n = 16) and no dyspareunia (n = 16). There were no statistically significant differences (p < 0.05) in RA, TrAb, OI and OE muscle thickness. No differences in APH or in supraumbilical and infraumbilical IRD were found. The findings of this study suggest that the relationship between the abdominal structure/levator ani hypertonia and dyspareunia remains uncertain.

2D pelvic floor ultrasound imaging in identifying levator ani muscle trauma agrees highly with 4D ultrasound imaging

INTRODUCTION AND HYPOTHESIS

The objective was to evaluate the agreement between 2D and 4D translabial ultrasound (TLUS) technique in showing levator ani muscle (LAM) states after vaginal birth.

METHODS

In a prospective observational cohort study between March 2017 and April 2019 we evaluated LAM states (intact, hematoma, partial, complete avulsion) of primiparous women having given birth vaginally with singletons in vertex presentation ≥ 36+0 gestational weeks by using 2D and 4D TLUS within 1-4 days postpartum (assessment A1) and again 6-10 weeks postpartum (assessment A2). Cohen's Kappa analysis was performed for each side separately to evaluate the test agreement between the two ultrasound techniques at every assessment period.

RESULTS

A total of 224 women participated at A1 and 213 at A2. The agreement between the two ultrasound techniques was good to very good at A1 (Cohen`s kappa right-sided 0.78, left-sided 0.82) and very good at A2 (Cohen`s kappa both sides 0.88). The agreement was best when assessing an intact LAM or a complete avulsion (Cohen`s kappa between 0.78-0.92 for complete avulsions).

CONCLUSIONS

The comparison between 2D and 4D TLUS showed a good to very good agreement in LAM trauma immediately after birth as well as 6-10 weeks postpartum. Therefore, 2D ultrasound could also be a valuable method for demonstrating a LAM abnormality and could be used in settings where 3D/4D ultrasound equipment is not available.

Postoperative Physiotherapy in Women Undergoing Pelvic Floor Reconstructive Surgery: A Randomized Controlled Clinical Trial

Purpose: Postoperative physiotherapy in conjunction with pelvic organ prolapse (POP) surgery is still under-investigated and controversial. In this randomized controlled trial, pelvic floor muscle training (PFMT) and abdominal training were compared with a control condition (standard in-hospital treatment). Method: Eighty-one women were randomized to one of three groups. The Prolapse Quality of Life questionnaire, two-dimensional ultrasound, Pelvic Organ Prolapse Quantification System scale, the PERFECT (power, endurance, repetitions, fast contractions, every contraction timed) scheme, electromyography, Sahrmann scale, and pressure biofeedback unit (PBU) were used to measure quality of life (QOL), POP, and pelvic floor and abdominal muscle function. A mixed-model analysis of variance and the Kruskal-Wallis test was used for analysis. Results: Beneficial effects (p < 0.05) were found for the PFMT group - increased power, number of fast contractions, amount of movement, endurance, and Sahrmann and PBU measures - compared with the control group. Abdominal training led to a significant (p < 0.05) increase in bulging and discomfort, number of pelvic floor muscle contractions, and Sahrmann and PBU measures compared with the control condition; both groups showed significantly increased urinary frequency (p < 0.05). Conclusions: Postoperative physiotherapy did not have a beneficial effect on QOL or POP symptoms. PFMT and abdominal training had beneficial effects on pelvic floor muscle function and abdominal muscle measures. Additional abdominal training led to increased symptoms.

Deep learning-based pelvic levator hiatus segmentation from ultrasound images

Purpose

To automatically segment and measure the levator hiatus with a deep learning approach and evaluate the performance between algorithms, sonographers, and different devices.

Methods

Three deep learning models (UNet-ResNet34, HR-Net, and SegNet) were trained with 360 images and validated with 42 images. The trained models were tested with two test sets. The first set included 138 images to evaluate the performance between the algorithms and sonographers. An independent dataset including 679 images assessed the performances of algorithms between different ultrasound devices. Four metrics were used for evaluation: DSC, HDD, the relative error of segmentation area, and the absolute error of segmentation area.

Results

The UNet model outperformed HR-Net and SegNet. It could achieve a mean DSC of 0.964 for the first test set and 0.952 for the independent test set. UNet was creditable compared with three senior sonographers with a noninferiority test in the first test set and equivalent in the two test sets collected by different devices. On average, it took two seconds to process one case with a GPU and 2.4 s with a CPU.

Conclusions

The deep learning approach has good performance for levator hiatus segmentation and good generalization ability on independent test sets. This automatic levator hiatus segmentation approach could help shorten the clinical examination time and improve consistency.

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.

The evolution of levator ani muscle trauma over the first 9 months after vaginal birth

INTRODUCTION AND HYPOTHESIS

The objective was to investigate the evolution of levator ani muscle (LAM) trauma over the first 9 months after birth and to evaluate their agreement between different assessment periods.

METHODS

From March 2017 to April 2019 we prospectively evaluated LAM states (intact, hematoma, partial or complete avulsion) of primiparous women after vaginal birth by using 4D translabial ultrasound (TLUS) at three different assessment periods. All women were examined 1-4 days (A1) and 6-10 weeks (A2) postpartum, and women with a trauma additionally 6-9 months postpartum (A3). Cohen's Kappa analysis was performed to evaluate the test agreement between the assessment periods.

RESULTS

Thirty-two percent of the women at A1 had a LAM trauma and 24% at A2. The higher number of LAM injuries at A1 can be explained by hematomas (14%), of which 51% spontaneously resolved at A2, 35% revealed themselves as partial, and 12% as complete avulsions. At A3, we observed anatomical improvement from complete to partial avulsions (23%) and few partial avulsions changed into an intact LAM (3%); none of the complete avulsions changed into an intact LAM. The agreement of 4D TLUS between A1 and A2 was moderate to good (0.64 for the right-sided LAM/0.60 for the left-sided LAM) and between A2 and A3 good to very good (0.76 right-sided/0.84 left-sided).

CONCLUSIONS

Levator ani muscle trauma can reliably be diagnosed during all assessment periods. However, the agreement between A1 and A2 was only moderate to good. This can be explained by hematomas inside the LAM that were only observed early postpartum. We observed some anatomical improvement at A3, but no complete avulsion improved to an intact LAM.

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.

Application of pelvic floor ultrasound during pregnancy to detect patients at risk of cesarean section due to failure of labor progression in a Spanish population

OBJECTIVE

Our study is aimed at evaluating the characteristics of the pelvic floor, assessed through transperineal ultrasound, since it may influence or increase the possibility of having a cesarean delivery, with the objective of acting on those variables that can be modified during pregnancy.

STUDY DESIGN

Transperineal ultrasound was performed on 109 primiparous pregnant women in their first trimester of pregnancy, recruited between May 2018 and February 2019, with the purpose of studying the hiatus area at rest, retention and Valsalva. We have reassessed them at the end of pregnancy and delivery data were recorded. We selected 8 patients as case-study, who had cesarean section delivery due to failure of labor progression. We selected 4 control-cases for each, reaching the total of 32 controls, with similar age and body mass index, to avoid obtaining a biased result from these data.

RESULTS

In the study of hiatal areas, patients who delivered by cesarean section had a smaller hiatal area at rest, during levator ani muscle contraction and during Valsalva maneuver, at all visits. In early pregnancy, the range of the resting hiatal area was 13.8 ± 2.0 cm² for cesarean sections, compared to 16.2 ± 2.7 cm² for vaginal deliveries with an OR of 0.57 (0.34-0.95, 95% CI). For hiatal area on Valsalva, the OR was 0.55 (0.35-0.88, 95% CI). Therefore, the smaller the hiatal area, the greater the possibility of cesarean section. At the end of pregnancy, between 34 and 36 weeks of gestation, the OR of hiatal area on Valsalva was 0.78 (0.60-1.00, 95% CI).

CONCLUSION

The hiatus area measured by transperineal ultrasonography at the beginning and at the end of the pregnancy may be useful to identify the patients who are at a higher risk of cesarean delivery due to failure of labor progression.

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.

Effects of yoga on the intervention of levator ani hiatus in postpartum women: a prospective study

[Purpose] This study aimed to explore the application value of yoga intervention in early postpartum recovery of the levator ani muscle hiatus (LAH) area. [Participants and Methods] Females in natural labor from May 2020 to November 2020 in the Third People’s Hospital of Sun Yat-sen University Ultrasound Research Center were prospectively included for a pelvic ultrasound examination. The control group received no intervention. The experimental group received 60-min yoga once a week from week 1 to week 12 postpartum. A pelvic ultrasound examination was performed on the week 6 and week 12 postpartum. The LAH area was measured at rest, during contraction and Valsalva maneuver. [Results] A total of 128 participants who met the inclusion criteria were selected and randomly assigned to the control group (n=66) and the experimental group (n=62) in pre and post intervention design. No significant differences were found in age, parity, body mass index, and fetal weight between the control and experimental groups. Further, no significant difference was observed in the LAH area between the control and experimental groups at rest, during contraction and Valsalva maneuver on the week 6 postpartum. However, the LAH area in experimental group significantly reduced at rest, during contraction and Valsalva maneuver on the week 12 postpartum. The differences of LAH area (date week 6 minus date week 12) in the control group at rest, during contraction and Valsalva maneuver were 0.12 ± 3.12 cm², 0.80 ± 2.29 cm², and 0.80 ± 4.22 cm², while in the control these were 1.95 ± 3.41 cm², 1.39 ± 1.91 cm², and 3.81 ± 5.49 cm², respectively. Compared with control group, the differences of LAH area significantly increased in experimental group at rest and during Valsalva maneuver. [Conclusion] Yoga intervention can help in the recovery of LAH.

Evaluation of acupuncture treatments of postpartum female pelvic floor dysfunction by four-dimensional transperineal pelvic floor ultrasound

INTRODUCTION

In the present investigation, a systematic evaluation of the clinical treatment performance of diagnosed with pelvic floor dysfunction is explored. By comparing the 4Dtransperineal pelvic floor ultrasound images with the acupuncture treatment performance of the patients, an evaluation system with various parameters is established to provide critical information to guide the clinical treatment fpostpartum female pelvic floor dysfunction (FPFD).

METHODS

Eighty patients diagnosed with FPFD are divided into 2 groups. After the designated treatment to the patients, they are carefully examined using transperineal pelvic floor ultrasound. The shape and activity of bladder neck, cervix and rectum anal canal under resting, anal sphincter and Valsalva movements are observed and recorded. The morphology and continuous shape of levator ani muscle in different states after 4D image reconstruction are obtained.

RESULTS

After the acupuncture treatment, the bladder neck descent is decreased by 3.8 cm and the anal levator muscle area is decreased by 3.4 cm2 comparing with the control group. The anal levator muscle hole diameter is decreased by 0.3 cm, while the anterior and posterior diameter is reduced by 0.5 cm. Reduced possibility of cystocele and uterine prolapse is demonstrated by X2 test. These changes upon acupuncture therapy are in line with the improved conditions of the patients, indicating these parameters can help evaluate the therapy performance.

CONCLUSION

4D pelvic floor ultrasound imaging provides objective and quantified information for the clinical diagnosis and treatment of FPFD and the assessment of therapy efficacy, making it a promising novel method in practical applications.

Interobserver variability of ultrasound measurements for the differential diagnosis of uterine prolapse and cervical elongation without uterine prolapse

OBJECTIVES

Our study aims to determine the interobserver variability of different ultrasound measurements (pubis-cervix distance, pubis-uterine fundus distance, and pubis-Douglascul-de-sac distance) previously analyzed for the ultrasound differential diagnosis of uterine prolapse (UP) and cervical elongation CE without UP.

MATERIALS AND METHODS

We conducted a prospective observational study with 40 patients scheduled to undergo surgical correction of UP and CE without UP. All patients underwent pelvic floor ultrasound examination by an examiner (E1) who acquired ultrasound images. Using these images, E1 measured the distances for the ultrasound differential diagnosis of UP and CE without UP, and these distances were compared with those measured by the other examiner (E2). Values were analyzed by calculating ICCs with 95% CIs.

RESULTS

For UP, excellent reliability was obtained for all measurements except the pubis-Douglascul-de-sac measurement at rest, which was moderate (ICC 0.596; p = 0.028) and for the difference between the pubis-Douglascul-de-sac measurement at rest and during the Valsalva maneuver, which was good (ICC 0.691; p < 0.0005). For CE without UP, interobserver reliability was excellent for all measurements analyzed except the pubis-cervix measurement during the Valsalva maneuver, which was moderate (ICC 0.535; p = 0.052) and for the pubis-Douglascul-de-sac measurement at rest, which was good (ICC 0.768; p < 0.0005).

CONCLUSIONS

There is excellent interobserver reliability in measurements of the difference in the distance from the pubic symphysis to the uterine fundus at rest and during the Valsalva maneuver for both UP and CE without UP, which are used for the ultrasound differential diagnosis of UP and CE without UP.

What improvements in levator ani motor function lead to improvement in stress urinary incontinence signs and symptoms in females?

INTRODUCTION AND HYPOTHESIS

The objectives were to determine whether levator ani muscle (LAM) motor function is associated with female stress urinary incontinence (SUI) severity, and whether changes in LAM motor function induced through pelvic floor muscle training (PFMT) are associated with improvements in SUI signs and symptoms.

METHODS

Pelvic morphology and LAM function were evaluated using ultrasound imaging and manual palpation using the elements of the PERFECT Scheme (Power, Endurance, Repetitions, Fast contractions, Elevation, Co-contraction and Timing) before and after women with SUI underwent a 12-week PFMT intervention. SUI severity was determined subjectively (ICIQ-FLUTS-UI) and objectively (30-min pad test [30MPT]).

RESULTS

At baseline (n = 97), less leakage on the 30MPT was weakly associated with higher bladder neck position (ρ_s = -0.209,p = 0.044), yet with lower LAM function based on the PERFECT Scheme (overall score: ρ_s = 0.206, p = 0.043; repeated maximum voluntary contractions (MVCs): ρ_s = 0.203, p = 0.046; power/motor control: ρ_s = 0.214, p = 0.035). Lower symptom severity (ICIQ-FLUTS-UI) was associated with observed perineal lift during coughing (U = 34.000; p = 0.042). All measures of SUI severity and LAM function were significantly improved after PFMT intervention. Greater improvements in bladder neck elevation during MVC (ρ_s = -0.261, p = 0.027) and greater reductions in levator plate length during MVC (ρ_s = 0.292, p = 0.016) were weakly associated with greater reductions in leakage (30MPT), the latter also being associated with more improvement symptoms (ICIQ-FLUTS-UI; ρ_s = 0.238, p = 0.041). Greater improvement in the ability to repeat MVCs (ρ_s = 0.303, p = 0.009) was weakly associated with smaller improvements in symptoms (ICIQ-FLUTS-UI).

CONCLUSION

Improvements in bladder neck support and elevation show weak associations with improvement in SUI signs and symptoms. LAM function as measured by the PERFECT Scheme is not associated with SUI severity in women, and improvements in LAM function when measured by the PERFECT Scheme are not associated with improvements in SUI signs and symptoms.

Ultrasonographic Imaging of the Pelvic Floor

This article discusses various pelvic floor ultrasonographic modalities and the clinical applications of ultrasonography of the pelvic floor. Ultrasonography provides a detailed anatomic assessment of the muscles and surrounding organs of the pelvic floor. Different anatomic variabilities and pathologic conditions, such as prolapse, fecal incontinence, urinary symptoms, vaginal wall cysts, synthetic implanted material, and pelvic pain, are assessed with pelvic floor ultrasonography. This imaging modality is an important adjunct to the evaluation and diagnosis of pelvic floor disorders.

The maternal pelvic floor and labor outcome

Vaginal birth is the major cause of pelvic floor damage. The development of transperineal ultrasound has improved our understanding of the relationship between vaginal birth and pelvic floor dysfunction. The female pelvic floor dimensions and function can be assessed reliably in pregnant women. Maternal pushing associated with pelvic floor muscle relaxation is the central requirement of vaginal birth. Many studies have evaluated the role of the pelvic floor on labor outcomes. Smaller levator hiatal dimensions and incomplete or absent levator ani muscle relaxation seem to be associated with a longer duration of the second stage of labor and a higher risk of cesarean and operative deliveries. Here, we presented an overview of the current knowledge of the correlation between female pelvic floor dimension and function, as assessed by transperineal ultrasound, and labor outcome.

Vaginal birth after Cesarean section and levator ani avulsion: a case-control study

OBJECTIVE

The aim of this study was to explore the risk of levator ani muscle (LAM) avulsion and enlargement of the levator hiatus following vaginal birth after Cesarean section (VBAC) in comparison with vaginal delivery in primiparous women.

METHODS

In this two-center observational case-control study, we identified all women who had a term VBAC for their second delivery at the Departments of Obstetrics and Gynecology at the Faculty of Medicine in Pilsen and the 1^st Faculty of Medicine in Prague, Charles University, Czech Republic, between 2012 and 2016. Women with a repeat VBAC, preterm birth or stillbirth were excluded from the study. As a control group, we enrolled a cohort of primiparous women who delivered vaginally during the study period. To increase our control sample, we also invited all primiparous women who delivered vaginally in both participating units between May and June 2019 to participate. All participants were invited for a four-dimensional pelvic floor ultrasound scan to assess LAM trauma. LAM avulsion and the area of the levator hiatus were assessed offline from the stored pelvic floor volumes obtained at rest, during maximum contraction and during Valsalva maneuver. The laterality of the avulsion was also noted. The cohorts were then compared using the χ² test and Wilcoxon's two-sample test according to the normality of the distribution. P < 0.05 was considered statistically significant. Multivariate regression analysis, controlling for age and body mass index (BMI), was also performed.

RESULTS

A total of 356 women had a VBAC for their second delivery during the study period. Of these, 152 (42.7%) attended the ultrasound examination and full data were available for statistical analysis for 141 women. The control group comprised 113 primiparous women. A significant difference was observed between the VBAC group and the control group in age (32.7 vs 30.1 years; P < 0.05), BMI (28.4 vs 27.4 kg/m² ; P < 0.05) and duration of the first and second stages of labor (293.1 vs 345.9 min; P < 0.05 and 27.6 vs 35.3 min; P < 0.05, respectively) at the time of the index birth. The LAM avulsion rate was significantly higher in the VBAC compared with the control group (32.6% vs 18.6%; P = 0.01). The difference between the groups was observed predominantly in the rate of unilateral avulsion and remained significant after controlling for age and BMI (adjusted odds ratio 2.061 (95% CI, 1.103-3.852)). There was no statistically significant difference in the area of the levator hiatus at rest (12.0 vs 12.6 cm² ; P = 0.28) or on maximum Valsalva maneuver (18.6 vs 18.7 cm² ; P = 0.55) between the VBAC and control groups. The incidence of levator hiatal ballooning was comparable between the groups (17.7% and 18.6%; P = 0.86).

CONCLUSIONS

VBAC is associated with a significantly higher rate of LAM avulsion than is vaginal birth in nulliparous women. The difference was significant even after controlling for age and BMI. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

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.

Levator ani avulsion: a Systematic evidence review (LASER)

BACKGROUND

There is variation in the reported incidence rates of levator avulsion (LA) and paucity of research into its risk factors.

OBJECTIVE

To explore the incidence rate of LA by mode of birth, imaging modality, timing of diagnosis and laterality of avulsion.

SEARCH STRATEGY

We searched MEDLINE, EMBASE, CINAHL, AMED and MIDIRS with no language restriction from inception to April 2019.

STUDY ELIGIBILITY CRITERIA

A study was included if LA was assessed by an imaging modality after the first vaginal birth or caesarean section. Case series and reports were not included.

DATA COLLECTION AND ANALYSIS

RevMan v5.3 was used for the meta-analyses and SW SAS and STATISTICA packages were used for type and timing of imaging analyses.

RESULTS

We included 37 primary non-randomised studies from 17 countries and involving 5594 women. Incidence rates of LA were 1, 15, 21, 38.5 and 52% following caesarean, spontaneous, vacuum, spatula and forceps births, respectively, with no differences by imaging modality. Odds ratio of LA following spontaneous birth versus caesarean section was 10.69. The odds ratios for LA following vacuum and forceps compared with spontaneous birth were 1.66 and 6.32, respectively. LA was more likely to occur unilaterally than bilaterally following spontaneous (P < 0.0001) and vacuum-assisted (P = 0.0103) births but not forceps. Incidence was higher if assessment was performed in the first 4 weeks postpartum.

CONCLUSIONS

LA incidence rates following caesarean, spontaneous, vacuum and forceps deliveries were 1, 15, 21 and 52%, respectively. Ultrasound and magnetic resonance imaging were comparable tools for LA diagnosis.

TWEETABLE ABSTRACT

Levator avulsion incidence rates after caesarean, spontaneous, vacuum and forceps deliveries were 1, 15, 21 and 52%, respectively.