Do women notice the impact of childbirth-related levator trauma on pelvic floor and sexual function? Results of an observational ultrasound study

Experiences of women with symptoms of vaginal laxity - a qualitative study

BACKGROUND

Vaginal laxity (VL) is rarely discussed among patients and their physicians possibly due to the lack of evidence-based treatments, embarrassment, and lack of knowledge in recognizing this condition. We aimed to understand the meanings that women attribute to the sensation of VL.

METHODS

This is a qualitative study using in-depth interviews and thematic analysis. Sixteen participants were intentionally selected from February 2020 to December 2021. One researcher interviewed each participant in a private room guaranteeing that rapport was established. Two independent researchers performed a complete transcript of each interview immediately after its end. The sample size was achieved according to the Information Power analysis. We followed the thematic analysis proposed by Braun and Clarke.

RESULTS

Of 16 patients, only one did not undergo delivery. Her complaint was not different from the rest of the group. Five major themes and subthemes were identified: the long and lonely pathway: from the identification of symptoms of VL to diagnosis (from the invisibility of VL to the perception of their symptoms; "everything will fall out!":shame, guilt and stigma as diagnosis barriers and "but I had no idea of looking for a treatment." Women's strategies to begin a help-seeking process), "the label of vaginal laxity is a heavy burden to bear" meanings associated with VL complaints, effect of VL on sexual intercourse and "I know it changed everything!" relationship with the partner.

CONCLUSION

VL is a symptom that is still little understood by women, and little explored by health professionals, with repercussions on personal and marital life.

Childbirth Acquired Perineal Trauma study (CHAPTER): a UK prospective cohort study protocol

INTRODUCTION

Childbirth-related perineal trauma (CRPT) is the most common complication of childbirth affecting 80% of women overall after vaginal birth. There remains a lack of comprehensive evidence relating to the prevalence of subsequent health problems. Current evidence is related to short-term outcomes, for example, pain, but there is less known about longer-term outcomes such as infection, wound dehiscence, pelvic floor function and psychological outcomes. This is a protocol for a cohort study assessing outcomes of women after CRPT.

METHODS AND ANALYSIS

A multicentre, prospective UK cohort study aiming to include 1000 women. All women who have sustained CRPT will be eligible for inclusion and will be followed-up for 12 months after childbirth. The primary outcome will be perineal infection at 6 weeks post-birth. Secondary outcomes will include antibiotic use for perineal infection, wound breakdown, use of analgesia, the requirement for admission or surgical intervention, urinary and faecal incontinence, anxiety and depressive symptoms, sexual function and impact on daily activities. Outcomes will be measured at 6 weeks, 6 months and 12 months post partum, with some outcomes being measured at all time points and others at selected most appropriate time points only. Outcome data will be obtained from a review of clinical notes and from patient questionnaires. Simple descriptive statistics will be used to summarise characteristics and outcomes, with categorical variables expressed as percentages and continuous variables as mean averages, alongside the corresponding standard deviatons.

ETHICS AND DISSEMINATION

Ethical approval has been granted by the Research Ethics Council with reference 23/WA/0169. Data collected from the Childbirth Acquired Perineal Trauma (CHAPTER) cohort study will highlight the prevalence and type of complications after CRPT and which women are more at risk. After the conclusion of this study, findings will be used to work with governmental organisations and Royal Colleges to target resources and ultimately improve care.

Treatment of Vulvovaginal Laxity by Electroporation: The Jett Plasma Medical for Her II Study

INTRODUCTION

Vaginal laxity is a widespread and undertreated medical condition associated especially with vaginal parity.

AIM

To evaluate the efficacy and safety of electroporation therapy treatment of vulvovaginal laxity by the Jett Plasma for Her II device.

METHODS

The Jett Plasma for Her II Study is a multicentric, prospective, randomized, single-blinded, and controlled study. Women presenting with vaginal laxity were randomized to receive electroporation therapy delivered to the vaginal tissue (active-82 patients) vs. therapy with zero intensity (placebo-9 patients).

RESULTS

A total of 91 subjects whose average age was 48.69 ± 10.89 were included. Due to the results of a one-way analysis of variance, it may be concluded that in the case of the vaginal laxity questionnaire (VLQ), there is a statistically significant difference between actively treated patients and the placebo group (F1,574 = 46.91; p < 0.001). In the case of the female sexual function index (FSFI), a one-way ANOVA test also showed a statistically significant difference between the actively treated patients and the placebo group (F1,278 = 7.97; p = 0.005). In the case of the incontinence impact questionnaire-7 (IIQ-7), a one-way ANOVA test showed a statistically significant difference between the actively treated patients and the placebo group (F1,384 = 15.51; p < 0.001). It confirms that improvement of vaginal laxity is conjoined with benefits in symptoms of urinary incontinence. Biopsy performed after the end of the treatment shows an increase in the vaginal mucosa thickness by an average of 100.04% in the active group. The treatment was well tolerated with no adverse events. No topical anesthetics were required.

CONCLUSIONS

Treatments of vulvovaginal laxity by electroporation therapy achieved significant and sustainable 12-month effectiveness. Responses to the questionnaires also suggest subjective improvement in self-reported sexual function, incontinence, sexual satisfaction, and urogenital distress.

Current Perspectives in Vaginal Laxity Measurement: A Scoping Review

This scoping review aimed to identify and categorize the available measurement options for vaginal laxity (VL), their indications of use, and whether these measurements can sufficiently provide objective clinical judgment for cases indicated for vaginal rejuvenation with many treatment options nowadays. Systematic searches were conducted on five electronic databases, manually searching articles' bibliographies and predetermined key journals with no date or study design limitations. We included all studies involving VL in their inclusion criteria, treatment indications, and outcome parameters. We used the Arksey and O'Malley frameworks as the guideline in writing this scoping review. Of the 9,464 articles identified, 66 articles and 11,258 subjects were included in the final analysis. The majority of studies were conducted in obstetrics and gynecology (73%), followed by plastic surgery (10%), medical rehabilitation (4.5%), dermatology (4.5%), and others (8%). Most studies originated from the North American region (30%). The following measurement tools were used: (1) interviews, (2) questionnaires, (3) physical/digital examinations, (4) perineometers, and (5) others. Our results suggested that subjective perception of laxity confirmed by directed interview or questionnaire is sufficient to confirm VL. Additional evaluation of pelvic floor muscle through digital examination or perineometer or other preferred tools and evaluation of sexual function through validated questionnaire (Female Sexual Function Index, Female Sexual Distress Scale-Revised, etc.) should follow to ensure holistic care to patients. Future research on the psychometric properties (reliability and validity) of commonly used measurements and the correlation in between subjective and objective measurements should be initiated before their clinical applications.

The 50 most cited articles and science mapping analysis of vaginal tightening

INTRODUCTION AND HYPOTHESIS

The study was aimed at exploring the 50 most cited articles related to vaginal tightening.

METHODS

The papers were searched through the Thomson Reuters Web of Science on 30 July 2022, and were ranked by the total number of citations. The included articles were analyzed for author, journal, country, number of citations, keywords, subject matter, and level of evidence. The search output was also imported into VOSviewer.

RESULTS

The 50 most cited articles were cited a combined total of 2,558 times. The papers were published between 1990 and 2020, of which 86% were published between 2010 and 2020. They included 38 original articles, 8 reviews, 3 editorial articles, and 1 letter. Most articles were published in gynecology-related journals (n=30, 60%). The articles covered a wide range of topics, the most common being laser/radiofrequency treatment, vaginal tightening procedures, and urinary incontinence. The majority presented findings supported by level IV or V evidence. Through co-occurrence analysis, high-frequency words and countries were displayed well.

CONCLUSIONS

The study shed light on frequently read articles and influential topics about vaginal tightening. The highly cited literature mainly focused on laser or radiofrequency treatments and gynecologists currently dominate the highly cited literature on vaginal tightening. The articles related to surgical treatments are low in number and evidence level so far. The co-occurrence analysis reveals the hot research content and active countries in the field. In general, the study provides useful evidence for future research and educational materials.

Sexual Function in Women at 6 and 12 Months After Obstetric Anal Sphincter Injury: Is Pelvic Floor Physical Therapy Associated With Improved Outcomes?

IMPORTANCE

Women with obstetric anal sphincter injury (OASI) are at increased risk of postpartum sexual dysfunction. Risk persists beyond 3 years after perineal trauma in up to half of patients with OASI.

OBJECTIVES

The aims of this study were to determine if postpartum pelvic floor physical therapy (PFPT) is associated with improved sexual function after vaginal delivery with OASI and to describe sexual function in patients with OASI at 6 and 12 months postpartum.

STUDY DESIGN

This is a retrospective cohort study of patients with OASI. Women were grouped according to PFPT attendance. The Postpartum Pelvic Floor and Birth Questionnaire (PPFBQ), which compares current sexual function to baseline prepregnancy sexual function, and the Female Sexual Function Index (FSFI) were administered at 6 and 12 months, respectively, to evaluate postpartum sexual function.

RESULTS

Two hundred women were included. Sixty-four (32%) women attended PFPT; 136 (68%) did not attend PFPT. Patients reported worse-than-baseline sexual function at 6 months postpartum in the PPFBQ sexual activity domain, but the PFPT group had lower median score than the non-PFPT group (2.3 [2.0, 2.8] vs 2.7 [2.1, 3.1], P = 0.034), with scores <3.0 indicating worse-than-baseline functioning. The FSFI composite scores were similar between groups and showed 80.7% of the patients with OASI meeting the criteria for female sexual dysfunction at 12 months postpartum. Attendance of PFPT was not significantly associated with composite FSFI scores and most domains of PPFBQ.

CONCLUSIONS

Attendance of PFPT did not significantly impact overall sexual function in OASI patients at 6 and 12 months postpartum. Sexual function is complex and may be more effectively addressed in the postpartum period using a multidimensional approach.

Impact of Obstetric Anal Sphincter Injuries on Postpartum Sexual Function: A Prospective Cohort Study

IMPORTANCE

Sexual dysfunction, which is common in the postpartum period, often does not resolve by 6 months and is likely more severe in women with severe obstetric lacerations.

OBJECTIVES

The aims are to describe sexual function at 6 months postpartum in women who experienced obstetric anal sphincter injury (OASI) and to compare sexual function between women with mild and severe OASI.

STUDY DESIGN

This is a prospective cohort study of women with OASI. At 6 months postpartum, women were surveyed regarding sexual function using the Postpartum Pelvic Floor Birth Questionnaire, which compares current sexual function to sexual function before vaginal birth.

RESULTS

One hundred fifty-one women were included. Eighty-one (53.6%) women had spontaneous vaginal delivery, and 70 (46.4%) had operative vaginal delivery. One hundred seventeen (77.5%) experienced a mild OASI, and 34 (22.5%) experienced a severe OASI. On the Postpartum Pelvic Floor Birth Questionnaire sexual activity domain, median score for all women was 2.6 (interquartile range, 2.1-3.0) with scores <3.0, indicating worse functioning. The sexual activity domain median scores were 2.4 (1.9-3.0) for mild OASI and 2.8 (2.6-3.0) for severe OASI ( P = 0.011), indicating worse scores for women with mild OASI. Within the sexual activity domain, women with mild OASI had worse median scores than women with severe OASI when reporting on enjoyment of sexual activity, frequency of intercourse, and enjoyment during sexual intercourse.

CONCLUSIONS

Women who experience OASI have worse sexual function compared with predelivery. Discussion of sexual function is critical for postpartum women, especially for those who are at increased risk after experiencing OASI.

Hyaluronic Acid and Radiofrequency in Patients with Urogenital Atrophy and Vaginal Laxity

Vaginal laxity (VL) and genitourinary syndrome of menopause (GSM), as well as aesthetic changes in the vulvar skin, often occur together and cause physical, psychological, and functional problems for women and their partners. The current study evaluated the efficacy of a nonsurgical radiofrequency device (RF) procedure combined with hyaluronic acid (HA) injection into the skin of the labia majora on clinical, histological, and aesthetic levels. Twenty women with GSM and VL, aged between 36 and 72 (mean age 53.4), were treated with bipolar RF SECTUM, vaginal and vulvar application, as well as with a hyaluronic acid (HA) injection into the skin of the labia majora. The Vaginal Laxity Questionnaire (VLQ), Vaginal Health Index (VHI), and Female Sexual Function Index (FSFI) were used to examine the clinical effects of the operations. The Global Aesthetic Improvement Scale was utilized to measure patient satisfaction. On a histochemical level, the concentrations of elastin and collagen in the vaginal wall and vulvar skin were examined. Results: There was significantly higher patient satisfaction and a considerable clinical improvement across all areas of analysis. On the histochemical level, elastin and collagen fiber concentration increased after the treatment protocol both in the vulvar skin and in the vaginal wall: elastin in the vaginal wall, 11.4%, and in the vulvar skin, 61%; collagen in the vaginal wall, 26%, and in the vulvar skin, 27%. The current study demonstrated the efficacy and safety of this nonsurgical RF procedure combined with a hyaluronic acid (HA) injection into the skin of the labia majora on clinical, histochemical, and aesthetic levels.

Episiotomy in vacuum extraction, do we cut the levator ani muscle? A prospective cohort study

INTRODUCTION AND HYPOTHESIS

Vaginal delivery may lead to levator ani muscle (LAM) injury or avulsion. Episiotomy may reduce obstetric anal sphincter injury in operative vaginal delivery, but may increase the risk of LAM injury. Our aim was to assess whether lateral episiotomy in vacuum extraction (VE) in primiparous women causes LAM injury.

METHODS

A prospective cohort study of 58 primiparous women with episiotomy nested within an ongoing multicenter randomized controlled trial of lateral episiotomy versus no episiotomy in VE (EVA trial) was carried out in Sweden. LAM injury was evaluated using 3D endovaginal ultrasound 6-12 months after delivery and Levator Ani Deficiency (LAD) score. Episiotomy scar properties were measured. Characteristics were described and compared using Chi-squared tests. We stipulated that if a lateral episiotomy cuts the LAM, ≥50% would have a LAM injury. Among those, ≥50% would be side specific. We compared the observed prevalence with a test of one proportion.

RESULTS

Twelve (20.7%, 95% CI 10.9-32.9) of 58 women had a LAD (p < 0.001, compared with the stipulated 50%). Six (50.0%, 95% CI 21.1% to 78.9%) of 12 women had a LAD on the episiotomy side, including those with bilateral LAD (p = 1.00). Two (16.7%, 95% CI 2.1% to 48.4%) of 12 women had a LAD exclusively on the episiotomy side (p = 0.02).

CONCLUSIONS

There was no excessive risk of cutting the LAM while performing a lateral episiotomy. LAD was not seen in women with episiotomies shorter than 18 mm.

Micro-Focused Ultrasound Therapy in Patients with Urogenital Atrophy and Vaginal Laxity

Vaginal laxity (VL) and genitourinary syndromes of menopause (GSM) create physical, psychological, and functional problem for women and their partners. We aimed to evaluate the efficacy and safety of micro-focused ultrasound (MFU) therapy performed twice in the vaginal canal in a patients with VL and GSM. A total of 20 women with GSM and VL were treated with MFU Ultravera by Hironic. The treatment course consisted of two vaginal applications of MFU at an interval of 6 weeks. The clinical effects of the protocol were evaluated using the Vaginal Laxity Questionnaire (VLQ), the Vaginal Health Index (VHI), and the Female Sexual Function Index (FSFI). The overall values of the vaginal laxity evaluation for the total subject population showed a statistically significant improvement between the baseline and the findings at 3 and 6 months after treatment. The effect of therapy was consistent across all domains of FSFI. It peaked at the 6 week follow-up visit (from 26.5 to 32) and plateaued at 12 weeks and 6 months. There was a significant VHI improvement over time, with the greatest and most significant change between the study entry and 21 days after treatment; the VHI score leveled off up to 3 months after the procedures. MFU therapy, performed twice in the vaginal canal, showed promising efficacy and safety profiles, meriting further investigation.

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

Introduction

Pelvic floor trauma in the form of partial or complete avulsions of the levator ani muscle (LAM) affects 6-42% of women after vaginal birth and can cause tremendous long-term morbidity. Many studies assessed morphological pelvic floor trauma after childbirth but lacked to evaluate women's associated short-term complaints. A proper assessment of trauma and subjective complaints after birth could help to assess possible associations between them and their relevance to women's daily life. Therefore, we aimed to assess women's complaints within the first months after birth in association to their LAM trauma.

Materials and Methods

Between 3/2017 and 4/2019, we prospectively evaluated vaginal births of 212 primiparous women with singletons in vertex presentation ≥ 36 + 0 gestational weeks for levator ani muscle (LAM) trauma by translabial ultrasound, for pelvic organ prolapse by clinical examination, and for urogynecological complaints using questionnaires 1-4 days (P1), 6-10 weeks (P2), and 6-9 months (P3) after birth. The questionnaires were self-designed but oriented to and modified from validated questionnaires. Women's complaints were evaluated for P1-P3 according to their LAM trauma state.

Results

At P1, 67% of women showed an intact LAM, whereas 14.6% presented a hematoma, 6.6% a partial avulsion (PAV), and 11.8% a complete avulsion (CAV). At P2, 75.9% showed an intact LAM, 9.9% a PAV, and 14.2% a CAV. At P3, 72.9% of women with a LAM trauma in P1 and/or P2 were assessed with 21.6% being intact and 39.2% having a PAV and CAV, respectively. Obstetrical and baseline characteristics differed slightly between the groups. When comparing the time before and during pregnancy with the time after childbirth, birth itself affected women's complaints in all LAM state groups, but the presence of a LAM trauma, especially a CAV, had more negative effects.

Conclusions

Vaginal birth changes the anatomical structure of the maternal birth canal and genital tract, and it alters women's perceptions and body function. In our study, LAM trauma did not change these effects tremendously within the first months. Therefore, other maternal, fetal, and obstetrical factors need consideration for the explanation of maternal complaints, in addition to long-term effects of trauma and dysfunction of the LAM and other birth canal structures.

Effects of Different Delivery Modes on Pelvic Floor Function in Parturients 6–8 Weeks after Delivery Using Transperineal Four-Dimensional Ultrasound

Objective

To evaluate the effects of different delivery modes on pelvic floor function in parturients 6–8 weeks after delivery using transperineal four-dimensional ultrasound.

Methods

Pelvic floor function 6–8 weeks after delivery in 40 vaginal delivery parturients between November 2018 and December 2020 was assessed by four-dimensional ultrasound, with 40 selective cesarean section delivery parturients as a control group. The imaging results of the two groups were compared.

Results

The levels of clinical indexes such as UVJ-M, A_r, A_v, θ, D_r, D_v, and ARJ-VDv in the selective cesarean section group were significantly lower than those in the vaginal delivery group 6–8 weeks after delivery (P < 0.05). However, no significant difference in CV-VD was observed under Valsalva action and at rest between the two groups (P > 0.05). No significant difference in ARJ-VD was found at rest between the two groups (P > 0.05). The incidence of pelvic organ prolapse in the selective cesarean section group (40.0%) was significantly lower than that in the vaginal delivery group (62.5%) (P < 0.05). No significant difference in the parameters of pelvic diaphragm hiatus at rest was observed between the two groups (P > 0.05). The parameters of pelvic diaphragm hiatus under maximum Valsalva action in the vaginal delivery group were significantly higher than those in the selective cesarean section group (P < 0.05). Whether the patient was complicated with diabetes had no significant effect on the functional injury of pelvic floor muscle (P > 0.05).

Conclusion

The pelvic floor function 6–8 weeks after delivery was significantly more affected in vaginal delivery than in selective cesarean section. Selective cesarean section had certain but limited protective effect on maternal pelvic floor tissue.

The Relationship Between Pelvic Floor Function and Sexual Function in Perimenopausal Women

INTRODUCTION

Perimenopausal women with pelvic floor dysfunction have worse sexual function than women with functional pelvic floor muscle (PFM), especially in terms of libido, orgasm, sexual satisfaction, and total Female Sexual Function Index (FSFI) scores.

AIM

To explore the relationship between pelvic floor muscle function, hormone levels and sexual function in perimenopausal women.

METHODS

An analytical cross-sectional study was conducted in 252 women aged 40-55 without pelvic floor disease with FSFI, pelvic floor muscle strength and the hormone levels.

MAIN OUTCOME MEASURE

The principle aim was to determine the relationships between sexual dysfunction, PFM strength, and hormone levels.

RESULTS

In the functional PFM group, the proportion of menopausal hormone therapy was higher. The proportion of overweight in the dysfunctional PFM group was higher, and had more sexual desire disorder, more orgasm disorder, lower sexual satisfaction, and poor FSFI scores. The correlation between PFM strength, sexual function and female sex hormones suggested that PFM strength and libido, sexual satisfaction and FSFI score are significantly positively correlated, while PFM strength and sexual arousal disorder and vaginal lubricity had a positive correlation. In the multivariate analysis of the risk of sexual dysfunction among perimenopausal women, the higher the PFM strength, the lower the risk of sexual dysfunction.

CONCLUSIONS

Perimenopausal women with pelvic floor dysfunction have worse sexual function than women with functional PFM, especially in obese women, those with central adiposity, and not using hormone replacement therapy. The PFM strength was weakly positively correlated with sexual arousal, orgasm, sexual satisfaction, and FSFI score. Zhuo Z, Wang C, Yu H, et al. The Relationship Between Pelvic Floor Function and Sexual Function in Perimenopausal Women. Sex Med 2021;9:100441.

Recognition and Management of Pelvic Floor Disorders in Pregnancy and the Postpartum Period

Often considered a condition of aging women, pelvic floor disorders may initially present in pregnancy and postpartum, having a negative impact on quality of life during this important time in a woman's life. This review outlines the clinical approach to implementing pelvic health into obstetric care through education and promotion of pelvic health in pregnancy, screening for pelvic floor disorders routinely, and providing support through resources, treatment, and referrals if pelvic floor disorders develop during pregnancy and postpartum.

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.

Is vaginal laxity an early symptom of pelvic organ prolapse?

INTRODUCTION AND HYPOTHESIS

We aimed to determine whether vaginal laxity (VL) may be an early symptom of pelvic organ prolapse (POP).

METHODS

This was a retrospective observational study including patients referred to a urogynecological clinic owing to symptoms of pelvic floor dysfunction. The interview included inquiry about VL and POP symptoms. Clinical examination and translabial ultrasound (TLUS) were performed to assess for POP and levator hiatal ballooning. Analysis of ultrasound datasets was performed with the reviewer blinded against all other data. Linear regression models were used to evaluate associations between age categories and symptoms.

RESULTS

The analysis included 531 patients. Mean age was 59.7 years (range 17.6-92.0), mean body mass index (BMI) was 29.5 kg/m² (14.7-53.5) and 458 (86%) were vaginally parous. Overall, POP symptoms were reported by 258 patients (49%) and VL by 118 (22%). Significant clinical POP was diagnosed in 384 patients (72%). Levator hiatal ballooning on TLUS was noticed in 56%. VL and POP symptoms showed a divergent association with age (p = 0.02). This trend remained significant after controlling for clinically significant POP (p = 0.01) and levator hiatal ballooning (p = 0.002). Of 384 women with significant objective POP, 231 (60%) reported symptoms of POP. Of 153 women with asymptomatic POP, 7 (5%) reported symptoms of VL.

CONCLUSIONS

With increasing age the prevalence of VL decreases, whereas symptoms of POP increase. However, only very few women with objective POP perceive VL as their only symptom, independent of age at presentation. Therefore, vaginal laxity does not seem to be an early symptom of prolapse.

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.

Peripartum pelvic floor disorder clinics inform obstetric provider practices

INTRODUCTION AND HYPOTHESIS

The objective of this study is to evaluate obstetric providers' knowledge and practice patterns since the establishment of a peripartum pelvic floor disorder clinic.

METHODS

This is a prospective, cross-sectional survey study of obstetric providers at an academic tertiary care health system. A 22-question survey was designed to collect provider demographic data, indications for and barriers to referrals, provider satisfaction, and impact of the clinic's existence on peripartum pelvic floor dysfunction diagnosis and management. Eligibility criteria included obstetrics and gynecology trainees, attending physicians, certified nurse midwives, and advanced practice providers.

RESULTS

There were 86 survey responses yielding a response rate of 72.1%. The majority of respondents were staff obstetricians (57.0%) or trainees (26.7%). Most commonly reported referral indications were third- and fourth-degree lacerations (94.9%), complex lacerations (70.5%), wound breakdown (57.7%), and urinary retention (53.8%). Regarding satisfaction with the peripartum pelvic floor disorder clinic, of referring providers, 77 (98.7%) agreed or strongly agreed that evaluations were useful for patients and 78 (100%) agreed or strongly agreed that evaluations were useful for themselves. Seventy-six (97.4%) respondents reported that they were very satisfied with the peripartum pelvic floor disorder clinic overall. The majority of respondents agreed or strongly agreed that the clinic increased their awareness of both obstetric anal sphincter injuries and their impact on maternal health (84.6%).

CONCLUSION

The introduction of a peripartum pelvic floor disorder clinic results in high obstetric provider satisfaction and positively impacts patient care through increased provider knowledge and awareness on the management of obstetric anal sphincter injuries.

Vaginal laxity: which measure of levator ani distensibility is most predictive?

OBJECTIVE

To assess the predictive value of measures of levator hiatal distension at rest and on maximum Valsalva maneuver for symptoms of vaginal laxity.

METHODS

This was a retrospective study of women seen at a tertiary urogynecological unit. All women underwent a standardized interview, clinical examination and four-dimensional translabial ultrasound examination. Area, anteroposterior diameter (APD) and coronal diameter (CD) of the levator hiatus were measured at rest and on maximum Valsalva maneuver in the plane of minimal hiatal dimensions using the rendered volume technique, by an operator blinded to all clinical data. The association between levator hiatal measurements and vaginal laxity was assessed, and receiver-operating-characteristics (ROC)-curve analysis was used to determine their predictive value.

RESULTS

Data from 490 patients were analyzed. Mean age was 58 (range, 18-88) years, and vaginal laxity was reported by 111 (23%) women. Measurements obtained on maximum Valsalva were significantly larger in women who reported vaginal laxity than in those who did not, with mean levator hiatal area, APD and CD of 30.45 ± 8.74 cm² , 7.24 ± 1.16 cm and 5.60 ± 0.89 cm, respectively, in the vaginal-laxity group, compared with 24.84 ± 8.63 cm² , 6.64 ± 1.22 cm and 5.01 ± 0.97 cm in the no-laxity group (P < 0.001 for all). Measurements obtained at rest were not significantly different between the groups. Multiple logistic regression analysis controlling for age, body mass index, vaginal parity and levator avulsion confirmed these results. The best regression model for the prediction of vaginal laxity included age, vaginal parity and levator hiatal area on maximum Valsalva. ROC-curve analysis of levator hiatal measurements on maximum Valsalva in the prediction of vaginal laxity demonstrated areas under the curve of 0.68 (95% CI, 0.63-0.73) for area, 0.63 (95% CI, 0.57-0.68) for APD and 0.68 (95% CI, 0.62-0.73) for CD.

CONCLUSIONS

Levator hiatal area on maximum Valsalva seems to be the measure of levator ani distensibility that is most predictive of symptoms of vaginal laxity. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Association between sexual dysfunction and avulsion of the levator ani muscle after instrumental vaginal delivery

INTRODUCTION

The effects of levator ani muscle (LAM) avulsion after instrumental delivery on the sexual function of patients are currently unknown. Therefore, the objective of our study was to use a validated questionnaire, namely, the Female Sexual Function Index (FSFI), to compare the sexual function in patients with and without LAM avulsion after instrumental vaginal delivery.

MATERIAL AND METHODS

This was a prospective observational study of 112 primiparous women after instrumental (vacuum or forceps) vaginal delivery. The obstetric and general characteristics of the population were studied. At 6 months postpartum, the contraceptive method used and the occurrence of LAM avulsion (using four-dimensional transperineal ultrasound) were determined, and the FSFI was administered.

RESULTS

A total of 100 patients (62 without avulsion and 38 with avulsion) completed the study. Thirty-eight (38%) were diagnosed with avulsion (42.1% after Kielland forceps delivery, 57.9% after Malmström vacuum delivery; P = .837). Women with LAM avulsion had significantly lower scores for desire (2.9 ± 1.2 vs 3.4 ± 1.1; P = .049), arousal (2.8 ± 1.7 vs 3.6 ± 1.4; P = .014), lubrication (2.3 ± 1.4 vs 3.0 ± 1.2; P = .011), orgasm (2.6 ± 1.6 vs 3.3 ± 1.2; P = .006) and satisfaction (3.1 ± 1.8 vs 3.9 ± 1.5; P = .051) than did women without LAM avulsion. The overall FSFI score was lower in patients with avulsion (16.7 ± 8.9 vs 20.7 ± 6.9, P = .033). These results were obtained after controlling for confounders (delivery mode, induced labor, birthweight, perineal tears, avulsion degree, contraceptive method and group assignment for the parent study) in the multivariate analysis (F = 4.974, P = .001).

CONCLUSIONS

Patients with LAM avulsion present a higher degree of sexual dysfunction compared wiith patients without avulsion at 6 months after instrumental vaginal delivery.

Postpartum sexual function; the importance of the levator ani muscle

Introduction and hypothesis

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

Methods

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

Results

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

Conclusions

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

Concordance of tomographic ultrasound and multiplanar ultrasound in detecting levator ani muscle injury in patients with pelvic organ prolapse

Aim

To compare the evaluations of evaluate levator ani muscle injury (LAMI) by tomographic ultrasound imaging (TUI) and multiplanar (MP) ultrasound in patients with pelvic organ prolapse (POP).

Method

This retrospective analysis studied women who underwent International Continence Society POP quantification examination between October 2015 and June 2016. LAMI was assessed by both TUI and MP ultrasounds. Concordance of these two testing results was analyzed. Their correlations with clinical symptoms were also studied.

Results

A total of 135 women were included. All the patients with POP had a minimal LAMI depth ≥ 7 mm. Two examinations, TUI and MP, had satisfactory concordance (k = 0.71, P < 0.01). Depth of LAMI in the coronal plane demonstrated good agreement with TUI scores (r = 0.84; P < 0.01). After controlling for age, BMI, and parity, to have clinically significant POP and POP symptoms, the odds ratios (ORs) for the depth of LAMI in the coronal plane were 1.31 (95% CI 1.19–1.44) and 1.25 (95% CI 1.14–1.36), and for TUI scores were 1.72 (95% CI 1.37–2.17) and 1.63 (95% CI 1.31–2.03). Receiver operating characteristic curve analyses showed a cutoff depth of 7 mm of LAMI yielded a sensitivity of 62% and specificity of 80% for POP symptoms.

Conclusions

TUI and MP had satisfactory concordance in detecting LAMI and correlated with clinical symptoms of POP.

Body after baby: a pilot survey of genital body image and sexual esteem following vaginal birth

OBJECTIVE

The aim of this study was to determine acceptability of the Vaginal Changes Sexual and Body Esteem (VSBE) scale for women post childbirth and explore the association between childbirth events and sexual/body esteem.

DESIGN

This is a cross-sectional study within the Evaluating Maternal Recovery from Labor and Delivery study.

SETTING

This study was conducted in a community setting.

POPULATION

The study was conducted in women post first vaginal birth with birth events that posed risk factors for levator ani muscle tears.

METHODS

Survey, magnetic resonance images of levator ani, and physical examination were the data collected 8 months postpartum. Birth variables were collected by hospital chart review. Descriptive analysis of VSBE response rates and distribution of responses was conducted. An exploratory analysis of the potential association of demographic, birth, clinical, and magnetic resonance image characteristics with VSBE scores was conducted.

MAIN OUTCOME MEASURES

The outcome measure used in this study is VSBE scale.

RESULTS

The majority of participants (97%) completed the scale, with responses to most questions skewed toward positive sexual/body esteem, with the exception of sexual enjoyment, where 38% indicated some interference due to genital changes. The scale showed high internal consistency (alpha =0.93). In the exploratory analysis of potential characteristics associated with VSBE, women with episiotomies had lower sexual/body esteem compared to those who did not (median VSBE scores 35 vs 42.5, P=0.01). Anal sphincter tear was not associated with sexual/body esteem (P=0.78). Additional study is indicated to further explore observed trends toward the association of severe levator ani tear, maternal age at childbirth, and forceps with VSBE scores.

CONCLUSION

The VSBE is suitable for use to assess sexual/body esteem in women post childbirth. Most women in this sample did not indicate negative genital body image/sexual esteem. However, some indicated that the changes post birth negatively affected their sexual/body esteem, particularly those who had episiotomies.

Pelvic floor morphometry and function in women with and without puborectalis avulsion in the early postpartum period

BACKGROUND

Pelvic floor muscles are subject to considerable stretching during vaginal birth. In 13-36% of women, stretching results in avulsion injury whereby the puborectalis muscle disconnects from its insertion points on the pubis bone. Until now, few studies have investigated the effect of this lesion on pelvic floor muscles in the early postpartum period.

OBJECTIVE

The primary aim of this study was to compare pelvic floor muscle morphometry and function in primiparous women with and without puborectalis avulsion in the early postpartum period. Our secondary objective was to compare the 2 groups for pelvic floor disorders and impact on quality of life.

STUDY DESIGN

In all, 52 primiparous women diagnosed with (n = 22) or without (n = 30) puborectalis avulsion injury were assessed at 3 months postpartum. Pelvic floor muscle morphometry was evaluated with 3-/4-dimensional transperineal ultrasound at rest, maximal contraction, and Valsalva maneuver. Different parameters were measured in the midsagittal and axial planes: bladder neck position, levator plate angle, anorectal angle, and levator hiatus dimensions. The dynamometric speculum was used to assess pelvic floor muscle function including: passive properties (passive forces and stiffness) during dynamic stretches, maximal strength, speed of contraction, and endurance. Pelvic floor disorder-related symptoms (eg, urinary incontinence, vaginal and bowel symptoms) and impact on quality of life were evaluated with the International Consultation on Incontinence Questionnaire and the Pelvic Floor Impact Questionnaire-Short Form. Pelvic Organ Prolapse Quantification was also assessed.

RESULTS

In comparison to women without avulsion, women with avulsion presented an enlarged hiatus area at rest, maximal contraction, and Valsalva maneuver (P ≤ .013) and all other ultrasound parameters were found to be significantly altered during maximal contraction (P ≤ .014). They showed lower passive forces at maximal and 20-mm vaginal apertures as well as lower stiffness at 20-mm aperture (P ≤ .048). Significantly lower strength, speed of contraction, and endurance were also found in women with avulsion (P ≤ .005). They also presented more urinary incontinence symptoms (P = .040) whereas vaginal and bowel symptoms were found to be similar in the 2 groups. Pelvic Organ Prolapse Quantification revealed greater anterior compartment descent in women with avulsion (P ≤ .010). The impact of pelvic floor disorders on quality of life was found to be significantly higher in women with avulsion (P = .038).

CONCLUSION

This study confirms that pelvic floor muscle morphometry and function are impaired in primiparous women with puborectalis avulsion in the early postpartum period. Moreover, it highlights specific muscle parameters that are altered such as passive properties, strength, speed of contraction, and endurance.

Vibrating vaginal balls to improve pelvic floor muscle performance in women after childbirth: a protocol for a randomised controlled feasibility trial

AIM

This paper presents a feasibility trial protocol the purpose of which is to prepare for a future randomised controlled trial to determine the effectiveness of vibrating vaginal pelvic floor training balls for postpartum pelvic floor muscle rehabilitation.

BACKGROUND

Vibrating vaginal pelvic floor training balls are available in Austria to enhance women's pelvic floor muscles and thus prevent or treat urinary incontinence and other pelvic floor problems following childbirth. Nonetheless, there is currently little empirical knowledge to substantiate their use or assess their relative effectiveness in comparison to current standard care, which involves pelvic floor muscle exercises.

DESIGN

Single blind, randomised controlled feasibility trial with two parallel groups.

METHODS

It is planned to recruit 56 postpartum women in Vienna, who will be randomised into one of two intervention groups to use either vibrating vaginal balls or a comparator pelvic floor muscle exercises for 12 weeks. As this is a feasibility study, study design features (recruitment, selection, randomisation, intervention concordance, data collection methods and tools) will be assessed and participants' views and experiences will be surveyed. Tested outcome measures, collected before and after the intervention, will be pelvic floor muscle performance as reported by participants and measured by perineometry. Descriptive and inferential statistics and content analysis will serve the preparation of the future trial.

DISCUSSION

The results of this feasibility trial will inform the design and conduct of a full randomised controlled trial and provide insight into the experiences of women regarding the interventions and study participation.

Delivery mode and pelvic organ prolapse: a retrospective observational study

OBJECTIVE

To analyse the associations between delivery mode and symptoms and signs of pelvic organ prolapse (POP) in a cohort of symptomatic women.

DESIGN

Retrospective observational study.

POPULATION

A total of 1258 consecutive women attending a tertiary urogynaecological unit for the investigation of lower urinary tract or pelvic floor disorders between January 2012 and December 2014.

METHODS

Obstetric history and clinical examination data were obtained from the unit database. Prolapse quantification on imaging was performed using stored four-dimensional translabial ultrasound volume data sets. Women were grouped into four groups according to the most traumatic delivery reported. The presence of symptoms and signs of POP were compared between delivery groups while controlling for potential confounders.

MAIN OUTCOME MEASURES

Prolapse symptoms, visual analogue score for prolapse bother, International Continence Society Prolapse Quantification System findings and ultrasound findings of anterior, central and posterior compartment descent.

RESULTS

Nulliparae showed the lowest prevalence of most measures of POP, followed by women exclusively delivered by caesarean section. Highest prevalences were consistently found in women delivered at least once by forceps, although the differences between this group and women delivered by normal vaginal delivery and/or vacuum extraction were significant in three out of eight measures only. Compared with women in the caesarean section group, the adjusted odds ratios for reporting symptoms of prolapse were 2.4 (95% CI 1.30-4.59) and 3.2 (95% CI 1.65-6.12) in the normal vaginal delivery/vacuum extraction group and forceps group, respectively.

CONCLUSIONS

There is a clear link between vaginal delivery and symptoms and signs of pelvic organ prolapse in urogynaecological patients.

TWEETABLE ABSTRACT

Compared with caesarean section a history of vaginal delivery more than doubles the risk for POP.

Impact of levator trauma on pelvic floor muscle function

INTRODUCTION AND HYPOTHESIS

Levator trauma is common after vaginal delivery, either as macrotrauma, i.e., levator avulsion, or microtrauma, i.e., irreversible overdistension of the levator hiatus. The effect of microtrauma on muscle function is unknown. We tested the hypothesis that levator trauma is associated with reduced contractile function of the levator ani.

METHODS

Pregnant nulliparous women were recruited and seen before and after childbirth. All underwent an interview, a clinical examination including pelvic floor muscle (PFM) assessment using the Modified Oxford scale (MOS) [as an optional component] and translabial ultrasound. Sonographic and clinical parameters of PFM function were assessed before and after childbirth.

RESULTS

Out of 560 women, 446 returned at a median of 5 months after childbirth and 433 were suitable for analysis. There was a significant reduction in all measures of PFM function except for MOS. Change in MOS was associated with delivery mode [analysis of variance (ANOVA) P = 0.006). Forty-seven (15 %) vaginally parous women were diagnosed with levator avulsion, which was associated with a reduction in PFM contractility on sonographic parameters and MOS. However, only clinical assessment reached statistical significance. Sixty-five of 312 (21 %) women were diagnosed with microtrauma. We found no evidence of impairment in PFM contractility on ultrasound, but there was a statistically significant reduction in MOS.

CONCLUSIONS

Both levator avulsion (macrotrauma) and irreversible overdistension (microtrauma) are associated with reduced contractile function. This effect is more easily detected by palpation than by sonographic indices of levator function.