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Hesham H, Orejuela F, Rood KM, Turrentine M, Casey B, Khandelwal M, Dajao R, Azad S, Rosen T, Hoffman MK, Wang EY, Hart L, Sheen JJ, Grisales T, Gibson KS, Torbenson V, Williams SF, Evantash E, Dietz HP, Wapner RJ. Effect of an Intrapartum Pelvic Dilator Device on Levator Ani Muscle Avulsion During Primiparous Vaginal Delivery: A Pilot Randomized Controlled Trial. Int Urogynecol J 2024:10.1007/s00192-024-05881-6. [PMID: 39096389 DOI: 10.1007/s00192-024-05881-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Accepted: 06/30/2024] [Indexed: 08/05/2024]
Abstract
INTRODUCTION AND HYPOTHESIS The objective was to evaluate the safety and effectiveness of an intrapartum electromechanical pelvic floor dilator designed to reduce the risk of levator ani muscle (LAM) avulsion during vaginal delivery. METHODS A multicenter, randomized controlled trial enrolled nulliparous participants planning vaginal delivery. During the first stage of labor, participants were randomized to receive the intravaginal device or standard-of-care labor management. The primary effectiveness endpoint was the presence of full LAM avulsion on transperineal pelvic-floor ultrasound at 3 months. Three urogynecologists performed blinded interpretation of ultrasound images. The primary safety endpoint was adverse events (AEs) through 3 months. RESULTS A total of 214 women were randomized to Device (n = 113) or Control (n = 101) arms. Of 113 Device assignees, 82 had a device placed, of whom 68 delivered vaginally. Of 101 Control participants, 85 delivered vaginally. At 3 months, 110 participants, 46 Device subjects who received full device treatment, and 64 Controls underwent ultrasound for the per-protocol analysis. No full LAM avulsions (0.0%) occurred in the Device group versus 7 out of 64 (10.9%) in the Control group (p = 0.040; two-tailed Fisher's test). A single maternal serious AE (laceration) was device related; no neonate serious AEs were device related. CONCLUSIONS The pelvic floor dilator device significantly reduced the incidence of complete LAM avulsion in nulliparous individuals undergoing first vaginal childbirth. The dilator demonstrated an acceptable safety profile and was well received by recipients. Use of the intrapartum electromechanical pelvic floor dilator in laboring nulliparous individuals may reduce the rate of LAM avulsion, an injury associated with serious sequelae including pelvic organ prolapse.
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Affiliation(s)
- Helai Hesham
- Department of Obstetrics & Gynecology, Columbia University Irving Medical Center, New York, NY, USA.
| | - Francisco Orejuela
- Department of Obstetrics & Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - Kara M Rood
- Department of Obstetrics & Gynecology, Wexner Medical Center, Ohio State University, Columbus, OH, USA
| | - Mark Turrentine
- Department of Obstetrics & Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - Brian Casey
- Department of Obstetrics & Gynecology, University Medical Center, University of Alabama, Tuscaloosa, AL, USA
| | - Meena Khandelwal
- Department of Obstetrics & Gynecology, Cooper University Hospital, Camden, NJ, USA
| | - Rori Dajao
- Department of Obstetrics & Gynecology, Cooper University Hospital, Camden, NJ, USA
| | - Sarah Azad
- El Camino Women's Medical Group, El Camino Health, Mountain View, CA, USA
| | - Todd Rosen
- Department of Obstetrics, Gynecology and Reproductive Medicine, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Matthew K Hoffman
- Department of Obstetrics and Gynecology, Christiana Care Health System, Newark, DE, USA
| | - Eileen Y Wang
- Department of Obstetrics & Gynecology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Laura Hart
- Department of Obstetrics, Gynecology and Reproductive Medicine, Temple University, Philadelphia, PA, USA
| | - Jean-Ju Sheen
- Department of Obstetrics & Gynecology, Columbia University Irving Medical Center, New York, NY, USA
| | - Tamara Grisales
- Department of Obstetrics & Gynecology, University of California-Los Angeles, Los Angeles, CA, USA
| | - Kelly S Gibson
- Division of Fetal Maternal Medicine, The Metro-Health System, Cleveland, OH, USA
| | - Vanessa Torbenson
- Department of Obstetrics & Gynecology, Mayo Clinic, Rochester, MN, USA
| | - Shauna F Williams
- Department of Obstetrics, Gynecology and Reproductive Health, Rutgers New Jersey Medical School, Newark, NJ, USA
| | | | - Hans P Dietz
- Sydney Urodynamic Centres, Sydney, NSW, Australia
| | - Ronald J Wapner
- Department of Obstetrics & Gynecology, Columbia University Irving Medical Center, New York, NY, USA
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Macedo MD, Risløkken J, Rotstein E, Benth JŠ, Ellström Engh M, Siafarikas F. Pelvic floor symptoms according to the severity of second-degree perineal tears within 12 months post-partum: A longitudinal prospective cohort study. Acta Obstet Gynecol Scand 2024; 103:1366-1376. [PMID: 38709004 PMCID: PMC11168255 DOI: 10.1111/aogs.14854] [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: 01/29/2024] [Revised: 04/10/2024] [Accepted: 04/14/2024] [Indexed: 05/07/2024]
Abstract
INTRODUCTION Second-degree perineal tears following vaginal birth are common and presumed to be of little clinical importance. However, the extent of damage to the perineal body varies widely, and there is reason to believe that larger second-degree tears may be associated with more pelvic floor symptoms, compared to lesser form. Therefore, the aim of this study was to assess differences in pelvic floor symptoms according to the severity of second-degree perineal tears up to 12 months post-partum, stratified by parity. MATERIAL AND METHODS This was a prospective cohort study conducted at Akershus University Hospital, a tertiary referral hospital in Norway. The study sample consisted of 409 primiparas and 394 multiparas with vaginal births. Perineal tears were classified using the classification system recommended by the Royal College of Obstetricians and Gynecologists. Further, second-degree tears were subclassified as 2A, 2B, or 2C, depending on the percentage of damage to the perineal body. Episiotomies were analyzed as a separate group. Pelvic floor symptoms were assessed using the Karolinska Symptoms After Perineal Tear Inventory (KAPTAIN). A linear mixed model was estimated to assess the trend in pelvic floor symptom scores according to perineal tear category and stratified by parity. The primary and secondary outcome measures were the mean sum scores of the KAPTAIN-Inventory, measured in pregnancy (at 18 weeks of gestation), at 3- and 12 months post-partum, and the reported impact of genital discomfort on quality of life measured in pregnancy and at 12 months post-partum. RESULTS There were no significant differences in pelvic floor symptom scores over time, or at any timepoint, between no tear, first-degree tear, or second-degree tear subcategories, for primi-, and multiparas. Pelvic floor symptoms increased from pregnancy to 3 months post-partum and remained higher at 12 months post-partum compared to pregnancy in all perineal tear categories. Compared to primiparas, multiparas reported a significantly higher impact of genital discomfort on quality of life in pregnancy and at 12 months post-partum. CONCLUSIONS There were no statistically significant differences in pelvic floor symptoms according to the severity of second-degree perineal tears.
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Affiliation(s)
- Marthe Dalevoll Macedo
- Division Akershus University Hospital, Faculty of Medicine, University of OsloOsloNorway
- Department of Obstetrics and GynecologyAkershus University HospitalLørenskogNorway
| | - Jeanette Risløkken
- Division Akershus University Hospital, Faculty of Medicine, University of OsloOsloNorway
- Department of Obstetrics and GynecologyAkershus University HospitalLørenskogNorway
| | - Emilia Rotstein
- Department of Clinical Science, Intervention and TechnologyKarolinska InstitutetStockholmSweden
- Department of Women's HealthKarolinska University HospitalStockholmSweden
| | - Jūratė Šaltytė Benth
- Institute of Clinical MedicineUniversity of OsloOsloNorway
- Health Services Research UnitAkershus University HospitalLørenskogNorway
| | - Marie Ellström Engh
- Division Akershus University Hospital, Faculty of Medicine, University of OsloOsloNorway
- Department of Obstetrics and GynecologyAkershus University HospitalLørenskogNorway
| | - Franziska Siafarikas
- Division Akershus University Hospital, Faculty of Medicine, University of OsloOsloNorway
- Department of Obstetrics and GynecologyAkershus University HospitalLørenskogNorway
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Fang J, Zhang R, Lin S, Lai B, Chen Y, Lu Y, Wang M, Lin Y, Weng Y, Lin J, Shen J. Impact of parity on pelvic floor morphology and function: A retrospective study. Medicine (Baltimore) 2023; 102:e35738. [PMID: 37960825 PMCID: PMC10637539 DOI: 10.1097/md.0000000000035738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 09/29/2023] [Indexed: 11/15/2023] Open
Abstract
To analyze the effect of parity on pelvic floor morphology and function during the postpartum period. A total of 971 participants, who attended the Fujian Maternity and Child Health Hospital (Fuzhou, China) between December 2019 and August 2021, were included. All participants were assessed using the modified Oxford scale (MOS), pelvic floor surface electromyography, and 3-dimensional pelvic floor ultrasound to assess pelvic floor morphology and function. Multivariate analysis revealed no differences among primipara, deuteripara, and tertipara in pre-baseline rest, phasic contraction, endurance contraction, post-baseline rest, and MOS, except for tonic contraction (P = .020), the amplitude of which was lower in primipara than in deuteripara in post hoc comparison (P = .008). Differences in bladder neck presentation and bladder neck descent were statistically significant in multivariate analysis (P = .002, P = .001, respectively), with the value of bladder neck presentation in primiparas being greater than that of deuteriparas and tertipara (P = .002, P = .008, respectively), and the value of bladder neck descent was lower than that of deuteripara and tertipara in further post hoc comparisons (P = .002, P = .003, respectively). Functional impairment was not statistically associated with parity according to the MOS score or surface electromyography. However, parity was significantly correlated with descent of the bladder neck, and most of the effects appeared to occur during the first delivery.
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Affiliation(s)
- Jianqi Fang
- Master of Medicine, Department of Women Health Care, Fujian Maternity and Child Health Hospital, Fuzhou, Fujian, People’s Republic of China
- Fujian Key Laboratory of Women and Children Critical Diseases Research [Fujian Maternity and Child Health Hospital (Fujian Women and Children Hospital)], Fujian, People’s Republic of China
| | - Ronghua Zhang
- Master of Medicine, Department of Women Health Care, Fujian Maternity and Child Health Hospital, Fuzhou, Fujian, People’s Republic of China
| | - Shuqin Lin
- Master of Medicine, Department of Women Health Care, Fujian Maternity and Child Health Hospital, Fuzhou, Fujian, People’s Republic of China
| | - Binglan Lai
- Master of Medicine, Department of Women Health Care, Fujian Maternity and Child Health Hospital, Fuzhou, Fujian, People’s Republic of China
| | - Yi Chen
- Master of Medicine, Department of Women Health Care, Fujian Maternity and Child Health Hospital, Fuzhou, Fujian, People’s Republic of China
| | - Yao Lu
- Master of Medicine, Department of Women Health Care, Fujian Maternity and Child Health Hospital, Fuzhou, Fujian, People’s Republic of China
| | - Miao Wang
- Master of Medicine, Department of Women Health Care, Fujian Maternity and Child Health Hospital, Fuzhou, Fujian, People’s Republic of China
| | - Yang Lin
- Master of Medicine, Department of Women Health Care, Fujian Maternity and Child Health Hospital, Fuzhou, Fujian, People’s Republic of China
| | - Yilin Weng
- Master of Medicine, Department of Women Health Care, Fujian Maternity and Child Health Hospital, Fuzhou, Fujian, People’s Republic of China
| | - Juan Lin
- Master of Medicine, Department of Women Health Care, Fujian Maternity and Child Health Hospital, Fuzhou, Fujian, People’s Republic of China
| | - Jinming Shen
- Master of Medicine, Department of Rehabilitation, Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, People’s Republic of China
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Worrall AP, O'Leary BD, Salameh F. Obstetric anal sphincter injury (OASI) in the presence of an intact perineum. BMJ Case Rep 2023; 16:e253922. [PMID: 37848273 PMCID: PMC10583107 DOI: 10.1136/bcr-2022-253922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2023] [Indexed: 10/19/2023] Open
Abstract
Obstetric anal sphincter injury (OASI) in the absence of concurrent injury to the perineal skin is not a common diagnosis. A primiparous woman delivered a healthy male infant by spontaneous vertex delivery. At time of delivery, a compound presentation of the fetal hand with the head was noted. Initial examination revealed a presumed second-degree tear; however, a small laceration above the anal verge was noted, which on exploration revealed a perineal injury through the anal sphincter complex. In the operating theatre, the perineal skin was incised to reveal a 3c OASI, which was repaired appropriately. While atypical OASI has been reported previously, this specific injury has never been described in detail in the literature. Awareness of atypical perineal injuries is needed and while careful perineal examination is required in all cases, this is especially important where the perineal skin appears intact to ensure appropriate diagnosis of any concurrent OASI.
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Affiliation(s)
- Amy P Worrall
- Obstetrics and Gynaecology, Rotunda Hospital, Dublin 1, Ireland
| | - Bobby D O'Leary
- Obstetrics and Gynaecology, Rotunda Hospital, Dublin 1, Ireland
| | - Fadi Salameh
- Obstetrics and Gynaecology, Rotunda Hospital, Dublin 1, Ireland
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Dublin 2, Ireland
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Dietz HP. Diagnosis of maternal birth trauma by pelvic floor ultrasound. Eur J Obstet Gynecol Reprod Biol 2023; 285:86-96. [PMID: 37087835 DOI: 10.1016/j.ejogrb.2023.04.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 04/01/2023] [Accepted: 04/06/2023] [Indexed: 04/25/2023]
Abstract
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.
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Shek KL, Dietz HP. Is urethral pressure associated with parity and delivery mode? Int Urogynecol J 2022; 33:3435-3439. [PMID: 35648180 DOI: 10.1007/s00192-022-05233-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 05/01/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Stress urinary incontinence is the most prevalent type of urinary incontinence and childbirth is a risk factor. The aim of this study is to evaluate the association between delivery mode and urethral sphincter function as measured by the maximum urethral pressure (MUP). METHODS A retrospective study on women seen in a tertiary urogynaecological center for urodynamic testing between January 2017 to December 2019. Women were classified into the following groups: (1) nulliparous; (2) caesarean section only; (3) at least one spontaneous vaginal delivery but no instrumental deliveries; (4) at least one vacuum delivery but no forceps; (5) at least one forceps delivery. RESULTS The complete data sets of 1238 women were analysed; 1112 (90%) were vaginally parous. Mean age was 58 (18-95) years. Mean parity was 2.6 (0-9); 57 (4.6%) were nulliparous, 69 (5.6%) had only been delivered by caesarean section, 762 (61.6%) had at least one spontaneous vaginal delivery but no instrumental deliveries, 41 (3.3%) had at least one vacuum but no forceps delivery, and 309 (25%) had at least one forceps delivery. Mean MUP was 41.8 cmH2O. There was a significant association between vaginal parity and MUP (P < 0.001). On ANOVA test, delivery mode was significantly associated with MUP. This became nonsignificant on regression analysis, with only age significantly associated with MUP (P < 0.001). CONCLUSIONS The effect of childbirth on urethral sphincter function seems to be largely due to the first vaginal birth. We failed to show an effect of instrumental delivery.
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Affiliation(s)
- Ka Lai Shek
- Liverpool Clinical School, Western Sydney University, Sydney, Australia. .,Nepean Clinical School, University of Sydney, Sydney, Australia.
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Yin W, Ma Q, Xie W, Zhu Y, Wang J. Three-dimensional ultrasound assessment of risk factors for cystocele and Green classification in primipara. Front Med (Lausanne) 2022; 9:979989. [PMID: 36530870 PMCID: PMC9747763 DOI: 10.3389/fmed.2022.979989] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 11/08/2022] [Indexed: 03/28/2024] Open
Abstract
BACKGROUND AND AIMS The present study aimed to analyze the effects of factors on cystocele and the Green classification. MATERIALS AND METHODS We conducted a cross-sectional study on 357 primiparous women examined at our hospital from January 2019 to May 2021. The following data were recorded: maternal characteristics, neonatal characteristics, and factors of childbirth. It was added to the multivariate logistic regression model to determine the independent predictors of the cystocele and the Green classification. RESULTS A total of 242 women had cystocele, including 71 women with Green type I cystocele, 134 women with Green type II cystocele, and 37 women with Green type III cystocele. In multivariate logistic regression analysis, body mass index (BMI) at delivery was associated with cystocele, while BMI at delivery and the second stage of labor (SSL) > 1 h were independently with the distance from the symphysis pubis to the bladder neck (SPBN) abnormal (P < 0.05). BMI at examination was associated with the large retrovesical angle (RVA) (P < 0.05). BMI at delivery and the fetal right occiput anterior position (ROA) were independently associated with the distance from the symphysis pubis to the posterior wall of the bladder (SPBP) abnormal (P < 0.05), while epidural anesthesia (EDA) was the protective factor (P < 0.05). CONCLUSION Primipara women should strive to avoid exposure to modifiable risk factors such as controlling weight during pregnancy, reducing weight after delivery, and shortening SSL to reduce the occurrence of cystocele.
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Affiliation(s)
- Weiwei Yin
- Department of Ultrasound, Second People’s Hospital of Wuhu, Wuhu, Anhui, China
| | - Qianqing Ma
- Department of Ultrasound, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Wen Xie
- Department of Ultrasound, Second People’s Hospital of Wuhu, Wuhu, Anhui, China
| | - Yuting Zhu
- Department of Ultrasound, Second People’s Hospital of Wuhu, Wuhu, Anhui, China
| | - Junli Wang
- Department of Ultrasound, Second People’s Hospital of Wuhu, Wuhu, Anhui, China
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Fang J, Ye J, Huang Q, Lin Y, Weng Y, Wang M, Chen Y, Lu Y, Zhang R. Risk factors of pelvic floor muscle strength in south Chinese women: a retrospective study. BMC Pregnancy Childbirth 2022; 22:624. [PMID: 35933360 PMCID: PMC9356495 DOI: 10.1186/s12884-022-04952-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 07/26/2022] [Indexed: 12/31/2022] Open
Abstract
Objectives To evaluate pelvic floor muscle strength using surface electromyography and risk factors for pelvic floor muscle strength in the early postpartum period. Methods This retrospective study included 21,302 participants who visited Fujian
Maternity and Child Health Hospital from September 2019 to February 2022. All participants
were assessed by
medical professionals for general information and surface electromyography. Results Univariate analysis indicated that age was inversely related to tonic and endurance contractions. In contrast, all the other variables, including education level, body mass index, neonatal weight, and number of fetuses, had a positive impact on rapid, tonic, and endurance contractions. Likewise, parity was also positively associated with rapid contractions. In addition, compared with vaginal delivery, cesarean section delivery had a protective effect on the amplitude of the three types of contractions. Stepwise regression analysis showed that both age and neonatal weight had a negative linear relationship with the amplitude of rapid, tonic and endurance contractions. In contrast, the amplitude of rapid, tonic and endurance contractions significantly increased as body mass index, parity (≤ 3), education level and gestational weight gain (endurance contractions only) increased. Participants with cesarean section delivery showed positive effects on rapid, tonic, and endurance contractions compared to participants with vaginal delivery. Conclusions We found that age, neonatal weight, vaginal delivery, episiotomy, and forceps delivery were risk factors for pelvic floor muscle strength; in contrast, body mass index, parity (≤ 3) and gestational weight gain had a positive relationship with pelvic floor muscle strength.
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Affiliation(s)
- Jianqi Fang
- Department of Women's Health Care, Fujian Maternity and Child Health Hospital, Fuzhou, Fujian, 350000, People's Republic of China.,Department of Rehabilitation Assessment, Rehabilitation Hospital Affiliated to Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, 350000, People's Republic of China
| | - Jiajia Ye
- Department of Rehabilitation Assessment, Rehabilitation Hospital, Fujian University of Traditional Chinese Medicine, Fujian, 350000, Fuzhou, People's Republic of China
| | - Qing Huang
- College of Environment and Public Health, Xiamen Huaxia University, Xiamen Fujian, People's Republic of China
| | - Yang Lin
- Department of Women's Health Care, Fujian Maternity and Child Health Hospital, Fuzhou, Fujian, 350000, People's Republic of China.,Department of Rehabilitation Assessment, Rehabilitation Hospital Affiliated to Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, 350000, People's Republic of China
| | - Yilin Weng
- Department of Women's Health Care, Fujian Maternity and Child Health Hospital, Fuzhou, Fujian, 350000, People's Republic of China.,Department of Rehabilitation Assessment, Rehabilitation Hospital Affiliated to Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, 350000, People's Republic of China
| | - Miao Wang
- Department of Women's Health Care, Fujian Maternity and Child Health Hospital, Fuzhou, Fujian, 350000, People's Republic of China.,Department of Rehabilitation Assessment, Rehabilitation Hospital Affiliated to Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, 350000, People's Republic of China
| | - Yi Chen
- Department of Women's Health Care, Fujian Maternity and Child Health Hospital, Fuzhou, Fujian, 350000, People's Republic of China.,Department of Rehabilitation Assessment, Rehabilitation Hospital Affiliated to Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, 350000, People's Republic of China
| | - Yao Lu
- Department of Women's Health Care, Fujian Maternity and Child Health Hospital, Fuzhou, Fujian, 350000, People's Republic of China.,Department of Rehabilitation Assessment, Rehabilitation Hospital Affiliated to Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, 350000, People's Republic of China
| | - Ronghua Zhang
- Department of Women's Health Care, Fujian Maternity and Child Health Hospital, Fuzhou, Fujian, 350000, People's Republic of China. .,Department of Rehabilitation Assessment, Rehabilitation Hospital Affiliated to Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, 350000, People's Republic of China.
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Zanetti MRD, Dourado VZ, Scudeller TT, Vieira ER, Amaral MTPD. Pelvic Floor Muscle Strength and the Postural Balance in Middle-Aged Women: A Pilot Study. PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS 2022. [DOI: 10.1080/02703181.2022.2044968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
| | - Victor Zuniga Dourado
- Department of Human Movement Sciences, Federal University of São Paulo, Santos, Brazil
| | | | - Edgar Ramos Vieira
- Department of Physical Therapy, Florida International University, Miami, Florida, USA
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Manzini C, Morsinkhof LM, van der Vaart CH, Withagen MIJ, Grob ATM. Parameters associated with unsuccessful pessary fitting for pelvic organ prolapse up to three months follow-up: a systematic review and meta-analysis. Int Urogynecol J 2022; 33:1719-1763. [PMID: 35037973 PMCID: PMC9270314 DOI: 10.1007/s00192-021-05015-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 04/05/2021] [Indexed: 11/30/2022]
Abstract
Objectives To clarify which parameters are associated with unsuccessful pessary fitting for pelvic organ prolapse (POP) at up to 3 months follow-up. Methods Embase, PubMed and Cochrane CENTRAL library were searched in May 2020. Inclusion criteria were: (1) pessary fitting attempted in women with symptomatic POP; (2) pessary fitting success among the study outcomes with a maximal follow-up of 3 months; (3) baseline parameters compared between successful and unsuccessful group. A meta-analysis was performed using the random effects model. Main results Twenty-four studies were included in the meta-analysis. Parameters associated with unsuccessful pessary fitting were: age (OR 0.70, 95% CI 0.56–0.86); BMI (OR 1.35, 95% CI 1.08–1.70); menopause (OR 0.65 95% CI 0.47–0.88); de novo stress urinary incontinence (OR 5.59, 95% CI 2.24–13.99); prior surgery, i.e. hysterectomy (OR 1.88, 95% CI 1.48–2.40), POP surgery (OR 2.13, 95% CI 1.34–3.38), pelvic surgery (OR 1.81, 05% CI 1.01–3.26) and incontinence surgery (OR 1.87, 95% CI 1.08–3.25); Colorectal-Anal Distress Inventory-8 scores (OR 1.92, 95% CI 1.22–3.02); solitary predominant posterior compartment POP (OR 1.59, 95% CI 1.08–2.35); total vaginal length (OR 0.56, 95% CI 0.32–0.97); wide introitus (OR 4.85, 95% CI 1.60–14.68); levator ani avulsion (OR 2.47, 95% CI 1.35–4.53) and hiatal area on maximum Valsalva (OR 1.89, 95% CI 1.27–2.80). Conclusion During counselling for pessary treatment a higher risk of failure due to the aforementioned parameters should be discussed and modifiable parameters should be addressed. More research is needed on the association between anatomical parameters and specific reasons for unsuccessful pessary fitting.
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Affiliation(s)
- Claudia Manzini
- Department of Obstetrics and Gynecology, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.,, Utrecht, The Netherlands
| | - Lisan M Morsinkhof
- Magnetic Detection and Imaging, Faculty of Science and Technology, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - C Huub van der Vaart
- Department of Obstetrics and Gynecology, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Mariëlla I J Withagen
- Department of Obstetrics and Gynecology, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Anique T M Grob
- Multi-Modality Medical Imaging, Faculty of Science and Technology, Technical Medical Centre, University of Twente, Enschede, The Netherlands
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van Gruting IMA, van Delft KWM, Sultan AH, Thakar R. Natural history of levator ani muscle avulsion 4 years following childbirth. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 58:309-317. [PMID: 32936957 DOI: 10.1002/uog.23120] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 08/25/2020] [Accepted: 09/03/2020] [Indexed: 06/11/2023]
Abstract
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.
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Affiliation(s)
- I M A van Gruting
- Department of Obstetrics and Gynaecology, Croydon University Hospital, Croydon, UK
| | - K W M van Delft
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - A H Sultan
- Department of Obstetrics and Gynaecology, Croydon University Hospital, Croydon, UK
- Department of Obstetrics and Gynaecology, St George's University of London, London, UK
| | - R Thakar
- Department of Obstetrics and Gynaecology, Croydon University Hospital, Croydon, UK
- Department of Obstetrics and Gynaecology, St George's University of London, London, UK
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Rusavy Z, Paymova L, Kozerovsky M, Veverkova A, Kalis V, Kamel RA, Ismail KM. Levator ani avulsion: a Systematic evidence review (LASER). BJOG 2021; 129:517-528. [PMID: 34245656 DOI: 10.1111/1471-0528.16837] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/10/2021] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Z Rusavy
- Department of Obstetrics and Gynaecology, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic.,Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic.,Department of Obstetrics and Gynaecology, University Hospital, Pilsen, Czech Republic
| | - L Paymova
- Department of Obstetrics and Gynaecology, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic.,Department of Obstetrics and Gynaecology, University Hospital, Pilsen, Czech Republic
| | - M Kozerovsky
- Department of Obstetrics and Gynaecology, University Hospital, Pilsen, Czech Republic
| | - A Veverkova
- Department of Obstetrics and Gynaecology, University Hospital, Pilsen, Czech Republic
| | - V Kalis
- Department of Obstetrics and Gynaecology, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic.,Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic.,Department of Obstetrics and Gynaecology, University Hospital, Pilsen, Czech Republic
| | - R A Kamel
- Maternal-Fetal Medicine Unit, Department of Obstetrics and Gynaecology, Cairo University, Cairo, Egypt
| | - K M Ismail
- Department of Obstetrics and Gynaecology, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic.,Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
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Rotstein E, Åhlund S, Lindgren H, Lindén Hirschberg A, Rådestad I, Tegerstedt G. Posterior compartment symptoms in primiparous women 1 year after non-assisted vaginal deliveries: a Swedish cohort study. Int Urogynecol J 2021; 32:1825-1832. [PMID: 33646348 PMCID: PMC8295137 DOI: 10.1007/s00192-021-04700-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 01/10/2021] [Indexed: 11/26/2022]
Abstract
Introduction and hypothesis This is a prospective cohort follow-up study based on the hypothesis that primiparous women with non-assisted vaginal deliveries and a second-degree perineal tear have more posterior compartment symptoms 1 year after delivery than those with no or first-degree tears. Methods A follow-up questionnaire, including validated questions on pelvic floor dysfunction, was completed 1 year postpartum by 410 healthy primiparas, delivered without instrumental assistance at two maternity wards in Stockholm between 2013 and 2015. Main outcome measures were posterior compartment symptoms in women with second-degree perineal tears compared with women with no or only minor tears. Results Of 410 women, 20.9% had no or only minor tears, 75.4% had a second-degree tear, and 3.7% had a more severe tear. Of women presenting with second-degree tears, 18.9% had bowel-emptying difficulties compared with 20.0% of women with minor tears. Furthermore, almost 3% of them with second-degree tears complained of faecal incontinence (FI) of formed stool, 7.2% of FI of loose stool compared with 1.2% and 3.5% respectively in women with no or only minor tears. Conclusions Symptomatic pelvic floor dysfunction is common among primiparous women within 1 year following uncomplicated vaginal delivery, and there are no significant differences between second-degree perineal tears and minor tears. These symptoms should be addressed in all women after delivery to improve pelvic floor dysfunction and quality of life.
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Affiliation(s)
- Emilia Rotstein
- Karolinska Pelvic Floor Centre, Karolinska University Hospital Huddinge, Stockholm, Sweden.
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, 171 77, Solna, Sweden.
| | - Susanne Åhlund
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Helena Lindgren
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Angelica Lindén Hirschberg
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Department of Gynaecology and Reproductive Medicine, Karolinska University Hospital, Stockholm, Sweden
| | | | - Gunilla Tegerstedt
- Karolinska Pelvic Floor Centre, Karolinska University Hospital Huddinge, Stockholm, Sweden
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, 171 77, Solna, Sweden
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Dietz HP. Ultrasound imaging of maternal birth trauma. Int Urogynecol J 2021; 32:1953-1962. [PMID: 33595672 DOI: 10.1007/s00192-020-04669-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 12/28/2020] [Indexed: 12/26/2022]
Abstract
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.
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Affiliation(s)
- Hans Peter Dietz
- Department of Obstetrics, Gynecology & Neonatology, Sydney Medical School Nepean, The University of Sydney, 62 Derby Street, Kingswood, NSW, 2747, Australia.
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Abstract
OBJECTIVE The goal of this study was to evaluate differences in levator ani hematoma formation within 3 days of delivery between adult women after their first vaginal delivery and adult women who have had multiple vaginal deliveries. METHODS This was a cross-sectional study at a single institution from 2013 to 2015 using a high-resolution endovaginal ultrasound transducer to identify postvaginal delivery hematoma formation. Logistic regression was used to examine the association between hematoma formation and vaginal parity while considering potential confounders including induction, vaginal operative delivery, vaginal birth after cesarean, fetal weight, fetal head circumference, race and ethnicity, body mass index, age at delivery, gestational age, and length of second-stage labor. RESULTS Ninety women (46 vaginal-primiparous; 44 vaginal-multiparous) were included in this study. After adjusting for oxytocin use, length of second-stage labor, and body mass index, the odds of pelvic floor hematoma of 1000 mm3 or greater were 2.93 (95% confidence interval, 0.78-10.91) times greater in women after their first vaginal delivery compared with women with a history of multiple vaginal deliveries. The adjusted odds of pelvic floor hematoma of 1500 mm3 or greater were 6.02 (95% confidence interval, 1.09-33.24) times greater in vaginal-primiparous compared with vaginal-multiparous women. CONCLUSIONS Although the prevalence of pelvic floor hematoma was higher in vaginal-primiparous women than vaginal-multiparous women after vaginal delivery, hematomas were present in both groups. Future prospective studies are needed to evaluate the additive effect of multiple vaginal deliveries on the pelvic floor.
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The effect of replacing vacuum with forceps in operative vaginal delivery: an observational study. Int Urogynecol J 2020; 31:1771-1776. [PMID: 32535687 DOI: 10.1007/s00192-020-04352-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 05/20/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION AND HYPOTHESIS An increase in vaginal delivery with forceps may increase rates of pelvic floor trauma. This study was designed to predict trauma rates resulting from policies preferencing forceps. METHODS This is an observational cohort study utilizing data from 660 primiparae enrolled in an RCT in two tertiary obstetric units in Sydney, Australia. Participants were assessed clinically and with 4D translabial ultrasound in the late third trimester and again at 3-6 months postpartum. Incidence of trauma associated with mode of delivery was adjusted to reflect change associated with a conversion of vacuum to forceps delivery. Primary outcome measures were third-/fourth-degree tear, levator avulsion (LA) and external anal sphincter (EAS) trauma diagnosed sonographically. RESULTS Five hundred four women were seen at a mean of 5.1 (2.3-24.3) months postpartum. After exclusion of 21 because of missing data, 483 women were analysed: 112 (23%) had a CS, 268 (55%) a normal vaginal delivery (NVD), 69 (14%) a vacuum (VD) and 34 (7%) a forceps (FD). One hundred fifty-two women had EAS trauma and/or LA; 17 sustained both. After VD, 32/69 (46%) women suffered LA and/or EAS trauma; after FD, it was 33/34 (97%). Converting VD to FD was estimated to result in an increase in trauma from 152/483 (31%) to 187/483 (39%). A formula can be generated based on local obstetric and ultrasound data to estimate trauma incidence. CONCLUSIONS A change in obstetric practice resulting in the conversion of primary VD to primary FD would be expected to substantially increase the likelihood of pelvic floor trauma.
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Dietz HP, Walsh C, Subramaniam N, Friedman T. Levator avulsion and vaginal parity: do subsequent vaginal births matter? Int Urogynecol J 2020; 31:2311-2315. [DOI: 10.1007/s00192-020-04330-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 04/29/2020] [Indexed: 11/28/2022]
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Gommesen D, Nohr EA, Qvist N, Rasch V. Obstetric perineal ruptures-risk of anal incontinence among primiparous women 12 months postpartum: a prospective cohort study. Am J Obstet Gynecol 2020; 222:165.e1-165.e11. [PMID: 31449804 DOI: 10.1016/j.ajog.2019.08.026] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 07/09/2019] [Accepted: 08/17/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Anal incontinence leads to impairment of the quality of life and lower self-esteem with implications for social, physical, and sexual health; anal incontinence after vaginal delivery is a major concern for many women. Only about half of the cases of postpartum anal incontinence can be related to anal sphincter injuries, and the remaining cases must thus be related to other factors. OBJECTIVE The aim of this study was to examine the association between maternal and obstetric characteristics, including the degree of perineal rupture and anal incontinence 12 months postpartum. Furthermore, the aim was to investigate the association between anal sphincter muscle defects, perineal length, and perineal strength and the risk of anal incontinence. MATERIALS AND METHODS We conducted a prospective cohort study at 4 Danish hospitals: Odense University Hospital, Aarhus University Hospital, Esbjerg Hospital, and Kolding Hospital. Baseline data were obtained 2 weeks postpartum in relation to an evaluation of perineal wound healing. Symptoms of anal incontinence were evaluated 12 months postpartum by a Web-based questionnaire (St. Mark's incontinence score questionnaire). In addition, defects in the anal sphincter muscles were examined using endoanal ultrasound, perineal length was measured, and perineal strength was examined using anal manometry. The main outcome measurement was anal incontinence defined as a St. Mark's score of >4. We performed multivariate analyses to investigate the risk factors for anal incontinence and to investigate the risk of anal incontinence according to endoanal ultrasound scanning and anal manometry findings. RESULTS A total of 603 primiparous women (203 with no/labia/first-degree ruptures, 200 with second-degree ruptures, and 200 with third-/fourth-degree ruptures) were included between July 2015 and January 2018. At 12 months postpartum, 575 women (95%) answered the questionnaire; 193 with no/labia/first-degree ruptures, 193 with second-degree ruptures, and 189 with third-/fourth-degree ruptures. A total of 499 women underwent an endoanal ultrasound scanning and 482 women underwent anal manometry. Anal incontinence with a St. Mark's score of >4 was reported by 7% and 9% of women with no/labia/first-degree ruptures or second-degree ruptures, respectively, and by 14%, 15%, 35%, and 33% of women with ruptures of degree 3a, 3b, 3c, and 4, respectively. Compared to women with no or minor tears, women with anal sphincter ruptures had a higher risk of anal incontinence (adjusted relative risk, 2.46; 95% confidence interval, 1.28-4.71). Ruptures of degree 3c and 4 were associated with a substantial increase in risk of anal incontinence (adjusted relative risk, 4.74; 95% confidence interval, 1.98-11.3; and adjusted relative risk, 2.23; 95% confidence interval, 1.59-11.3, respectively), especially if a defect in the external or internal anal sphincter muscle was present (adjusted relative risk, 4.74; 95% confidence interval, 1.54-14.5; and adjusted relative risk, 6.58; 95% confidence interval, 3.35-12.9, respectively). The risk of anal incontinence increased by 8% per 1-unit increase in body mass index (adjusted relative risk, 1.08; 95% confidence interval, 1.03-1.14). CONCLUSION Obesity with body mass index of >29.9 and a high-degree rupture (3c or 4), especially with a persistent defect in the internal or external anal sphincter muscle, increased the risk of anal incontinence.
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Anal sphincter imaging: better done at rest or on pelvic floor muscle contraction? Int Urogynecol J 2019; 31:1191-1196. [PMID: 31813034 DOI: 10.1007/s00192-019-04130-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 09/16/2019] [Indexed: 12/31/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Exo-anal ultrasound imaging of the anal sphincter is usually undertaken on pelvic floor muscle contraction (PFMC) as this seems to enhance tissue discrimination. Some women are unable to achieve a satisfactory PFMC, and in this situation, the sphincter is assessed at rest. We aimed to determine whether sphincter imaging at rest is inferior to imaging on PFMC. METHODS We analysed 441 women in this retrospective study. All underwent a standardised interview, including St Mark's incontinence score, clinical examination and 4D trans-labial ultrasound (TLUS). On analysing volume data, tomographic imaging was used to obtain a standardised set of slices at rest and on PFMC to evaluate external anal sphincter (EAS) and internal anal sphincter (IAS) trauma as described previously. RESULTS When assessments obtained from volumes acquired at rest and on PFMC were tested against measures of anal incontinence (AI), all associations between the diagnosis of significant anal sphincter defects and AI were no stronger when imaging was performed on PFMC. On cross-tabulation, the percentage agreement for significant defects of the EAS and IAS at rest and on PFMC was 96.5% and 98.9% respectively, if discrepancy by one slice was allowed. CONCLUSIONS Exo-anal tomographic imaging of sphincter defects at rest seems sufficiently valid for clinical use and may not be inferior to sphincter assessment on pelvic floor muscle contraction.
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Coital resumption after delivery among OASIS patients: differences between instrumental and spontaneous delivery. BMC WOMENS HEALTH 2019; 19:154. [PMID: 31810460 PMCID: PMC6896346 DOI: 10.1186/s12905-019-0845-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 11/13/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Obstetric anal sphincter injuries (OASIS) are associated with sexual dysfunction and a lower likelihood of sexual activity in the postpartum period. The aim of the present study was to compare coital resumption and the variables influencing this activity after delivery in women with and without a history of obstetric anal sphincter injury (OASIS) and according to the mode of delivery. METHODS A prospective, observational, case-control study was performed at 6 months postpartum in 318 women: 140 with a history of primary repaired OASIS and 178 women without OASIS. Demographic and obstetric data, breastfeeding, and symptoms of urinary and anal incontinence were collected. Patients were asked about coital resumption and completed the validated specific Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12 (PISQ-12). Continuous and non-continuous variables were compared using ANOVA and the Fisher exact tests, respectively. A multivariate logistic regression model and a multiple regression analysis were constructed to assess the impact of demographic and clinical variables on the percentage of coital resumption and on the PISQ-12 score, respectively. RESULTS After a spontaneous delivery (SD), patients without OASIS showed a higher percentage of coital resumption than those with OASIS (98% vs. 77%; p = 0.003), and the PISQ-12 score was also higher (p < 0.001). PISQ-12 score was better in women with SD compared to those with operative vaginal delivery (OVD)(p < 0.001), independently of the history of OASIS. Current breastfeeding, a higher Wexner score and OVD negatively influenced the PISQ-12 score. CONCLUSIONS After SD, women with OASIS resumed coital activity later than women without OASIS. Women with OVD resumed coital activity later, and had a lower PISQ-12 score than women with SD.
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Li Y, Shek KL, Subramaniam N, Friedman T, Dietz HP. Parity and anal sphincter trauma. Int Urogynecol J 2019; 31:553-556. [DOI: 10.1007/s00192-019-04093-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Accepted: 08/17/2019] [Indexed: 12/28/2022]
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Birthweight and pelvic floor trauma after vaginal childbirth. Int Urogynecol J 2019; 30:985-990. [DOI: 10.1007/s00192-019-03882-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 01/15/2019] [Indexed: 12/28/2022]
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Dietz HP. Ultrasound in the assessment of pelvic organ prolapse. Best Pract Res Clin Obstet Gynaecol 2018; 54:12-30. [PMID: 30082146 DOI: 10.1016/j.bpobgyn.2018.06.006] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 05/20/2018] [Accepted: 06/12/2018] [Indexed: 10/28/2022]
Abstract
Imaging is increasingly being used in urogynaecology. Because of low cost and universal availability, ultrasound (US) is the most commonly used diagnostic modality, which allows the observation of manoeuvres such as Valsalva and pelvic floor muscle contraction in real time. The ability to see beyond surface anatomy is particularly important in the posterior compartment and in obstructed defecation where this method may replace defecation proctography. Imaging is especially useful in the form of 3D/4D multiplanar and tomographic translabial US, as these modalities give access to the axial plane and the levator ani. This allows assessment of both avulsion, i.e. major maternal birth trauma, and hiatal overdistension, i.e. ballooning. Both are major risk factors for both prolapse and prolapse recurrence. This review will outline current clinical utility, introduce recent research in the respective field and provide an overview of likely future utility of imaging in the investigation of pelvic organ prolapse.
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Affiliation(s)
- Hans Peter Dietz
- Sydney Medical School Nepean, University of Sydney, 62 Derby St, Kingswood, NSW, 2747, Australia.
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