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Bowen ST, Moalli PA, Abramowitch SD, Luchristt DH, Meyer I, Rardin CR, Harvie HS, Hahn ME, Mazloomdoost D, Iyer P, Carper B, Gantz MG. Vaginal morphology and position associated with prolapse recurrence after vaginal surgery: A secondary analysis of the DEMAND study. BJOG 2024; 131:267-277. [PMID: 37522240 PMCID: PMC10828105 DOI: 10.1111/1471-0528.17620] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 06/10/2023] [Accepted: 07/11/2023] [Indexed: 08/01/2023]
Abstract
OBJECTIVE To identify vaginal morphology and position factors associated with prolapse recurrence following vaginal surgery. DESIGN Secondary analysis of magnetic resonance images (MRI) of the Defining Mechanisms of Anterior Vaginal Wall Descent cross-sectional study. SETTING Eight clinical sites in the US Pelvic Floor Disorders Network. POPULATION OR SAMPLE Women who underwent vaginal mesh hysteropexy (hysteropexy) with sacrospinous fixation or vaginal hysterectomy with uterosacral ligament suspension (hysterectomy) for uterovaginal prolapse between April 2013 and February 2015. METHODS The MRI (rest, strain) obtained 30-42 months after surgery, or earlier for participants with recurrence who desired reoperation before 30 months, were analysed. MRI-based prolapse recurrence was defined as prolapse beyond the hymen at strain on MRI. Vaginal segmentations (at rest) were used to create three-dimensional models placed in a morphometry algorithm to quantify and compare vaginal morphology (angulation, dimensions) and position. MAIN OUTCOME MEASURES Vaginal angulation (upper, lower and upper-lower vaginal angles in the sagittal and coronal plane), dimensions (length, maximum transverse width, surface area, volume) and position (apex, mid-vagina) at rest. RESULTS Of the 82 women analysed, 12/41 (29%) in the hysteropexy group and 22/41 (54%) in the hysterectomy group had prolapse recurrence. After hysteropexy, women with recurrence had a more laterally deviated upper vagina (p = 0.02) at rest than women with successful surgery. After hysterectomy, women with recurrence had a more inferiorly (lower) positioned vaginal apex (p = 0.01) and mid-vagina (p = 0.01) at rest than women with successful surgery. CONCLUSIONS Vaginal angulation and position were associated with prolapse recurrence and suggestive of vaginal support mechanisms related to surgical technique and potential unaddressed anatomical defects. Future prospective studies in women before and after prolapse surgery may distinguish these two factors.
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Affiliation(s)
- Shaniel T Bowen
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Pamela A Moalli
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Pittsburgh Medical Center, Magee Women's Research Institute, Pittsburgh, Pennsylvania, USA
| | - Steven D Abramowitch
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Douglas H Luchristt
- Division of Urogynecology, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Isuzu Meyer
- Division of Urogynecology and Pelvic Reconstructive Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Charles R Rardin
- Division of Urogynecology, Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Heidi S Harvie
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael E Hahn
- Department of Radiology, University of California, San Diego, La Jolla, California, USA
| | - Donna Mazloomdoost
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
| | - Pooja Iyer
- Biostatistics Division, PPD Incorporated, San Francisco, California, USA
| | - Benjamin Carper
- Social, Statistical, and Environmental Sciences, RTI International, Research Triangle Park, North Carolina, USA
| | - Marie G Gantz
- Social, Statistical, and Environmental Sciences, RTI International, Research Triangle Park, North Carolina, USA
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Routzong MR, Moalli PA, Rostaminia G, Abramowitch SD. Morphological Variation in the Pelvic Floor Muscle Complex of Nulliparous, Pregnant, and Parous Women. Ann Biomed Eng 2023:10.1007/s10439-023-03150-z. [PMID: 36715838 DOI: 10.1007/s10439-023-03150-z] [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: 10/07/2022] [Accepted: 01/12/2023] [Indexed: 01/31/2023]
Abstract
Specific levator ani muscle imaging measures change with pregnancy and vaginal parity, though entire pelvic floor muscle complex (PFMC) shape variation related to pregnancy-induced and postpartum remodeling has never been quantified. We used statistical shape modeling to compute the 3D variation in PFMC morphology of reproductive-aged nulliparous, late pregnant, and parous women. Pelvic magnetic resonance images were collected retrospectively and PFMCs were segmented. Modes of variation and principal component scores, generated via statistical shape modeling, defined significant morphological variation. Nulliparous (have never given birth), late pregnant (3rd trimester), and parous (have given birth and not currently pregnant) PFMCs were compared via MANCOVA. The overall PFMC shape, mode 2, and mode 3 significantly differed across patient groups (p < 0.001, = 0.002, = 0.001, respectively). This statistical shape analysis described greater perineal and external anal sphincter descent, increased iliococcygeus concavity, and a proportionally wider mid-posterior levator hiatus in late pregnant compared to nulliparous and parous women. The late pregnant group was the most divergent, highlighting differences that likely reduce the mechanical burden of vaginal childbirth. This robust quantification of PFMC shape provides insight to pregnancy and postpartum remodeling and allows for generation of representative non-patient-specific PFMCs that can be used in biomechanical simulations.
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Affiliation(s)
- Megan R Routzong
- Department of Bioengineering, University of Pittsburgh, 3700 O'Hara Street, 406 Benedum Hall, Pittsburgh, PA, 15260, USA
| | - Pamela A Moalli
- Department of Obstetrics, Gynecology & Reproductive Surgery, Magee-Womens Research Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ghazaleh Rostaminia
- Female Pelvic Medicine and Reconstructive Surgery (FPMRS), Division of Urogynecology, University of Chicago Pritzker School of Medicine, Northshore University HealthySystem, Skokie, IL, USA
| | - Steven D Abramowitch
- Department of Bioengineering, University of Pittsburgh, 3700 O'Hara Street, 406 Benedum Hall, Pittsburgh, PA, 15260, USA.
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Burkett LS, Canavan TP, Glass Clark SM, Giugale LE, Artsen AM, Moalli PA. Reducing pelvic floor injury by induction of labor. Int Urogynecol J 2022; 33:3355-3364. [PMID: 35976420 PMCID: PMC9383672 DOI: 10.1007/s00192-022-05296-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 06/27/2022] [Indexed: 11/16/2022]
Abstract
INTRODUCTION AND HYPOTHESIS We hypothesized that elective induction of labor (eIOL) at 39 weeks is protective of levator ani muscle injury (LAMI) and is associated with decreased pelvic symptoms at 6 weeks postpartum compared to expectant management of labor. METHODS Prospective cohort pilot study of uncomplicated, primiparous women with a singleton, vertex gestation enrolled immediately post-vaginal delivery (VD). Subjects were dichotomized into two groups based on labor management: eIOL without complication defined by the ARRIVE trial versus spontaneous VD between 39 weeks0/7 and 42 weeks5/7 or no indication for IOL prior to 40 weeks5/7. The primary outcome was LAMI at 6 weeks postpartum as evidenced by any of the following ultrasound measures: (1) increased levator hiatal area (LHA) > 2500 mm2, (2) increased elasticity index (EI, > 75th quartile) or (3) levator enthesis avulsion. RESULTS Analysis represents 45/102 consented women from July 2019-October 2020 (eIOL n = 22 and spontaneous VD, n = 23). Neither maternal, clinical, sociodemographic characteristics nor pelvic symptoms differed between groups. Fewer women had LAMI as defined by the primary outcome with eIOL (n = 5, 23.8%) compared to spontaneous VD (n = 15, 65.2%), p = 0.008. Levator enthesis was more deformable (increased EI) with spontaneous VD as compared to the eIOL [10.66 (8.99) vs. 5.68 (2.93), p = 0.046]. On univariate logistic regression women undergoing spontaneous VD had unadjusted OR of 6.0 (1.6-22.5, p = 0.008) of sustaining LAMI compared to those undergoing eIOL. CONCLUSIONS Composite measures of LAMI though not pelvic floor symptoms were markedly increased in women undergoing spontaneous VD compared to those undergoing eIOL at 39 weeks.
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Affiliation(s)
- Linda S Burkett
- Magee-Womens Hospital University of Pittsburgh Medical Center, 300 Halket Street, Pittsburgh, PA, 15232, USA
- Magee-Womens Research Institute (MWRI), 204 Craft Street, Pittsburgh, PA, 15232, USA
- Virginia Commonwealth University Health System, 1250 East Marshall Street, Richmond, VA, 23298, USA
| | - Timothy P Canavan
- Magee-Womens Hospital University of Pittsburgh Medical Center, 300 Halket Street, Pittsburgh, PA, 15232, USA
- Magee-Womens Research Institute (MWRI), 204 Craft Street, Pittsburgh, PA, 15232, USA
| | - Stephanie M Glass Clark
- Magee-Womens Hospital University of Pittsburgh Medical Center, 300 Halket Street, Pittsburgh, PA, 15232, USA
- Magee-Womens Research Institute (MWRI), 204 Craft Street, Pittsburgh, PA, 15232, USA
| | - Lauren E Giugale
- Magee-Womens Hospital University of Pittsburgh Medical Center, 300 Halket Street, Pittsburgh, PA, 15232, USA
- Magee-Womens Research Institute (MWRI), 204 Craft Street, Pittsburgh, PA, 15232, USA
| | - Amanda M Artsen
- Magee-Womens Hospital University of Pittsburgh Medical Center, 300 Halket Street, Pittsburgh, PA, 15232, USA
- Magee-Womens Research Institute (MWRI), 204 Craft Street, Pittsburgh, PA, 15232, USA
| | - Pamela A Moalli
- Magee-Womens Hospital University of Pittsburgh Medical Center, 300 Halket Street, Pittsburgh, PA, 15232, USA.
- Magee-Womens Research Institute (MWRI), 204 Craft Street, Pittsburgh, PA, 15232, USA.
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Escalona-Vargas D, Siegel ER, Oliphant S, Eswaran H. Evaluation of Pelvic Floor Muscles in Pregnancy and Postpartum With Non-Invasive Magnetomyography. IEEE JOURNAL OF TRANSLATIONAL ENGINEERING IN HEALTH AND MEDICINE 2022; 10:1800106. [PMID: 34950538 PMCID: PMC8673696 DOI: 10.1109/jtehm.2021.3130785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 11/10/2021] [Accepted: 11/13/2021] [Indexed: 11/07/2022]
Abstract
Objective: To record and characterize features of levator ani muscles (LAM) activity in pregnancy and postpartum using non-invasive and novel Magnetomyography (MMG) technique with amplitude and spectral parameters. Methods: Nulliparous women with uncomplicated pregnancies participated in the MMG data collection during rest and voluntary LAM contractions (Kegels) with modulated intensity in third trimester and approximately 2 months postpartum (PP). Simultaneous surface electromyography was recorded to document the recruitment of accessory muscles. Moderate strength Kegel (MK) MMG trials were analyzed. Amplitude and spectral parameters including root-mean square (RMS) amplitude, power spectrum density (PSD) and normalized PSD (rPSD) in three frequency bands (low, middle, high) were computed on MK epochs. Statistical comparisons between pregnancy and postpartum were calculated. Results: MMG recordings were measured from 10 pregnant women. Results showed decreased RMS and power between third trimester and postpartum, trending towards significance. rPSD values in the low frequency band decreased significantly (p = 0.028) from third trimester to postpartum, while significant increase was observed in the middle frequency band (p = 0.018). Conclusions: This study shows that MMG as non-invasive tool has the ability to detect and characterize changes of LAM activity with amplitude and spectral parameters during pregnancy and postpartum.
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Affiliation(s)
- D Escalona-Vargas
- Department of Obstetrics and GynecologyUniversity of Arkansas for Medical Sciences Little Rock AR 72205 USA
| | - E R Siegel
- Department of BiostatisticsUniversity of Arkansas for Medical Sciences Little Rock AR 72205 USA
| | - S Oliphant
- Department of Obstetrics and GynecologyUniversity of Arkansas for Medical Sciences Little Rock AR 72205 USA
| | - H Eswaran
- Department of Obstetrics and GynecologyUniversity of Arkansas for Medical Sciences Little Rock AR 72205 USA
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Damitz LA. Commentary on: New Method for Genital Aesthetic Surgery: An Easy-To-Learn Two-Step Approach With Acellular Dermal Matrix (ADM). Aesthet Surg J 2022; 42:1053-1055. [PMID: 35435226 DOI: 10.1093/asj/sjac078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Lynn A Damitz
- Department of Plastic Surgery, University of North Carolina , Chapel Hill, NC , USA
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Li Y, Xia Z, Bai M, Wei L, Xiao Y, Zhang D, Chen J, Zhang H, Long X, Wang X. New Method for Genital Aesthetic Surgery: An Easy-To-Learn Two-Step Approach With Acellular Dermal Matrix (ADM). Aesthet Surg J 2022; 42:1045-1052. [PMID: 35352100 DOI: 10.1093/asj/sjac071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Vaginal laxity, usually accompanied with prolapse symptoms, affects women's sexual satisfaction and quality of life. Vaginal tightening surgery aims to reinforce the peri-vaginal muscle strength and restore the normal vaginal anatomy. OBJECTIVES The objective of this study was to introduce a new surgical approach with vaginal tightening using acellular dermal matrix (ADM). METHODS In this retrospective study, we analyzed data from 80 patients with vaginal laxity who underwent surgery from April 2017 to April 2021. Three-dimensional transvaginal ultrasound (3D-TVS) and the Female Sexual Function Index (FSFI) were evaluated among the patients. RESULTS The mean age of the patients was 44.6 years. The mean patient follow-up was 13.2 months. No infection, rectovaginal fistula, or implant explantation occurred. 3D-TVS demonstrated a significant reduction of introital diameter on a maximum Valsalva maneuver (2.3 cm vs. 4.1 cm; p<0.05) and the reconstruction of acute vaginal angulation. FSFI orgasm subscore increased significantly. CONCLUSIONS Vaginal tightening with ADM is a minimally invasive surgery with safety and efficacy for patients with vaginal laxity.
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Affiliation(s)
- Yunzhu Li
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences , Beijing , China
| | - Zenan Xia
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences , Beijing , China
| | - Ming Bai
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences , Beijing , China
| | - Lan Wei
- Department of Ultrasound, Beijing Erlong Road Hospital , Beijing , China
| | - Yiding Xiao
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences , Beijing , China
| | - Dingyue Zhang
- Chinese Academy of Medical Sciences and Peking Union Medical College Dr D. Zhang is a medical student, , Beijing , China
| | - Jie Chen
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences , Beijing , China
| | - Hailin Zhang
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences , Beijing , China
| | - Xiao Long
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences , Beijing , China
| | - Xiaojun Wang
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences , Beijing , China
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Deprest JA, Cartwright R, Dietz HP, Brito LGO, Koch M, Allen-Brady K, Manonai J, Weintraub AY, Chua JWF, Cuffolo R, Sorrentino F, Cattani L, Decoene J, Page AS, Weeg N, Varella Pereira GM, Mori da Cunha de Carvalho MGMC, Mackova K, Hympanova LH, Moalli P, Shynlova O, Alperin M, Bortolini MAT. International Urogynecological Consultation (IUC): pathophysiology of pelvic organ prolapse (POP). Int Urogynecol J 2022; 33:1699-1710. [PMID: 35267063 DOI: 10.1007/s00192-022-05081-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 12/27/2021] [Indexed: 10/18/2022]
Abstract
INTRODUCTION AND HYPOTHESIS This manuscript is the International Urogynecology Consultation (IUC) on pelvic organ prolapse (POP) chapter one, committee three, on the Pathophysiology of Pelvic Organ Prolapse assessing genetics, pregnancy, labor and delivery, age and menopause and animal models. MATERIALS AND METHODS An international group of urogynecologists and basic scientists performed comprehensive literature searches using pre-specified terms in selected biomedical databases to summarize the current knowledge on the pathophysiology of the development of POP, exploring specifically factors including (1) genetics, (2) pregnancy, labor and delivery, (3) age and menopause and (4) non-genetic animal models. This manuscript represents the summary of three systematic reviews with meta-analyses and one narrative review, to which a basic scientific comment on the current understanding of pathophysiologic mechanisms was added. RESULTS The original searches revealed over 15,000 manuscripts and abstracts which were screened, resulting in 202 manuscripts that were ultimately used. In the area of genetics the DNA polymorphisms rs2228480 at the ESR1 gene, rs12589592 at the FBLN5 gene, rs1036819 at the PGR gene and rs1800215 at the COL1A1 gene are significantly associated to POP. In the area of pregnancy, labor and delivery, the analysis confirmed a strong etiologic link between vaginal birth and symptoms of POP, with the first vaginal delivery (OR: 2.65; 95% CI: 1.81-3.88) and forceps delivery (OR: 2.51; 95% CI: 1.24-3.83) being the main determinants. Regarding age and menopause, only age was identified as a risk factor (OR : 1.102; 95% CI: 1.02-1.19) but current data do not identify postmenopausal status as being statistically associated with POP. In several animal models, there are measurable effects of pregnancy, delivery and iatrogenic menopause on the structure/function of vaginal support components, though not on the development of POP. CONCLUSIONS Genetics, vaginal birth and age all have a strong etiologic link to the development of POP, to which other factors may add or protect against the risk.
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Affiliation(s)
- Jan A Deprest
- Department Development and Regeneration, Cluster Urogenital Surgery, Biomedical Sciences, and Clinical Department Obstetrics and Gynaecology, University Hospitals Leuven, KU Leuven, Herestraat 49, B-3000, Leuven, Belgium.
| | - Rufus Cartwright
- Department of Epidemiology & Biostatistics, Imperial College London, Norfolk Place, London and Department of Urogynaecology, LNWH NHS Trust, London, UK
| | - Hans Peter Dietz
- Sydney Medical School Nepean, Nepean Hospital, Penrith, NSW, 2750, Australia
| | - Luiz Gustavo Oliveira Brito
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, SP, Brazil
| | - Marianne Koch
- Department of Obstetrics and Gynaecology, Medical University of Vienna, Vienna, Austria
| | - Kristina Allen-Brady
- Department of Internal Medicine, Genetic Epidemiology, University of Utah, Salt Lake City, UT, USA
| | - Jittima Manonai
- Department of Obstetrics and Gynaecology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Adi Y Weintraub
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - John W F Chua
- Department of Gynecology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Romana Cuffolo
- Department of Obstetrics & Gynaecology, John Radcliffe Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Felice Sorrentino
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynecology, University of Foggia, Foggia, Italy
| | - Laura Cattani
- Department Development and Regeneration, Cluster Urogenital Surgery, Biomedical Sciences, and Clinical Department Obstetrics and Gynaecology, University Hospitals Leuven, KU Leuven, Herestraat 49, B-3000, Leuven, Belgium
| | - Judith Decoene
- Department Development and Regeneration, Cluster Urogenital Surgery, Biomedical Sciences, and Clinical Department Obstetrics and Gynaecology, University Hospitals Leuven, KU Leuven, Herestraat 49, B-3000, Leuven, Belgium
| | - Anne-Sophie Page
- Department Development and Regeneration, Cluster Urogenital Surgery, Biomedical Sciences, and Clinical Department Obstetrics and Gynaecology, University Hospitals Leuven, KU Leuven, Herestraat 49, B-3000, Leuven, Belgium
| | - Natalie Weeg
- Sydney Medical School Nepean, Nepean Hospital, Penrith, NSW, 2750, Australia
| | - Glaucia M Varella Pereira
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, SP, Brazil
| | - Marina Gabriela M C Mori da Cunha de Carvalho
- Department Development and Regeneration, Cluster Urogenital Surgery, Biomedical Sciences, and Clinical Department Obstetrics and Gynaecology, University Hospitals Leuven, KU Leuven, Herestraat 49, B-3000, Leuven, Belgium
| | - Katerina Mackova
- Department Development and Regeneration, Cluster Urogenital Surgery, Biomedical Sciences, and Clinical Department Obstetrics and Gynaecology, University Hospitals Leuven, KU Leuven, Herestraat 49, B-3000, Leuven, Belgium
| | - Lucie Hajkova Hympanova
- Department Development and Regeneration, Cluster Urogenital Surgery, Biomedical Sciences, and Clinical Department Obstetrics and Gynaecology, University Hospitals Leuven, KU Leuven, Herestraat 49, B-3000, Leuven, Belgium
| | - Pamela Moalli
- Division of Urogynecology & Pelvic Reconstructive Surgery, UPMC Magee-Womens Hospital, Pittsburgh, PA, USA
| | - Oksana Shynlova
- Department of Obstetrics, Gynaecology and Physiology, Lunenfeld-Tanenbaum Research Institute, University of Toronto, Toronto, ON, Canada
| | - Marianna Alperin
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Diego, School of Medicine, San Diego, CA, USA
| | - Maria Augusta T Bortolini
- Department of Gynecology, Sector of Urogynecology, Universidade Federal de São Paulo, São Paulo, SP, Brazil
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Li S, Wen X, Gao Z, Ke K, Yang J, Wang H, Mo Y, Zeng Y, Li Y, Tian D, Shen J. Comparison of the Axes and Positions of the Uterus and Vagina Between Women With and Without Pelvic Floor Organ Prolapse. Front Surg 2022; 9:760723. [PMID: 35223974 PMCID: PMC8866694 DOI: 10.3389/fsurg.2022.760723] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 01/10/2022] [Indexed: 12/05/2022] Open
Abstract
Purpose To analyze the role of the axial positions of the uterus and vagina in providing pelvic floor support, encourage evaluations of pelvic floor function, and improve the understanding of the pathogenesis of pelvic organ prolapse. Methods The lengths and angles of the upper, middle, and lower axes of the vagina, uterine body, and cervix of 81 women with prolapse (prolapse group) and 57 women without prolapse (non-prolapse group) were measured and compared using magnetic resonance images. The pelvic inclination correction system (PICS) line was also compared between the groups. The coordinate parameters of the anatomical points of the uterus and vagina were measured, and their positions were analyzed. Results In the prolapse group, the uterine body-cervical angle, cervical-upper vaginal angle, uterine body-PICS line angle, cervical-PICS line angle, and lower vaginal-PICS line angle were smaller (p < 0.05) and the middle-lower vaginal angle, upper vaginal-PICS line angle, and middle vaginal-PICS line angles were larger (p < 0.05) than those in the non-prolapse group. The cervical length was longer (p < 0.05) and the middle and lower vaginal lengths were shorter (p < 0.05) in the prolapse group. The coordinate system revealed that the uterine and vaginal axes were shifted backward and downward in the prolapse group. Conclusion Patients in the prolapse group were more likely to have retroversion and retroflexion of the uterus than those in the non-prolapse group. The vagina was shortened, turned forward, and straightened, and the uterus and vagina were shifted backward and downward in the prolapse group. Changes in the axial position of the uterus and vagina are important mechanisms of pelvic floor organ prolapse.
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Affiliation(s)
- Song Li
- Urology Department, Kunming Medical University First Affiliated Hospital, Kunming, China
| | - Xuewei Wen
- Ophthalmology Department, Kunming Medical University First Affiliated Hospital, Kunming, China
| | - Zhenhua Gao
- Urology Department, Kunming Medical University First Affiliated Hospital, Kunming, China
| | - Kunbin Ke
- Urology Department, Kunming Medical University First Affiliated Hospital, Kunming, China
| | - Jing Yang
- Urology Department, Kunming Medical University First Affiliated Hospital, Kunming, China
| | - Haifeng Wang
- Urology Department, Kunming Medical University First Affiliated Hospital, Kunming, China
| | - Yin Mo
- Medical Imaging Department, Kunming Medical University First Affiliated Hospital, Kunming, China
| | - Yizhen Zeng
- Medical Imaging Department, Kunming Medical University First Affiliated Hospital, Kunming, China
| | - Yuan Li
- Urology Department, Kunming Medical University First Affiliated Hospital, Kunming, China
| | - Daoming Tian
- Urology Department, Kunming Medical University First Affiliated Hospital, Kunming, China
| | - Jihong Shen
- Urology Department, Kunming Medical University First Affiliated Hospital, Kunming, China
- *Correspondence: Jihong Shen
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Kamel R, Montaguti E, Nicolaides KH, Soliman M, Dodaro MG, Negm S, Pilu G, Momtaz M, Youssef A. Contraction of the levator ani muscle during Valsalva maneuver (coactivation) is associated with a longer active second stage of labor in nulliparous women undergoing induction of labor. Am J Obstet Gynecol 2019; 220:189.e1-189.e8. [PMID: 30321525 DOI: 10.1016/j.ajog.2018.10.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 10/02/2018] [Accepted: 10/07/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND The Valsalva maneuver is normally accompanied by relaxation of the levator ani muscle, which stretches around the presenting part, but in some women the maneuver is accompanied by levator ani muscle contraction, which is referred to as levator ani muscle coactivation. The effect of such coactivation on labor outcome in women undergoing induction of labor has not been previously assessed. OBJECTIVE The aim of the study was to assess the effect of levator ani muscle coactivation on labor outcome, in particular on the duration of the second and active second stage of labor, in nulliparous women undergoing induction of labor. STUDY DESIGN Transperineal ultrasound was used to measure the anteroposterior diameter of the levator hiatus, both at rest and at maximum Valsalva maneuver, in a group of nulliparous women undergoing induction of labor in 2 tertiary-level university hospitals. The correlation between anteroposterior diameter of the levator hiatus values and levator ani muscle coactivation with the mode of delivery and various labor durations was assessed. RESULTS In total, 138 women were included in the analysis. Larger anteroposterior diameter of the levator hiatus at Valsalva was associated with a shorter second stage (r = -0.230, P = .021) and active second stage (r = -0.338, P = .001) of labor. Women with levator ani muscle coactivation had a significantly longer active second stage duration (60 ± 56 vs 28 ± 16 minutes, P < .001). Cox regression analysis, adjusted for maternal age and epidural analgesia, demonstrated an independent significant correlation between levator ani muscle coactivation and a longer active second stage of labor (hazard ratio, 2.085; 95% confidence interval, 1.158-3.752; P = .014). There was no significant difference between women who underwent operative delivery (n = 46) when compared with the spontaneous vaginal delivery group (n = 92) as regards anteroposterior diameter of the levator hiatus at rest and at Valsalva maneuver, nor in the prevalence of levator ani muscle coactivation (10/46 vs 15/92; P = .49). CONCLUSION Levator ani coactivation is associated with a longer active second stage of labor.
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