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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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Dietz HP, Shek KL, Low GK. All or nothing? A second look at partial levator avulsion. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 60:693-697. [PMID: 35872659 DOI: 10.1002/uog.26034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 06/21/2022] [Accepted: 07/14/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To define associations between partial levator trauma and symptoms and signs of pelvic organ prolapse (POP). METHODS This was a retrospective study of 3484 women attending a tertiary urogynecology unit for symptoms of pelvic floor dysfunction between January 2012 and February 2020. All women underwent a standardized interview, clinical pelvic organ prolapse quantification (POP-Q) examination and tomographic ultrasound imaging of the pelvic floor. Women with full levator avulsion were excluded from analysis. Partial levator avulsion was quantified using the tomographic trauma score (TTS), in which slices 3-8 are scored bilaterally for abnormal insertions. Binomial multiple logistic regression was analyzed independently for the outcome variables prolapse symptoms, symptom bother and objective prolapse on clinical examination and imaging, with age and body mass index as covariates. Two continuous outcome variables, prolapse bother score and hiatal area on Valsalva, were analyzed using multiple linear regression. RESULTS Of the 3484 women, ultrasound data were missing or incomplete in 164 due to lack of equipment, clerical error and/or inadequate image quality. Full levator avulsion was diagnosed in 807 women, leaving 2513 for analysis. TTS ranged from 0-10, with a median of 0. Partial trauma (TTS > 0) was observed in 667/2513 (26.5%) women. All subjective and objective measures of POP were associated significantly with TTS, most strongly for cystocele. Associations were broadly linear and similar for all slice locations but disappeared after accounting for hiatal area on Valsalva. CONCLUSION Partial avulsion is associated with POP and prolapse symptoms. This association was strongest for cystocele, both on POP-Q and ultrasound imaging. The effect of partial avulsion on POP and prolapse symptoms is explained fully by its effect on hiatal area. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- H P Dietz
- Sydney Urodynamic Centres, Penrith, NSW, Australia
| | - K L Shek
- Western Sydney University, Liverpool, NSW, Australia
| | - G K Low
- Research Operations, Nepean Hospital, Nepean Blue Mountain Local Health District, Kingswood, NSW, Australia
- Professorial Unit, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
- Faculty of Medicine and Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
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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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Giannini A, Caretto M, Russo E, Mannella P, Simoncini T. Advances in surgical strategies for prolapse. Climacteric 2020; 22:60-64. [PMID: 30721638 DOI: 10.1080/13697137.2018.1543266] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Pelvic floor dysfunctions are a complex condition in elderly women; pelvic organ prolapse, urinary or fecal incontinence, constipation, pelvic pain, and sexual dysfunction are common problems. The goal of surgical treatment is functional reconstruction with symptom management and repair of anatomic defects. The recent advancements in surgical treatment of pelvic floor dysfunction allow several good options for choosing the best surgery for each patient. The vaginal procedure is traditionally the gold standard approach for elderly patients, but abdominal surgery is increasing as a mini-invasive approach and the robotic approach is gaining acceptance for treatment of pelvic floor dysfunctions. In elderly individuals, a multitude of factors affects the final result of any reconstructive surgery such as postmenopausal or aging-associated changes in muscle tone and nerve function or changes in the function of the bladder or of the rectum: an understanding of the underlining functional status of pelvic organs is very important in aging women before proceeding to surgery. In this context, pelvic floor dysfunction, particularly in elderly women, should be addressed in a multidisciplinary manner and, at the forefront, centers for surgical planning could be helpful to perform safer, patient-tailored surgery.
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Affiliation(s)
- A Giannini
- a Division of Obstetrics and Gynecology, Department of Experimental and Clinical Medicine , University of Pisa , Pisa , Italy
| | - M Caretto
- a Division of Obstetrics and Gynecology, Department of Experimental and Clinical Medicine , University of Pisa , Pisa , Italy
| | - E Russo
- a Division of Obstetrics and Gynecology, Department of Experimental and Clinical Medicine , University of Pisa , Pisa , Italy
| | - P Mannella
- a Division of Obstetrics and Gynecology, Department of Experimental and Clinical Medicine , University of Pisa , Pisa , Italy
| | - T Simoncini
- a Division of Obstetrics and Gynecology, Department of Experimental and Clinical Medicine , University of Pisa , Pisa , Italy
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La Rosa VL, Ciebiera M, Lin LT, Sleiman Z, Cerentini TM, Lordelo P, Kahramanoglu I, Bruni S, Garzon S, Fichera M. Multidisciplinary management of women with pelvic organ prolapse, urinary incontinence and lower urinary tract symptoms.A clinical and psychological overview. PRZEGLAD MENOPAUZALNY = MENOPAUSE REVIEW 2019; 18:184-190. [PMID: 31975987 PMCID: PMC6970416 DOI: 10.5114/pm.2019.89496] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Accepted: 08/24/2019] [Indexed: 02/05/2023]
Abstract
Although female sexual dysfunctions are common among women with urogynecological conditions, they have not been thoroughly studied and there are still many questions without an answer. The recent evidence on sexual disorders in women with urogynecological diseases shows a quite wide spectrum of therapeutic approaches, which require the physicians to take into account not only the primary symptoms, but also all the associated factors negatively affected. It has been widely underlined that gynecological diseases are often associated with high stress and have a negative impact on quality of life and psychological well-being of women affected. For this reason, a multidisciplinary approach for the management of these diseases is highly recommended. Also in the case of urogynecological disorders, it is important to take into account psychological outcomes throughout the diagnostic and therapeutic process. In the light of these considerations, the aim of this short review is to evaluate the impact of the main urogynecological diseases and the currently available therapeutic options in order to improve quality of life and sexuality of these patients and to stress the need for a multidisciplinary approach in order to minimize the negative consequences of these diseases for the sexual well-being of women and their partners.
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Affiliation(s)
- Valentina Lucia La Rosa
- Unit of Psychodiagnostics and Clinical Psychology, University of Catania, Catania, Italy
- Corresponding author: Valentina Lucia La Rosa, Unit of Psychodiagnostics and Clinical Psychology, University of Catania, Via Santa Sofia 78, 95123 Catania, Italy, e-mail:
| | - Michał Ciebiera
- Second Department of Obstetrics and Gynecology, The Center of Postgraduate Medical Education, Warsaw, Poland
| | - Li-Te Lin
- Department of Obstetrics and Gynecology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Zaki Sleiman
- Department of Obstetrics and Gynecology, Lebanese American University, Beirut, Lebanon
| | - Tais Marques Cerentini
- Postgraduate Program in Rehabilitation Sciences, Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil
| | | | - Ilker Kahramanoglu
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Simone Bruni
- Department of Molecular and Developmental Medicine, Division of Obstetrics and Gynecology, University of Siena, Siena, Italy
| | - Simone Garzon
- Department of Obstetrics and Gynecology, “Filippo Del Ponte” Hospital, University of Insubria, Varese, Italy
| | - Michele Fichera
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
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Krause HG, Wong V, Ng S, Tan GI, Goh JT. Pelvic floor ultrasound findings in Ugandan women with obstetric fistula, unrepaired fourth degree obstetric tear, and pelvic organ prolapse. Aust N Z J Obstet Gynaecol 2019; 59:585-589. [DOI: 10.1111/ajo.12990] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 04/20/2019] [Indexed: 01/02/2023]
Affiliation(s)
- Hannah G. Krause
- Griffith University Nathan and Gold Coast Queensland Australia
- Greenslopes Private Hospital Brisbane Queensland Australia
- Queen Elizabeth II Jubilee Hospital Brisbane Queensland Australia
| | - Vivien Wong
- Pindara Private Hospital Gold Coast Queensland Australia
- Gold Coast University Hospital Robina Gold Coast Queensland Australia
| | - Shu‐Kay Ng
- Griffith University Nathan and Gold Coast Queensland Australia
| | | | - Judith T.W. Goh
- Griffith University Nathan and Gold Coast Queensland Australia
- Greenslopes Private Hospital Brisbane Queensland Australia
- Queen Elizabeth II Jubilee Hospital Brisbane Queensland Australia
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Brook G. Obstetric fistula: The role of physiotherapy: A report from the Physiotherapy Committee of the International Continence Society. Neurourol Urodyn 2018; 38:407-416. [DOI: 10.1002/nau.23851] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 09/11/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Gill Brook
- International Organization of Physical Therapists in Women's Health; Burras Lynd, Otley West Yorkshire United Kingdom
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Shek KL, Dietz HP. Assessment of pelvic organ prolapse: a review. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 48:681-692. [PMID: 26865209 DOI: 10.1002/uog.15881] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Revised: 01/27/2016] [Accepted: 01/30/2016] [Indexed: 06/05/2023]
Affiliation(s)
- K L Shek
- Department of Obstetrics and Gynaecology, Liverpool Hospital, Western Sydney University, Locked Bag 7103, Liverpool BC, NSW 1871, Australia
- Department of Obstetrics and Gynaecology, Nepean Clinical School, University of Sydney, Sydney, Australia
| | - H P Dietz
- Department of Obstetrics and Gynaecology, Nepean Clinical School, University of Sydney, Sydney, Australia
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Rostaminia G, Peck J, Quiroz L, Shobeiri SA. Levator Plate Upward Lift on Dynamic Sonography and Levator Muscle Strength. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2015; 34:1787-1792. [PMID: 26333568 PMCID: PMC4881840 DOI: 10.7863/ultra.15.14.11075] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 01/08/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVES To compare digital palpation with levator plate lift measured by endovaginal and transperineal dynamic sonography. METHODS Dynamic transperineal and endovaginal sonographic examinations were performed as part of multicompartmental pelvic floor functional assessment. Patients were instructed to perform Kegel contractions while a probe captured a video clip of levator plate movement at rest and during contraction in a 2-dimensional midsagittal posterior view. We measured the distance between the levator plate and the probe on endovaginal sonography as well as the distance between the levator plate and the gothic arch of the pubis on transperineal sonography. The change in diameter (lift) and levator plate lift ratio (lift/rest × 100) were calculated. Pelvic floor muscle strength was assessed by digital palpation and divided into functional and nonfunctional groups according to the Modified Oxford Scale. Mean differences in levator plate upward lift were compared by Modified Oxford Scale scores using Student t tests and analysis of variance. RESULTS Seventy-four women were available for analysis. The mean age was 55 (SD, 11.9) years. When measured by vaginal dynamic sonography, mean lift and lift/rest ratio values increased with increasing Modified Oxford Scale score (analysis of variance, P= .09 and .04, respectively). When scores were categorized to represent nonfunctional (0-1) and functional (2-5) muscle strength groups, the mean lift (3.2 versus 4.6 mm; P = .03) and lift/rest ratio (13% versus 20%; P = .01) values were significantly higher in women with functional muscle strength. All patients with lift of 30% or greater detected by vaginal sonography had functional muscle strength. CONCLUSIONS A greater levator plate lift ratio detected by dynamic endovaginal sonography was associated with higher muscle strength as determined by the Modified Oxford Scale. This novel measurement can be incorporated into sonographic evaluation of levator ani function.
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Affiliation(s)
- Ghazaleh Rostaminia
- Department of Obstetrics and Gynecology, Inova Fairfax Hospital, Falls Church, Virginia USA (G.R.); and Departments of Obstetrics and Gynecology and Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma USA (J.P., L.Q., S.A.S.)
| | - Jennifer Peck
- Department of Obstetrics and Gynecology, Inova Fairfax Hospital, Falls Church, Virginia USA (G.R.); and Departments of Obstetrics and Gynecology and Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma USA (J.P., L.Q., S.A.S.)
| | - Lieschen Quiroz
- Department of Obstetrics and Gynecology, Inova Fairfax Hospital, Falls Church, Virginia USA (G.R.); and Departments of Obstetrics and Gynecology and Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma USA (J.P., L.Q., S.A.S.)
| | - S Abbas Shobeiri
- Department of Obstetrics and Gynecology, Inova Fairfax Hospital, Falls Church, Virginia USA (G.R.); and Departments of Obstetrics and Gynecology and Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma USA (J.P., L.Q., S.A.S.).
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Dixit P, Shek KL, Dietz HP. How common is pelvic floor muscle atrophy after vaginal childbirth? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 43:83-88. [PMID: 23784670 DOI: 10.1002/uog.12543] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Revised: 04/28/2013] [Accepted: 06/01/2013] [Indexed: 06/02/2023]
Abstract
OBJECTIVE To determine if there is evidence of levator ani atrophy in primiparous women. METHODS This was a prospective observational cohort study of 202 primiparous women recruited between November 2006 and March 2008. Translabial ultrasound volumes were obtained at 36-38 weeks' gestation and at a mean of 4.5 months postpartum. Peripartum changes in bladder neck elevation and reduction of anteroposterior hiatal diameter on pelvic floor muscle contraction (PFMC) and changes in muscle thickness were analyzed. RESULTS Of the 202 participants enrolled, 158 (78%) completed the study. There was a significant reduction in bladder neck elevation (P = 0.001) and change in anteroposterior hiatal diameter (P = 0.03) on PFMC when comparing antenatal and postnatal results, the latter being significantly associated with delivery mode (P = 0.013). No significant changes were detected in muscle thickness (P = 0.76). CONCLUSIONS There is a reduction in sonographic measures of pelvic floor function after childbirth, but muscle atrophy is unlikely to be a significant factor.
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Affiliation(s)
- P Dixit
- Sydney Medical School Nepean, University of Sydney, Penrith, New South Wales, Australia
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The female pelvic floor through midlife and aging. Maturitas 2013; 76:230-4. [DOI: 10.1016/j.maturitas.2013.08.008] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Revised: 08/25/2013] [Accepted: 08/27/2013] [Indexed: 02/07/2023]
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Dietz HP. Pelvic floor trauma in childbirth. Aust N Z J Obstet Gynaecol 2013; 53:220-30. [PMID: 23452259 DOI: 10.1111/ajo.12059] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Accepted: 01/08/2013] [Indexed: 11/28/2022]
Abstract
The investigation of female pelvic floor function and anatomy is moving from the fringes to the mainstream of urogynaecology and female urology, and it is becoming increasingly relevant for obstetrics. We are coming to realise that pelvic floor trauma in labour is common, usually overlooked, and a major factor in the causation of pelvic organ prolapse. Modern imaging methods such as magnetic resonance and 3D/4D ultrasound have enabled us to diagnose such trauma reliably and accurately, most commonly in the form of an avulsion of the puborectalis muscle; that is, a disconnection of the muscle from its insertion on the os pubis. Such damage to the levator muscle is macroscopically evident and can also be palpated, a skill that is available to every clinician, requiring neither investment nor specialised equipment. In this review, I will describe pelvic floor assessment by palpation and ultrasound and illustrate the commonest abnormalities and their clinical consequences. This paper will not focus on magnetic resonance imaging due to technical restrictions, cost and access issues in most jurisdictions, and because several papers have recently shown that ultrasound is at least as effective in diagnosing such trauma. Anal sphincter trauma is generally well covered in the literature and hence not subject of this review.
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Affiliation(s)
- Hans Peter Dietz
- Sydney Medical School Nepean, University of Sydney, Penrith, NSW 2750, Australia.
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