Levator ani defects and the severity of symptoms in women with anterior compartment pelvic organ prolapse

Diagnosis of maternal birth trauma by pelvic floor ultrasound

BRIEF SUMMARY

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

The association between levator plate integrity and pelvic floor defaecatory dysfunction

AIMS

Levator ani deficiency has been implicated in anterior pelvic floor pathology but its association with pelvic floor defaecatory dysfunction is less clear. The aim was to examine the relationship of levator ani deficiency with anatomical abnormalities (rectocoele, intussusception, enterocoele, perineal descent) and patient symptoms (bowel, vagina) in patients with pelvic floor defaecatory dysfunction.

METHODS

The prospective observational case series of 223 women presenting to a tertiary colorectal pelvic floor unit with defaecatory dysfunction. Each underwent assessment with symptom severity and quality of life (QoL) scores, integrated total pelvic floor ultrasound (PFUS) (transvaginal, transperineal) and defaecation proctography (DP). Rectocoele, intussusception, enterocoele and perineal descent were assessed on both. Levator ani deficiency was scored using endovaginal ultrasound (score 0-18; mild [0-6], moderate [>6-12], severe [>12-18]).

RESULTS

The proportion of patients with rectocoele, enterocoele, and intussusception increased with increasing levator ani damage (mild, moderate, severe). There was a weakly positive correlation between size of rectocoele and levator ani deficiency. On PFUS, there was a weakly positive correlation between severity of intussusception and enterocoele with levator ani deficiency. On DP, there was a weakly positive correlation between perineal descent and levator ani deficiency. There was no association between bowel symptom and QoL scores and levator ani deficiency. Vaginal symptoms were associated with levator ani deficiency.

CONCLUSIONS

Anatomical abnormalities which are implicated in pelvic floor defaecatory dysfunction (rectocoele, intussusception, enterocoele, perineal descent) were associated with worsening levator ani deficiency. There was no association between bowel symptoms and levator ani deficiency. Vaginal symptoms were associated with levator ani deficiency.

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

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

Ultrasonographic Imaging of the Pelvic Floor

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

Natural history of levator ani muscle avulsion 4 years following childbirth

OBJECTIVES

The primary aim was to evaluate prospectively the natural history of levator ani muscle (LAM) avulsion 4 years following first delivery and its correlation with signs and symptoms of pelvic floor dysfunction (PFD). The secondary aim was to investigate the effect of a second vaginal delivery on the incidence of LAM avulsion and PFD.

METHODS

This was a prospective longitudinal study of nulliparous women recruited antenatally, who were assessed at 36 weeks' gestation and 3 months, 1 year and 4 years postpartum for signs and symptoms of PFD and presence of LAM avulsion. Pelvic floor muscle strength was assessed by digital palpation, and pelvic organ prolapse (POP) was assessed using the POP quantification (POP-Q) system. Validated questionnaires were used to evaluate urinary, bowel and sexual function and symptoms of POP. Transperineal ultrasound was performed to assess LAM integrity and hiatal biometry. Differences in signs and symptoms of PFD over time were evaluated using a linear mixed model, separately in women who had had one delivery and in those who had two or more deliveries during the study period.

RESULTS

Of 269 women recruited, 147 (55%) attended the 4-year follow-up and were examined at a mean interval of 3.8 ± 0.4 years after their first delivery. Of these, 74 (50%) had a subsequent delivery. The prevalence of LAM avulsion 4 years after a first vaginal delivery was 13%, with no difference between women who had one and those who had two or more vaginal deliveries. Women with an intact LAM and one or more deliveries showed no change in signs and symptoms of PFD at 4 years compared with the previous assessments. Of women with one vaginal delivery who were diagnosed with LAM avulsion 3 months or 1 year postpartum, those in whom the LAM avulsion was no longer evident at 4 years (42%) showed worsening of POP-Q measurements, whereas those with persistent LAM avulsion (58%) showed significant worsening in pelvic floor muscle strength and hiatal area on ultrasound. After a second vaginal delivery, no new avulsions were diagnosed, however, previous LAM avulsion became more extensive in 44% of women and hiatal area increased in women with persistent LAM avulsion.

CONCLUSIONS

The first vaginal delivery carries the greatest risk for LAM avulsion, with impact on signs of PFD 4 years later. A second vaginal delivery could result in deterioration of LAM avulsion, but no new avulsions were found. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Four-Dimensional Introital Ultrasound in Assessing Perioperative Pelvic Floor Muscle Functions of Women with Cystoceles

PURPOSE

 Research on the use of ultrasound to explore the pelvic floor in women is rarely done with introital ultrasound. This study aimed to investigate the performance of four-dimensional (4D) introital ultrasound in the perioperative assessment of pelvic floor muscle (PFM) function in women with cystocele.

MATERIALS AND METHODS

 The reliability and agreement of ultrasound measurements were determined by intraclass correlation coefficients (ICC) with 95 % confidence interval and Bland-Altman analysis in 20 women. The validity of ultrasound parameters was assessed by correlating squeezing ultrasound measurements with the modified Oxford scale (MOS) in 317 women. 4D introital ultrasound data of 241 women with (n = 29) and without (n = 212) postoperative cystocele at the 12-month postoperative assessment were retrospectively analyzed. Levator avulsion was diagnosed using tomographic ultrasound imaging. Involuntary and voluntary PFM functions were explored by dynamic changes in the bladder neck and genital hiatus, respectively, upon coughing and squeezing on 4D introital ultrasound.

RESULTS

 The ICC for the reliability of all tested ultrasound parameters was good to very good. The changes and change ratios of most ultrasound measurements from resting to squeezing were fairly correlated with MOS. Women with postoperative cystocele demonstrated more rates of complete levator avulsion [41.3 % vs. 4.7 %, P < 0.001, odds ratio (OR) 14.26, 95 % confidence interval (CI) 4.88-42.42] and fewer rates of capable voluntary PFM contraction (65.5 % vs. 92.5 %, P < 0.001, OR 0.16, 95 % CI 0.06-0.43) than those without postoperative cystocele postoperatively.

CONCLUSION

 4D introital ultrasound is feasible to assess perioperative PFM function in women with cystocele.

Multimodality imaging of pelvic floor anatomy

The pelvic floor is composed of a network of muscles, ligaments, and fasciae, which provide active and passive support for the pelvic organs. Impairment of these pelvic floor elements can result in a variety of functional abnormalities and single or multicompartment organ prolapse. Knowledge of normal pelvic floor anatomy can aid the radiologist in understanding the complex nature of pelvic floor dysfunction and is important for comprehensive image interpretation. This article provides an overview of normal anatomy of the pelvic floor as seen on magnetic resonance imaging, ultrasound, and fluoroscopic studies performed in the evaluation of pelvic floor function.

Ultrasound imaging of maternal birth trauma

INTRODUCTION AND HYPOTHESIS

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

METHODS

Narrative review.

RESULTS

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

CONCLUSIONS

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

Ultrasound assessment of pelvic floor muscle contraction: reliability and development of an ultrasound-based contraction scale

OBJECTIVES

To determine intra- and interrater reliability and agreement for ultrasound measurements of pelvic floor muscle contraction and to assess the correlation between ultrasound and vaginal palpation. We also aimed to develop an ultrasound scale for assessment of pelvic floor muscle contraction.

METHODS

This was a cross-sectional study of 195 women scheduled for stress urinary incontinence (n = 65) or prolapse (n = 65) surgery or who were primigravid (n = 65). Pelvic floor muscle contraction was assessed by vaginal palpation using the Modified Oxford Scale (MOS) and by two- and three-dimensional (2D/3D) transperineal ultrasound. Proportional change in 2D and 3D levator hiatal anteroposterior (AP) diameter and 3D levator hiatal area between rest and contraction were used as measures of pelvic floor muscle contraction. One rater repeated all ultrasound measurements on stored volumes, which were used for intrarater reliability and agreement analysis, and three independent raters analyzed 60 ultrasound volumes for interrater reliability and agreement analysis. Reliability was assessed using the intraclass correlation coefficient (ICC) and agreement using Bland-Altman analysis. Tomographic ultrasound was used to identify women with major levator injury. Spearman's rank correlation coefficient (r_S ) was used to assess the correlation between ultrasound measurements of pelvic floor muscle contraction and MOS score. The proportion of women allocated to each category of muscle contraction (absent, weak, moderate or strong) by palpation was used to determine the cut-offs for the ultrasound scale.

RESULTS

Intrarater ICC was 0.81 (95% CI, 0.74-0.85) for proportional change in 2D levator hiatal AP diameter. Interrater ICC was 0.82 (95% CI, 0.72-0.89) for proportional change in 2D AP diameter, 0.80 (95% CI, 0.69-0.88) for proportional change in 3D AP diameter and 0.72 (95% CI, 0.56-0.83) for proportional change in hiatal area. The prevalence of major levator injury was 22.6%. The strength of correlation (r_S ) between ultrasound measurements and MOS score was 0.52 for 2D AP diameter, 0.62 for 3D AP diameter and 0.47 for hiatal area (P < 0.001 for all). On the ultrasound contraction scale, proportional change in 2D levator hiatal AP diameter of < 1% corresponds to absent, 2-14% to weak, 15-29% to normal and > 30% to strong contraction.

CONCLUSIONS

Ultrasound seems to be an objective and reliable method for evaluation of pelvic floor muscle contraction. Proportional change in 2D levator hiatal AP diameter had the highest ICC and moderate correlation with MOS score assessed by vaginal palpation, and we constructed an ultrasound scale for assessment of pelvic floor muscle contraction based on this measure. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Impact of levator muscle avulsions on Manchester procedure outcomes in pelvic organ prolapse surgery

INTRODUCTION

Levator ani muscle avulsions potentially increase recurrence after anterior colporrhaphies. We aimed at evaluating the impact of avulsions on anatomical and patient-reported outcomes 1 year after the Manchester procedure for primary anterior compartment pelvic organ prolapse.

MATERIAL AND METHODS

Prospective cohort study of 189 women undergoing the Manchester procedure between October 2014 and January 2017. Avulsions were diagnosed by transperineal ultrasound. Women with and without avulsions were compared for 1-year postoperative outcomes; Pelvic Organ Prolapse Quantification measurements, subjective satisfaction (1-worse to 4-cured), failure (new prolapse treatment), response to validated questionnaires on pelvic floor distress and sexual function, and a composite outcome (subjectively cured and optimal anterior compartment outcome (stage 0-I)). Optimal mid-compartment outcome was defined as cervix ≥5 cm above the hymen. Factors potentially associated with poor anatomical outcomes (anterior compartment stage ≥II) or pelvic floor distress were analyzed using regression analyses.

RESULTS

Fewer women with avulsions (present in 50.8%) obtained optimal mid-compartment outcomes (88.2% vs 77.1%; P = 0.05). The groups were otherwise similar in terms of mid-compartment reduction, anterior compartment results, failure rate, subjective satisfaction, pelvic floor/sexual symptoms, and combined optimal subjective and anatomical outcome. Only preoperative anterior compartment stage ≥III was associated with poor anatomical outcome (P < 0.01). A high preoperative symptom score was associated with a high postoperative symptom score (P < 0.001).

CONCLUSIONS

Although fewer women with avulsions obtained optimal mid-compartment results, avulsions had no impact on other anatomical or symptomatic outcomes 1 year after the Manchester procedure for primary anterior compartment prolapse.

Pelvic, anorectal and urinary symptoms according to the nutritional status of adult women: A cross-sectional study

ABSTRACT To review the occurrence of pelvic, anorectal and urinary symptoms according to the nutritional status of adultwomen. Methods This is a cross-sectional study with 54 women, aged 18 to 35 years, divided into normal weight (<25kg/m2), overweight (25kg/m2 to 29.99kg/m2) and obesity (≥30kg/m2) according to the body mass index. The presence of pelvic floor muscle dysfunction symptoms was assessed by the Pelvic Floor Distress Inventory and the impact of these symptoms by the Pelvic Floor Impact Questionnaire. Descriptive and inferential statistics were used, with a significance level of 5%. Results Pelvic Floor Distress Inventory total score was 22.95 (SD=26.11) in the eutrophic group and 59.67 (SD=47.80) in the obesity group (p=0.01). Considering the scales, urinary symptoms were higher in obese women than in the eutrophic group (p=0.01). In the assessment of patients with each symptom, a difference (p<0.01) was observed in incomplete bowel emptying, in which the highest frequency occurred in overweight women (47.4%) compared to eutrophic and obese women (both 26.3%). Urinary incontinence symptoms (18.2% in eutrophic women, 27.3% overweight and 54.5% obese), stress urinary incontinence (8.3% eutrophic, 41.7% overweight and 50.0%, obese) and difficulty in emptying the bladder (0.0% eutrophic, 33.3% overweight and 66.7% obese) exhibited higher frequencies (p=0.03; p<0,01 and p=0.02, respectively) in obese women. Conclusion Symptoms of pelvic floor muscles dysfunction, especially urinary tract muscles, occur more frequently in obese adult women when compared to eutrophic women.