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DeLancey JO, Mastrovito S, Masteling M, Horner W, Ashton-Miller JA, Chen L. A unified pelvic floor conceptual model for studying morphological changes with prolapse, age, and parity. Am J Obstet Gynecol 2024; 230:476-484.e2. [PMID: 38036167 PMCID: PMC11210379 DOI: 10.1016/j.ajog.2023.11.1247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 11/21/2023] [Accepted: 11/23/2023] [Indexed: 12/02/2023]
Abstract
Several 2-dimensional and 3-dimensional measurements have been used to assess changes in pelvic floor structures and shape. These include assessment of urogenital and levator hiatus dimensions, levator injury grade, levator bowl volume, and levator plate shape. We argue that each assessment reflects underlying changes in an individual aspect of the overall changes in muscle and fascial structures. Vaginal delivery, aging, and interindividual variations in anatomy combine to affect pelvic floor structures and their connections in different ways. To date, there is no unifying conceptual model that permits the evaluation of how these many measures relate to one another or that reflects overall pelvic floor structure and function. Therefore, this study aimed to describe a unified pelvic floor conceptual model to better understand how the aforementioned changes to the pelvic floor structures and their biomechanical interactions affect pelvic organ support with vaginal birth, prolapse, and age. In this model, the pelvic floor is composed of 5 key anatomic structures: the (1) pubovisceral, (2) puborectal, and (3) iliococcygeal muscles with their superficial and inferior fascia; (4) the perineal membrane or body; and (5) the anal sphincter complex. Schematically, these structures are considered to originate from pelvic sidewall structures and meet medially at important connection points that include the anal sphincter complex, perineal body, and anococcygeal raphe. The pubovisceral muscle contributes primarily to urogenital hiatus closure, whereas the puborectal muscle is mainly related to levator hiatus closure, although each muscle contributes to the other. Dorsally and laterally, the iliococcygeal muscle forms a shelflike structure in women with normal support that spans the remaining area between these medial muscles and attachments to the pelvic sidewall. Other features include the levator plate, bowl volume, and anorectal angle. The pelvic floor conceptual model integrates existing observations and points out evident knowledge gaps in how parturition, injury, disease, and aging can contribute to changes associated with pelvic floor function caused by the detachment of one or more important connection points or pubovisceral muscle failure.
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Affiliation(s)
- John O DeLancey
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
| | - Sara Mastrovito
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; Department of Obstetrics and Gynecology, Istituto di Ricovero e Cura a Carattere Scientifico, Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy.
| | - Mariana Masteling
- Departments of Mechanical Engineering, University of Michigan, Ann Arbor, MI
| | - Whitney Horner
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
| | - James A Ashton-Miller
- Departments of Mechanical Engineering, University of Michigan, Ann Arbor, MI; Biomedical Engineering, University of Michigan, Ann Arbor, MI
| | - Luyun Chen
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
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Mitteroecker P, Fischer B. Evolution of the human birth canal. Am J Obstet Gynecol 2024; 230:S841-S855. [PMID: 38462258 DOI: 10.1016/j.ajog.2022.09.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 09/07/2022] [Accepted: 09/07/2022] [Indexed: 03/12/2024]
Abstract
It seems puzzling why humans have evolved such a small and rigid birth canal that entails a relatively complex process of labor compared with the birth canal of our closest relatives, the great apes. This study reviewed insights into the evolution of the human birth canal from recent theoretical and empirical studies and discussed connections to obstetrics, gynecology, and orthopedics. Originating from the evolution of bipedality and the large human brain million years ago, the evolution of the human birth canal has been characterized by complex trade-off dynamics among multiple biological, environmental, and sociocultural factors. The long-held notion that a wider pelvis has not evolved because it would be disadvantageous for bipedal locomotion has not yet been empirically verified. However, recent clinical and biomechanical studies suggest that a larger birth canal would compromise pelvic floor stability and increase the risk of incontinence and pelvic organ prolapse. Several mammals have neonates that are equally large or even larger than human neonates compared to the size of the maternal birth canal. In these species, the pubic symphysis opens widely to allow successful delivery. Biomechanical and developmental constraints imposed by bipedality have hindered this evolutionary solution in humans and led to the comparatively rigid pelvic girdle in pregnant women. Mathematical models have shown why the evolutionary compromise to these antagonistic selective factors inevitably involves a certain rate of fetopelvic disproportion. In addition, these models predict that cesarean deliveries have disrupted the evolutionary equilibrium and led to new and ongoing evolutionary changes. Different forms of assisted birth have existed since the stone age and have become an integral part of human reproduction. Paradoxically, by buffering selection, they may also have hindered the evolution of a larger birth canal. Many of the biological, environmental, and sociocultural factors that have influenced the evolution of the human birth canal vary globally and are subject to ongoing transitions. These differences may have contributed to the global variation in the form of the birth canal and the difficulty of labor, and they likely continue to change human reproductive anatomy.
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Affiliation(s)
- Philipp Mitteroecker
- Unit for Theoretical Biology, Department of Evolutionary Biology, University of Vienna, Vienna, Austria.
| | - Barbara Fischer
- Unit for Theoretical Biology, Department of Evolutionary Biology, University of Vienna, Vienna, Austria
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3
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Higher preoperative expectations predict better outcomes in shoulder surgery patients. Knee Surg Sports Traumatol Arthrosc 2023; 31:185-192. [PMID: 35780400 DOI: 10.1007/s00167-022-07053-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 06/09/2022] [Indexed: 01/25/2023]
Abstract
PURPOSE The purpose of this study is to determine if preoperative expectations (PE) are an independent predictor of greater 2-year outcomes and greater improvement from baseline in shoulder surgery patients. METHODS Two-hundred and sixteen patients who underwent shoulder surgery at one institution were studied. Patients completed both preoperative and 2-year follow-up questionnaires including PROMIS (Patient-Reported Outcome Measurement Information System) computer-adaptive testing in six domains, American Shoulder and Elbow Surgeons (ASES) score, shoulder numeric pain scale (NPS), and the Marx Shoulder Activity Rating Scale (MARS). PE were measured using the Musculoskeletal Outcomes and Data Evaluation Management System (MODEMS) expectations domain, and satisfaction was measured via the Surgical Satisfaction Questionnaire (SSQ-8). RESULTS The mean PE score was 86.2 ± 17.8. Greater PE were associated with significantly better 2-year scores for ASES, NPS, MARS, SSQ8, and PROMIS domains of Physical Function, Fatigue, Pain Interference Fatigue and Social Satisfaction. Multivariable analyses demonstrated that greater PE were an independent predictor of both better 2-year scores and greater improvement for PROMIS SS (p < 0.001), ASES (p = 0.007), and shoulder NPS (p = 0.011). CONCLUSION Greater PE are positively associated with numerous patient-based outcomes 2 years after surgery. With regards to pain relief, shoulder function, and social satisfaction, higher PE are also predictive of better outcome scores and more improvement. This study suggests that preoperative assessment of shoulder surgery PE is important, and that counseling patients to optimize realistic expectations may lead to superior outcomes. LEVEL OF EVIDENCE III.
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Neshatian L, Lam JP, Gurland BH, Liang T, Becker L, Sheth VR. MRI biomarker of muscle composition is associated with severity of pelvic organ prolapse. Tech Coloproctol 2022; 26:725-733. [PMID: 35727428 DOI: 10.1007/s10151-022-02651-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 05/29/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND The pathophysiology of pelvic organ prolapse is largely unknown. We hypothesized that reduced muscle mass on magnetic resonance defecography (MRD) is associated with increased pelvic floor laxity. The aim of this study was to compare the psoas and puborectalis muscle mass composition and cross-sectional area among patients with or without pelvic laxity. METHODS An observational retrospective study was conducted on women > age 18 years old who had undergone MRD for pelvic floor complaints from January 2020 to December 2020 at Stanford Pelvic Health Center. Pelvic floor laxity, pelvic organ descent, and rectal prolapse were characterized by standard measurements on MRD and compared to the psoas (L4 level) and puborectalis muscle index (cross-sectional area adjusted by height) and relative fat fraction, quantified by utilizing a 2-point Dixon technique. Regression analysis was used to quantify the association between muscle characteristics and pelvic organ measurements. RESULTS The psoas fat fraction was significantly elevated in patients with abnormally increased resting and strain H and M lines (p < 0.05) and increased with rising grades of Oxford rectal prolapse (p = 0.0001), uterovaginal descent (p = 0.001) and bladder descent (p = 0.0005). In multivariate regression analysis, adjusted for age and body mass index, the psoas fat fraction (not muscle index) was an independent risk factor for abnormal strain H and M line; odds ratio (95% confidence interval) of 17.8 (2-155.4) and 18.5 (1.3-258.3) respectively, and rising Oxford grade of rectal prolapse 153.9 (4.4-5383) and bladder descent 12.4 (1.5-106). Puborectalis fat fraction was increased by rising grades of Oxford rectal prolapse (p = 0.0002). CONCLUSIONS Severity of pelvic organ prolapse appears to be associated with increasing psoas muscle fat fraction, a biomarker for reduced skeletal muscle mass. Future prospective research is needed to determine if sarcopenia may predict postsurgical outcomes after pelvic organ prolapse repair.
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Affiliation(s)
- L Neshatian
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, CA, Stanford, USA.
| | - J P Lam
- American Radiology Associates, Dallas, TX, USA
| | - B H Gurland
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - T Liang
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - L Becker
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, CA, Stanford, USA
| | - V R Sheth
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
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Kung JE, Zhang T, Weir TB, Schneider MB, Aneizi A, Leong NL, Packer JD, Meredith SJ, Henn RF. Correlation of Press Ganey Scores With Early Patient Satisfaction After Anterior Cruciate Ligament Reconstruction. Orthop J Sports Med 2022; 10:23259671221083704. [PMID: 35386839 PMCID: PMC8977719 DOI: 10.1177/23259671221083704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 12/31/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Patient satisfaction metrics are commonly used to assess the quality of
health care and affect reimbursement. The Press Ganey Ambulatory Surgery
(PGAS) is a satisfaction survey that has emerged as a prominent quality
assessment tool; however, no data exist on whether PGAS scores correlate
with early postsurgical satisfaction during the PGAS survey administration
period in patients who underwent anterior cruciate ligament reconstruction
(ACLR). Purpose: To determine if PGAS scores correlate with measures of satisfaction and
patient-reported outcomes (PROs) at 2 weeks postoperatively in ACLR
patients. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: A retrospective review of patients who underwent ACLR at a single institution
was performed. Patients who completed the PGAS survey and PROs at 2 weeks
postoperatively were included in the study. Surgical satisfaction was
measured with the Surgical Satisfaction Questionnaire (SSQ-8), and PROs
included 6 Patient-Reported Outcomes Measurement Information System domains.
Bivariate analysis between PGAS and PRO scores was conducted using the
Spearman rank correlation coefficient (rS). Results: Of the 716 patients who received the PGAS survey after ACLR, 81 patients
completed the survey, and 39 patients also completed PROs and were included
in the study. Total converted (mean scaled score) and “top box” (percentages
of questions with highest rating selected) PGAS scores showed no significant
correlations with the SSQ-8 (rS =–0.24; P = .14). There were no significant
correlations between SSQ-8 and PGAS domain scores except for a negative
correlation with Facility domain top box scores (rS =–0.33; P = .04), meaning that patients with
higher surgical satisfaction had lower PGAS Facility scores. Total PGAS
(converted and top box scores) and PGAS domain scores showed no significant
correlation with any of the other PROs. Conclusion: PGAS scores showed no significant positive correlation with surgical
satisfaction, function, pain, mental health, activity, or expectations of
surgery in patients 2 weeks after ACLR. This suggests little to no
relationship between PGAS score and surgical satisfaction in the early
recovery period after ACLR.
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Affiliation(s)
- Justin E. Kung
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Tina Zhang
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Tristan B. Weir
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Matheus B. Schneider
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Ali Aneizi
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Natalie L. Leong
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jonathan D. Packer
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Sean J. Meredith
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - R. Frank Henn
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland, USA
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VanSickle C, Liese KL, Rutherford JN. Textbook typologies: Challenging the myth of the perfect obstetric pelvis. Anat Rec (Hoboken) 2022; 305:952-967. [PMID: 35202515 PMCID: PMC9303659 DOI: 10.1002/ar.24880] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 01/18/2022] [Accepted: 01/22/2022] [Indexed: 12/03/2022]
Abstract
Medical education's treatment of obstetric-related anatomy exemplifies historical sex bias in medical curricula. Foundational obstetric and midwifery textbooks teach that clinical pelvimetry and the Caldwell-Moloy classification system are used to assess the pelvic capacity of a pregnant patient. We describe the history of these techniques-ostensibly developed to manage arrested labors-and offer the following criticisms. The sample on which these techniques were developed betrays the bias of the authors and does not represent the sample needed to address their interest in obstetric outcomes. Caldwell and Moloy wrote as though the size and shape of the bony pelvis are the primary causes of "difficult birth"; today we know differently, yet books still present their work as relevant. The human obstetric pelvis varies in complex ways that are healthy and normal such that neither individual clinical pelvimetric dimensions nor the artificial typologies developed from these measurements can be clearly correlated with obstetric outcomes. We critique the continued inclusion of clinical pelvimetry and the Caldwell-Moloy classification system in biomedical curricula for the racism that was inherent in the development of these techniques and that has clinical consequences today. We call for textbooks, curricula, and clinical practices to abandon these outdated, racist techniques. In their place, we call for a truly evidence-based practice of obstetrics and midwifery, one based on an understanding of the complexity and variability of the physiology of pregnancy and birth. Instead of using false typologies that lack evidence, this change would empower both pregnant people and practitioners.
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Affiliation(s)
- Caroline VanSickle
- Department of AnatomyA.T. Still University, Kirksville College of Osteopathic MedicineKirksvilleMissouriUSA
| | - Kylea L. Liese
- Department of Human Development Nursing Science, College of NursingUniversity of Illinois ChicagoChicagoIllinoisUSA
| | - Julienne N. Rutherford
- Department of Human Development Nursing Science, College of NursingUniversity of Illinois ChicagoChicagoIllinoisUSA
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7
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Sinex DCE, Bowen ST, Kashkoush A, Rosemond A, Carter D, Menon PG, Moalli PA, Abramowitch SD. The establishment of a 3D anatomical coordinate system for defining vaginal axis and spatial position. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2021; 208:106175. [PMID: 34082373 PMCID: PMC9277768 DOI: 10.1016/j.cmpb.2021.106175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 05/05/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND AND OBJECTIVE Pelvic organ prolapse (POP), the herniation of the pelvic organs toward the vaginal opening, is a common pelvic floor disorder (PFD) whose etiology is poorly understood. Traditional methods for evaluating POP are often constrained to external vaginal examination, limited to 2D, or have poor reproducibility. We propose a reliable 3D anatomic coordinate system for standardized 3D assessment of pelvic anatomy using magnetic resonance imaging (MRI). METHODS The novel 3D anatomic reference system is based on six bony landmarks of the pelvis manually identified in MRI: the ischial spines and the superior and inferior pubic points of the left and right pubic symphysis. The origin of this system is defined as the midpoint of the ischial spines. The reproducibility and applicability of the pelvic coordinate system were evaluated by (1) implementing it in a new method to quantify vaginal position and axis (angulation) in 3D space from MRI segmentations of the vagina and (2) computing the intraclass correlation (ICC) on coordinate system and vaginal measures. The MRI analysis was performed by four non-medically trained observers on five pelvic MRI datasets on approximately five separate occasions. RESULTS Overall, all bony landmarks had excellent intra-observer reliability and inter-observer reliability (ICC>0.90); intra-observer reliability was moderate-to-good among the vaginal position parameters (0.5<ICC≤0.90) and moderate for the vaginal axis angles (0.50<ICC≤0.75); inter-observer reliability was moderate in the vaginal position coordinates and vaginal axis measures. On average, within-observer differences in the vaginal position and angle measures relative to the overall mean were <1 mm and <1°, respectively. CONCLUSIONS The proposed anatomic coordinate system and vaginal analysis approach allow quantitative assessment of pelvic anatomy that is robust to the experience level of the observer. The application of these methods in radiographic studies will give new insight into the underlying anatomic changes involved in the pathogenesis of POP and other PFDs and help better understand their etiology.
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Affiliation(s)
- Deanna C E Sinex
- Department of Bioengineering, University of Pittsburgh, 406 Benedum Hall, 3700 O'Hara Street, Pittsburgh, PA 15260, United States
| | - Shaniel T Bowen
- Department of Bioengineering, University of Pittsburgh, 406 Benedum Hall, 3700 O'Hara Street, Pittsburgh, PA 15260, United States
| | | | | | | | - Prahlad G Menon
- Department of Bioengineering, University of Pittsburgh, 406 Benedum Hall, 3700 O'Hara Street, Pittsburgh, PA 15260, United States
| | - Pamela A Moalli
- Department of Bioengineering, University of Pittsburgh, 406 Benedum Hall, 3700 O'Hara Street, Pittsburgh, PA 15260, United States; Department of Obstetrics, Gynecology & Reproductive Sciences, University of Pittsburgh Medical Center, Magee Women's Research Institute, Pittsburgh, PA, United States
| | - Steven D Abramowitch
- Department of Bioengineering, University of Pittsburgh, 406 Benedum Hall, 3700 O'Hara Street, Pittsburgh, PA 15260, United States.
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Biomechanical trade-offs in the pelvic floor constrain the evolution of the human birth canal. Proc Natl Acad Sci U S A 2021; 118:2022159118. [PMID: 33853947 DOI: 10.1073/pnas.2022159118] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Compared with most other primates, humans are characterized by a tight fit between the maternal birth canal and the fetal head, leading to a relatively high risk of neonatal and maternal mortality and morbidities. Obstetric selection is thought to favor a spacious birth canal, whereas the source for opposing selection is frequently assumed to relate to bipedal locomotion. Another, yet underinvestigated, hypothesis is that a more expansive birth canal suspends the soft tissue of the pelvic floor across a larger area, which is disadvantageous for continence and support of the weight of the inner organs and fetus. To test this "pelvic floor hypothesis," we generated a finite element model of the human female pelvic floor and varied its radial size and thickness while keeping all else constant. This allowed us to study the effect of pelvic geometry on pelvic floor deflection (i.e., the amount of bending from the original position) and tissue stresses and stretches. Deflection grew disproportionately fast with increasing radial size, and stresses and stretches also increased. By contrast, an increase in thickness increased pelvic floor stiffness (i.e., the resistance to deformation), which reduced deflection but was unable to fully compensate for the effect of increasing radial size. Moreover, larger thicknesses increase the intra-abdominal pressure necessary for childbirth. Our results support the pelvic floor hypothesis and evince functional trade-offs affecting not only the size of the birth canal but also the thickness and stiffness of the pelvic floor.
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D’Amico F, Wexner SD, Vaizey CJ, Gouynou C, Danese S, Peyrin-Biroulet L. Tools for fecal incontinence assessment: lessons for inflammatory bowel disease trials based on a systematic review. United European Gastroenterol J 2020; 8:886-922. [PMID: 32677555 PMCID: PMC7707876 DOI: 10.1177/2050640620943699] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 06/09/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Fecal incontinence is a disabling condition affecting up to 20% of women. OBJECTIVE We investigated fecal incontinence assessment in both inflammatory bowel disease and non-inflammatory bowel disease patients to propose a diagnostic approach for inflammatory bowel disease trials. METHODS We searched on Pubmed, Embase and Cochrane Library for all studies on adult inflammatory bowel disease and non-inflammatory bowel disease patients reporting data on fecal incontinence assessment from January 2009 to December 2019. RESULTS In total, 328 studies were included; 306 studies enrolled non-inflammatory bowel disease patients and 22 studies enrolled inflammatory bowel disease patients. In non-inflammatory bowel disease trials the most used tools were the Wexner score, fecal incontinence quality of life questionnaire, Vaizey score and fecal incontinence severity index (in 187, 91, 62 and 33 studies). Anal manometry was adopted in 41.2% and endoanal ultrasonography in 34.0% of the studies. In 142 studies (46.4%) fecal incontinence evaluation was performed with a single instrument, while in 64 (20.9%) and 100 (32.7%) studies two or more instruments were used. In inflammatory bowel disease studies the Wexner score, Vaizey score and inflammatory bowel disease quality of life questionnaire were the most commonly adopted tools (in five (22.7%), five (22.7%) and four (18.2%) studies). Anal manometry and endoanal ultrasonography were performed in 45.4% and 18.2% of the studies. CONCLUSION Based on prior validation and experience, we propose to use the Wexner score as the first step for fecal incontinence assessment in inflammatory bowel disease trials. Anal manometry and/or endoanal ultrasonography should be taken into account in the case of positive questionnaires.
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Affiliation(s)
- Ferdinando D’Amico
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Department of Gastroenterology and Inserm NGERE U1256, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France
| | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston USA
| | | | - Célia Gouynou
- Department of Gastroenterology and Inserm NGERE U1256, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France
| | - Silvio Danese
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center-IRCCS, Rozzano, Milan, Italy
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology and Inserm NGERE U1256, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France
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10
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Routzong MR, Rostaminia G, Moalli PA, Abramowitch SD. Pelvic floor shape variations during pregnancy and after vaginal delivery. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2020; 194:105516. [PMID: 32473515 DOI: 10.1016/j.cmpb.2020.105516] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 04/10/2020] [Accepted: 04/21/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND AND OBJECTIVE Strong evidence suggests that pelvic soft tissues soften during pregnancy to facilitate vaginal delivery while protecting against maternal birth injury. We hypothesized that these adaptations likely result in changes to the shape of the pelvic floor. Thus, this study aimed to compare midsagittal pelvic floor shapes from MRIs of nulliparous, gravid, and vaginally parous women using statistical shape modeling. METHODS A retrospective study of 22 nulliparous, 29 gravid (vaginally nulliparous), and 18 vaginally parous women who underwent pelvic MRI was performed. The pelvic floor was segmented from pubic symphysis to coccyx as a 2D polyline in the midsagittal plane. Once corresponding landmarks were computed and the variances between them determined by principal component analysis, the principal component scores were calculated for modes that explained variance greater than noise. These became the dependent variables in a MANOVA with univariate ANOVAs, linear regressions, and Benjamini-Hochberg corrections post hoc. Two initial statistical shape analyses were conducted to analyze differences based on gestational age (1st/2nd vs 3rd trimester) and vaginal parity (VP1 vs VP2-4). There were significant differences based on gestational age, but not vaginal parity. Thus, the final statistical shape analysis evaluated pelvic floor shapes of nulliparous, 3rd trimester gravid, and all vaginally parous subjects. RESULTS In the final analysis, six modes described variance-a measure of shape variability-greater than noise. Groups differed significantly for modes 1, 2, and 4 (p < 0.001, p = 0.021, and p = 0.015, respectively) and only differed between the nulliparous and gravid groups (p < 0.001, p = 0.018, and p = 0.012, respectively). Anatomically, these modes described levator plate relaxation and level III support protrusion in gravid compared to nulliparous subjects while the parous group straddled the other two. CONCLUSIONS The shape of the pelvic floor changes significantly during pregnancy and some of those changes are present after vaginal delivery. The fact that the nulliparous and gravid groups differ while the parous is similar to both suggests that some parous women regain their nulliparous shape after pregnancy and delivery while others do not. This indicates that remodeling during pregnancy and/or injury during vaginal delivery can have lasting effects on the pelvic floor.
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Affiliation(s)
- Megan R Routzong
- Translational Biomechanics Laboratory, Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, Benedum Hall, Room 406, 3700 O'Hara Street, Pittsburgh, 15260, PA, USA
| | - Ghazaleh Rostaminia
- Female Pelvic Medicine and Reconstructive Surgery (FPMRS), Division of Urogynecology, University of Chicago Pritzker School of Medicine, Northshore University HealthSystem, Skokie, IL, USA
| | - Pamela A Moalli
- Department of Obstetrics, Gynecology & Reproductive Surgery, University of Pittsburgh, Magee-Womens Research Institute, Pittsburgh, PA, USA
| | - Steven D Abramowitch
- Translational Biomechanics Laboratory, Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, Benedum Hall, Room 406, 3700 O'Hara Street, Pittsburgh, 15260, PA, USA.
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11
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Wu E, Kuehl TJ, Gendron JM, White W, Yandell PM. Pelvic floor changes in the first term pregnancy and postpartum period. Int Urogynecol J 2020; 32:1897-1905. [PMID: 32737534 DOI: 10.1007/s00192-020-04456-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 07/20/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To follow a prospective cohort of women during their first term pregnancy to elucidate the nature and timing of changes to the pelvic floor during pregnancy and after vaginal delivery. METHODS Enrolled subjects were evaluated at four time points with dynamic MRI, POP-Q examinations, and validated symptom questionnaires. The four assessments occurred during the first trimester (ePG), late third trimester (lPG), within a week after vaginal delivery (ePP), and three months postpartum (lPP). Two-dimensional T1-weighted MRI measurements included bladder descent and area of the levator hiatus at rest and during Valsalva maneuvers. Sample size of ten subjects was calculated for a power of 0.8 to detect a 20% change in bladder position with p < 0.05. Comparative statistical tests were used for parametric and non-parametric data, respectively. RESULTS Twelve subjects completed the study. At lPP, the bladder descent was increased (p = 0.03) at rest and with Valsalva compared to ePG. Levator hiatus area did not differ (p = 0.63) between time points at rest or with Valsalva. Median POP stage increased (p = 0.001) to 1.5 at lPP. Mean genital hiatus increased (p = 0.0003) at each time point. Higher scores were recorded on the UDI-6 (p < 0.001) and the PFDI-20 (p = 0.003) questionnaires at lPG and ePP, but returned to ePG levels by lPP. CONCLUSION Anatomic changes measured by dynamic MRI and POP-Q examinations demonstrate significant descent at 3 months postpartum. However, these anatomic changes did not significantly correlate with changes in symptoms.
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Affiliation(s)
- Emily Wu
- Baylor Scott & White Medical Center - Temple, 2401 South 31st Street, Temple, TX, 76508, USA.
| | - Thomas J Kuehl
- Baylor Scott & White Medical Center - Temple, 2401 South 31st Street, Temple, TX, 76508, USA
| | - Jilene M Gendron
- Baylor Scott & White Medical Center - Temple, 2401 South 31st Street, Temple, TX, 76508, USA
| | - Wendy White
- Baylor Scott & White Medical Center - Temple, 2401 South 31st Street, Temple, TX, 76508, USA
| | - Paul M Yandell
- Baylor Scott & White Medical Center - Temple, 2401 South 31st Street, Temple, TX, 76508, USA
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Maternal, obstetrical and neonatal risk factors' impact on female urinary incontinence: a systematic review. Int Urogynecol J 2020; 31:2205-2224. [PMID: 32712698 DOI: 10.1007/s00192-020-04442-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 07/09/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Urinary incontinence (UI) is one of the most serious problems during pregnancy and after delivery. It can influence the quality of life and cause psychological problems that lead to depression and decreased self-esteem. We aimed to investigate the maternal, obstetrical and neonatal risk factors of urinary incontinence 3 to 12 months after childbirth. METHODS The Cochrane Library, Medline, Science Direct and Web of Science were searched for studies published from the inception of the databases up to December 2019, including any observational full-text papers. All data were analyzed using Review Manager 5.3. Of 338 articles reviewed, 20 studies were considered for meta-analysis. RESULTS The results of our study showed that vaginal delivery in contrast to cesarean section (OR = 3.74, 95% CI: [2.71, 5.15], P < 0.00001), UI in pregnancy (OR = 5.27, 95% CI: [3.40, 8.17], P < 0.00001), episiotomy (OR = 1.23, 95% CI: [1.05, 1.45], P < 0.01), perineal tear > grade 2, instrumental delivery in contrast to cesarean section, epidural or spinal anesthesia, maternal age, pre-pregnancy BMI and neonatal birthweight have a direct relationship with UI. CONCLUSIONS This study confirmed that urinary incontinence during pregnancy and vaginal births had the strongest relationship with postpartum urinary incontinence. Also, the maternal upright positions during labor did not reduce the likelihood of urinary incontinence. The awareness of this issue helps find effective strategies to reduce the likelihood of female urinary incontinence.
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de Tayrac R, Schantz C. [Childbirth pelvic floor trauma: Anatomy, physiology, pathophysiology and special situations - CNGOF perineal prevention and protection in obstetrics guidelines]. ACTA ACUST UNITED AC 2018; 46:900-912. [PMID: 30396762 DOI: 10.1016/j.gofs.2018.10.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To assess whether pelvic size and shape, spinal curvature, perineal body length and genital hiatus size are associated with the incidence of childbirth pelvic floor trauma. Special situations, such as obesity, ethnicity and hyperlaxity, will also be studied. METHODS A bibliographic research using Pubmed and Cochrane Library databases was conducted until May 2018. Publications in English and French were selected by initial reading of the abstracts. Randomized trials, meta-analyzes, case-control studies and large cohorts were studied in a privileged way. RESULTS A pubic arch angle<90° (measured clinically) does not appear to increase the risk of OASIS (Level 3), but appears to be a risk factor for postnatal anal incontinence at short-term, but not at long-term (Level 3). Measurement of pelvic dimensions and the subpubic angle is not recommended to predict OASIS or to choose the mode of delivery for the purpose of protecting the perineum (GradeC). Prenatal measurement of both perineal body (Level 3) and genital hiatus (Level 2) does not predict the incidence of 2nd or 3rd degree OASIS. Therefore, the routine prenatal measurement of the length of the perineal body or the genital hiatus is not recommended for any objective related to perineal protection (Grade C). Levator avulsion, resulting in a widening of the genital hiatus, is potentially a source of long-term pelvic floor dysfunction. Biomechanical models suggest that performing a mediolateral episiotomy and applying the fingers to the posterior perineum at the time of expulsive phase may reduce pelvic floor trauma. Obese women have a longer perineal body (Level 3), and obesity does not seem to increase the risk of OASIS (Level 2). There is no difference between Asian and non-Asian women perineal body (Level 3). No studies have validated that the liberal practice of episiotomy in Asian women reduced the risk of OASIS. It is therefore not recommended to practice an episiotomy for simple ethnic reasons in Asian women (GradeC). Compared to white women, black women do not appear to have an increased risk of OASIS and even appear to have a decreased risk of perineal tears of all stages (Level 2). Ligament hyperlaxity seems to be associated with an increased risk of OASIS (Level 2). CONCLUSIONS Prenatal assessment of pelvis bone, spine curvature, perineal body and genital hiatus do not allow to predict the incidence of childbirth pelvic floor trauma. Obesity and ethnicity are not risk factors for OASIS.
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Affiliation(s)
- R de Tayrac
- Service de gynécologie-obstétrique, CHU Carémeau, place du Pr-Debré, 30900 Nîmes, France.
| | - C Schantz
- Commission Scientifique du Collège National des Sages-Femmes (CNSF), Centre population et développement (Ceped), institut de la recherche et du développement (IRD), université Paris Descartes, Inserm, 75006, Paris, France
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14
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A review of functional pelvic floor imaging modalities and their effectiveness. Clin Imaging 2015; 39:559-65. [DOI: 10.1016/j.clinimag.2015.02.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Revised: 02/06/2015] [Accepted: 02/23/2015] [Indexed: 02/06/2023]
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15
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The value of dynamic magnetic resonance imaging in interdisciplinary treatment of pelvic floor dysfunction. ACTA ACUST UNITED AC 2015; 40:2242-7. [DOI: 10.1007/s00261-015-0476-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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16
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LI R, Song Y, Ma M. Relationship between levator ani and bony pelvis morphology and clinical grade of prolapse in women. Clin Anat 2015; 28:813-9. [DOI: 10.1002/ca.22536] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Revised: 02/22/2015] [Accepted: 02/22/2015] [Indexed: 11/09/2022]
Affiliation(s)
- Ran LI
- Department of Obstetrics and Gynecology; Fuzong Clinical College of Fujian Medical University; Fuzhou Fujian 350025 China
| | - Yanfeng Song
- Department of Obstetrics and Gynecology; Fuzong Clinical College of Fujian Medical University; Fuzhou Fujian 350025 China
| | - Ming Ma
- Department of Radiology; Fuzhou General Hospital; Fuzhou Fujian 350025 China
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Pontbriand-Drolet S, Tang A, Madill SJ, Tannenbaum C, Lemieux MC, Corcos J, Dumoulin C. Differences in pelvic floor morphology between continent, stress urinary incontinent, and mixed urinary incontinent elderly women: An MRI study. Neurourol Urodyn 2015; 35:515-21. [PMID: 25727524 DOI: 10.1002/nau.22743] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 01/12/2015] [Indexed: 12/24/2022]
Abstract
AIMS To compare magnetic resonance imaging (MRI) of the pelvic floor musculature (PFM), bladder neck and urethral sphincter morphology under three conditions (rest, PFM maximal voluntary contraction (MVC), and straining) in older women with symptoms of stress (SUI) or mixed urinary incontinence (MUI) or without incontinence. METHODS This 2008-2012 exploratory observational cohort study was conducted with community-dwelling women aged 60 and over. Sixty six women (22 per group), mean age of 67.7 ± 5.2 years, participated in the study. A 3 T MRI examination was conducted under three conditions: rest, PFM MVC, and straining. ANOVA or Kruskal-Wallis tests (data not normally distributed) were conducted, with Bonferroni correction, to compare anatomical measurements between groups. RESULTS Women with MUI symptoms had a lower PFM resting position (M-Line P = 0.010 and PC/H-line angle P = 0.026) and lower pelvic organ support (urethrovesical junction height P = 0.013) than both continent and SUI women. Women with SUI symptoms were more likely to exhibit bladder neck funneling and a larger posterior urethrovesical angle at rest than both continent and MUI women (P = 0.026 and P = 0.008, respectively). There were no significant differences between groups on PFM MVC or straining. CONCLUSIONS Women with SUI and MUI symptoms present different morphological defects at rest. These observations emphasize the need to tailor UI interventions to specific pelvic floor defects and UI type in older women. PATIENT SUMMARY Older women with UI demonstrate different problems with their pelvic organ support structures depending on the type of UI. These new findings should be taken into consideration for future research into developing new treatment strategies for UI in older women. Neurourol. Urodynam. 35:515-521, 2016. © 2015 Wiley Periodicals, Inc.
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Affiliation(s)
- Stéphanie Pontbriand-Drolet
- Faculty of Medicine, University of Montreal, Montreal, Canada.,Research Centre, Institut Universitaire de Gériatrie de Montréal, Montreal, Canada
| | - An Tang
- Faculty of Medicine, University of Montreal, Montreal, Canada.,Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, Canada.,Research Centre of the Centre Hospitalier de l'Université de Montréal, Montreal, Canada
| | - Stephanie J Madill
- School of Physical Therapy, University of Saskatchewan, Saskatchewan, Canada
| | - Cara Tannenbaum
- Faculty of Medicine, University of Montreal, Montreal, Canada.,Research Centre, Institut Universitaire de Gériatrie de Montréal, Montreal, Canada
| | - Marie-Claude Lemieux
- Faculty of Medicine, University of Montreal, Montreal, Canada.,Department of Obstetrics & Gynecology, Maisonneuve Rosemont Hospital, Montreal, Canada
| | - Jacques Corcos
- Department of Urology, Jewish General Hospital, McGill University, Montreal, Canada
| | - Chantale Dumoulin
- Faculty of Medicine, University of Montreal, Montreal, Canada.,Research Centre, Institut Universitaire de Gériatrie de Montréal, Montreal, Canada
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18
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Does bilateral sacrospinous fixation with synthetic mesh recreate nulliparous pelvic anatomy? An MRI evaluation. Female Pelvic Med Reconstr Surg 2015; 20:222-7. [PMID: 24978089 DOI: 10.1097/spv.0000000000000066] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aim of this study was to determine whether the bilateral sacrospinous vault fixation (BSSVF) with synthetic, polypropylene mesh arms restores the nulliparous anatomic relationships of the vaginal vault in women with and without uterus using magnetic resonance imaging (MRI). METHODS This was a prospective case series of women with symptomatic pelvic organ prolapse (POP) who, after BSSVF, underwent a pelvic MRI (1-13 months postoperatively). Postsurgical pelvic distances were measured from MRI scans and compared with measurements from a group of 11 nulliparous women with adequate pelvic support who underwent MRI in a previous study. Our primary outcome measure was the difference in average distance from the vault to the ischial spine among women after BSSVF when compared with the average nulliparous distances. The secondary outcome measures were the difference in average distance from the posterior fornix to the sacrum and the change in apical POP quantification parameters 6 weeks after surgery. RESULTS Ten women underwent MRI post-BSSVF-4 women with and 6 women without uterine preservation. In the BSSVF group, similar to the nulliparous group measurements, the average distance between the vaginal apex and the spine was 5.2 cm (SD, 0.8) (95% confidence interval, -0.6 to 0.5; P = 0.92). There was an anterior-inferior displacement of the line between the vaginal apex and the sacrum in women who underwent BSSVF. The posterior fornix was 7.4 cm (SD, 1.2) from the second sacral vertebra versus 5.6 cm (SD, 1.5) in women without POP (P < 0.01). Adequate clinical resolution of apical prolapse was confirmed in all women 6 weeks post-BSSVF. CONCLUSIONS The BSSVF with synthetic mesh restores the anatomy between the vagina and the ischial spines. Clinical studies are underway to compare BSSVF with standard techniques of vaginal vault prolapse repair.
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Browning A, Lewis A, Whiteside S. Predicting women at risk for developing obstetric fistula: a fistula index? An observational study comparison of two cohorts. BJOG 2014; 121:604-9. [DOI: 10.1111/1471-0528.12527] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2013] [Indexed: 11/26/2022]
Affiliation(s)
| | - A Lewis
- Aberdeen Women's Centre; Freetown Sierra Leone
| | - S Whiteside
- Medical Statistics; University of Manchester; Manchester UK
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20
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Liu F, Xu L, Ying T, Tao J, Hu B. Three-dimensional ultrasound appearance of pelvic floor in nulliparous women and postpartum women one week after their first delivery. Int J Med Sci 2014; 11:234-9. [PMID: 24522119 PMCID: PMC3917110 DOI: 10.7150/ijms.7384] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Accepted: 12/11/2013] [Indexed: 11/15/2022] Open
Abstract
This study investigated the morphology and structure of pelvic floor in 50 nulliparous and 95 postpartum women (47 vaginal delivery, 48 Cesarean section) using translabial three-dimensional (3D) ultrasound. All the primiparae underwent ultrasound examination within one week after their first delivery. Volume datasets were acquired and analyzed to determine the alterations of levator hiatus after childbirth. Significant differences were observed in the levator hiatus of postpartum women compared with that of nullipara women. In postpartum women, the levator hiatus, with their dimensions increased, expanded into a circular shape. Puborectalis was avulsed in eight cases (accounting for 8.42% of all) and pelvic organ prolapse was found in 12 cases (accounting for 12.63%). The hiatal dimensions were larger and the incidence of pubrectalis muscle avulsion (17.02% vs. 0%) and pelvic organ prolapse (21.28% vs. 4.17%) was significantly higher in Vaginal delivery group than Cesarean section group. In summary, 3D ultrasound is an effective tool to detect the pelvic floor of postpartum women who present with morphological abnormalities, and such abnormalities are more likely to show in vaginal delivery women compared to Cesarean section.
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Affiliation(s)
- Feifei Liu
- Department of Ultrasound in Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital; Shanghai Institute of Ultrasound in Medicine, Shanghai, People's Republic of China
| | - Lian Xu
- Department of Ultrasound in Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital; Shanghai Institute of Ultrasound in Medicine, Shanghai, People's Republic of China
| | - Tao Ying
- Department of Ultrasound in Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital; Shanghai Institute of Ultrasound in Medicine, Shanghai, People's Republic of China
| | - Junjia Tao
- Department of Ultrasound in Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital; Shanghai Institute of Ultrasound in Medicine, Shanghai, People's Republic of China
| | - Bing Hu
- Department of Ultrasound in Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital; Shanghai Institute of Ultrasound in Medicine, Shanghai, People's Republic of China
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Madill SJ, Pontbriand-Drolet S, Tang A, Dumoulin C. Effects of PFM rehabilitation on PFM function and morphology in older women. Neurourol Urodyn 2013; 32:1086-95. [PMID: 23359286 DOI: 10.1002/nau.22370] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Accepted: 12/11/2012] [Indexed: 11/08/2022]
Abstract
AIMS The purpose of this study was to examine the effect of a pelvic floor muscle (PFM) rehabilitation program on incontinence symptoms, PFM function, and morphology in older women with SUI. METHODS Women 60 years old and older with at least weekly episodes of SUI were recruited. Participants were evaluated before and after a 12-week group PFM rehabilitation intervention. The evaluations included 3-day bladder diaries, symptom, and quality of life questionnaires, PFM function testing with dynamometry (force) and electromyography (activation) during seven tasks: rest, PFM maximum voluntary contraction (MVC), straining, rapid-repeated PFM contractions, a 60 sec sustained PFM contraction, a single cough and three repeated coughs, and sagittal MRI recorded at rest, during PFM MVCs and during straining to assess PFM morphology. RESULTS Seventeen women (68.9 ± 5.5 years) participated. Following the intervention the frequency of urine leakage decreased and disease-specific quality of life improved significantly. PFM function improved significantly: the participants were able to perform more rapid-repeated PFM contractions; they activated their PFMs sooner when coughing and they were better able to maintain a PFM contraction between repeated coughs. Pelvic organ support improved significantly: the anorectal angle was decreased and the urethrovescial junction was higher at rest, during contraction and while straining. CONCLUSIONS This study indicated that improvements in urine leakage were produced along with improvements in PFM co-ordination (demonstrated by the increased number of rapid PFM contractions and the earlier PFM activation when coughing), motor-control, pelvic organ support.
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Affiliation(s)
- Stéphanie J Madill
- School of Physical Therapy, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
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22
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Brown KM, Handa VL, Macura KJ, DeLeon VB. Three-dimensional shape differences in the bony pelvis of women with pelvic floor disorders. Int Urogynecol J 2012; 24:431-9. [DOI: 10.1007/s00192-012-1876-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2012] [Accepted: 06/23/2012] [Indexed: 10/28/2022]
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Berger MB, Doumouchtsis SK, DeLancey JO. Bony pelvis dimensions in women with and without stress urinary incontinence. Neurourol Urodyn 2012; 32:37-42. [PMID: 22674676 DOI: 10.1002/nau.22275] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2011] [Accepted: 04/24/2012] [Indexed: 11/06/2022]
Abstract
AIMS To test the null hypothesis that bony pelvis dimensions are similar in women with and without stress urinary incontinence (SUI), both in the postpartum and midlife periods. METHODS Secondary analyses were performed of two case-control studies comparing women with SUI to asymptomatic controls. One study examined primiparas in the first 9-12 months postpartum; the other study involved middle-aged women. SUI was confirmed by full-bladder stress test. All subjects underwent pelvic magnetic resonance imaging. The interspinous and intertuberous diameters, subpubic angle, and sacrococcygeal joint-to-the inferior pubic point distance were measured from the images independently by two authors. RESULTS In the young cohorts, we compared primiparas with de novo postpartum SUI to both continent primiparas and nulliparas. Postpartum SUI is associated with a wider subpubic angle. There is also a trend towards wider interspinous and intertuberous diameters in the stress-incontinent primiparas as compared to the continent cohorts, although this did not reach statistical significance with our sample sizes. By contrast, no significant differences in bony pelvis dimensions were identified when comparing middle-aged women with SUI and their continent controls. CONCLUSIONS Bony pelvis dimensions are different in women with SUI than in matched continent controls. However, these differences are only identified in young primiparas in the postpartum period, not in middle-aged women.
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Affiliation(s)
- Mitchell B Berger
- Pelvic Floor Research Group, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA.
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Madill S, Tang A, Pontbriand-Drolet S, Dumoulin C. Comparison of two methods for measuring the pubococcygeal line from sagittal-plane magnetic resonance imaging. Neurourol Urodyn 2011; 30:1613-9. [DOI: 10.1002/nau.21079] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2010] [Accepted: 01/27/2011] [Indexed: 11/12/2022]
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25
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Alterations in pelvic floor muscles and pelvic organ support by pregnancy and vaginal delivery in squirrel monkeys. Int Urogynecol J 2011; 22:1109-16. [PMID: 21567260 DOI: 10.1007/s00192-011-1443-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2011] [Accepted: 04/19/2011] [Indexed: 12/27/2022]
Abstract
INTRODUCTION AND HYPOTHESIS The objective of this study was to measure the effects of pregnancy and parturition on pelvic floor muscles and pelvic organ support. METHODS Levator ani, obturator internus, and coccygeus (COC) muscle volumes and contrast uptake were assessed by MRI of seven females prior to pregnancy, 3 days, and 4 months postpartum. Bladder neck and cervix position were measured dynamically with abdominal squeezing. RESULTS The sides of three paired muscles were similar (p > 0.66). COC volumes were greater (p < 0.004) after parturition than before pregnancy or after recovery. COC contrast uptake increased (p < 0.02) immediately after delivery. Bladder neck position both in the relaxed state and abdominal pressure descended (p < 0.04) after delivery and descended further (p < 0.001) after recovery. Cervical position in the relaxed state before delivery was higher (p < 0.001) than postpartum but was unchanged (p = 0.50) with abdominal pressure relative to delivery. CONCLUSION In squirrel monkeys, coccygeus muscles demonstrate the greatest change related to parturition, and parturition-related bladder neck descent seems permanent.
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Bogusiewicz M, Rosińska-Bogusiewicz K, Drop A, Rechberger T. Anatomical variation of bony pelvis from the viewpoint of transobturator sling placement for stress urinary incontinence. Int Urogynecol J 2011; 22:1005-9. [PMID: 21484367 PMCID: PMC3132277 DOI: 10.1007/s00192-011-1421-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2010] [Accepted: 03/22/2011] [Indexed: 09/20/2023]
Abstract
Introduction and hypothesis The aim of the study was to investigate the variability of bony pelvis architecture from the viewpoint of transobturator sling placement. Methods The pelvimetry was performed on 122 women who underwent pelvic computed tomography. Measurements included: the distance between the interobturator foramina line and inferior pubic symphysis (IF-PS distance) as well as pubic arch angle, pubic ramus width, and pubic symphysis length. Results The length of the IF-PS distance varied between 7.4 and 26.9 mm (mean 15.2 ± 4.3 mm, median 14.2 mm). The distribution of measurements was asymmetrical with a tilt of the values towards shorter distances. In 11.5% of women, the IF-PS distance was longer than 20 mm. The IF-PS distance correlated with the pubic ramus width (r = 0.37, p < 0.0001) and pubic arch angle (r = −0.22, p = 0.017). Conclusion The IF-PS distance varies considerably in the general population of women.
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Affiliation(s)
- Michał Bogusiewicz
- Second Department of Gynaecology, Medical University of Lublin, Jaczewskiego 8, 20-090 Lublin, Poland.
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Do repetitive Valsalva maneuvers change maximum prolapse on dynamic MRI? Int Urogynecol J 2010; 21:1247-51. [PMID: 20544342 DOI: 10.1007/s00192-010-1178-1] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2009] [Accepted: 04/25/2010] [Indexed: 10/19/2022]
Abstract
INTRODUCTION AND HYPOTHESIS This study seeks to quantify differences in anterior vaginal wall prolapse during sequential Valsalva attempts on dynamic magnetic resonance imaging (MRI). METHODS Subjects were taken from an on-going case-control study evaluating anterior vaginal wall prolapse. Women with a prolapse whose leading edge extended >or=1 cm beyond the hymenal ring were included (n = 40). All subjects performed three maximal Valsalva efforts while mid-sagittal dynamic MRI scans were obtained. Bladder descent between the first, second, and third maximal Valsalva efforts were compared. RESULTS Forty percent of women had a greater than 2-cm increase in prolapse size from their first to third Valsalva attempt. Ninety-five percent of women extended their prolapse further with a third Valsalva. CONCLUSIONS As is true during clinical examination, several attempts may be required to have maximal anterior compartment prolapse present during dynamic MRI of the pelvic floor.
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Heilbrun ME, Nygaard IE, Lockhart ME, Richter HE, Brown MB, Kenton KS, Rahn DD, Thomas JV, Weidner AC, Nager CW, Delancey JO. Correlation between levator ani muscle injuries on magnetic resonance imaging and fecal incontinence, pelvic organ prolapse, and urinary incontinence in primiparous women. Am J Obstet Gynecol 2010; 202:488.e1-6. [PMID: 20223445 DOI: 10.1016/j.ajog.2010.01.002] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2009] [Revised: 10/18/2009] [Accepted: 01/04/2010] [Indexed: 02/01/2023]
Abstract
OBJECTIVE The objective of the study was to correlate the presence of major levator ani muscle (LAM) injuries on magnetic resonance imaging (MRI) with fecal incontinence (FI), pelvic organ prolapse (POP), and urinary incontinence (UI) in primiparous women 6-12 months postpartum. STUDY DESIGN A published scoring system was used to characterize LAM injuries on MRI dichotomously (MRI negative, no/mild vs MRI positive, major). RESULTS Major LAM injuries were observed in 17 of 89 (19.1%) women who delivered vaginally with external anal sphincter (EAS) injuries, 3 of 88 (3.5%) who delivered vaginally without EAS injury, and 0 of 29 (0%) who delivered by cesarean section before labor (P=.0005). Among women with EAS injuries, those with major LAM injuries trended toward more FI, 35.3% vs 16.7% (P=.10) and POP, 35.3% vs 15.5% (P=.09), but not UI (P=1.0). CONCLUSION These data support the growing body of literature suggesting that both EAS and LAM are important for fecal continence and that multiple injuries contribute to pelvic floor dysfunction.
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Affiliation(s)
- Marta E Heilbrun
- Department of Radiology, University of Utah, Salt Lake City, UT, USA
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Fritel X. Périnée et grossesse. ACTA ACUST UNITED AC 2010; 38:332-46. [DOI: 10.1016/j.gyobfe.2010.03.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2010] [Accepted: 03/16/2010] [Indexed: 01/26/2023]
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Word RA, Pathi S, Schaffer JI. Pathophysiology of Pelvic Organ Prolapse. Obstet Gynecol Clin North Am 2009; 36:521-39. [DOI: 10.1016/j.ogc.2009.09.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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