Anatomy of pelvic floor dysfunction

Gynecological technical notes for appropriate spacer injections

BACKGROUND

Despite its efficacy, if adherence to dose constraints for surrounding normal tissues proves unattainable, the risk of late radiation-related adverse events after primary radiotherapy involving brachytherapy remains a noteworthy concern. Some studies suggest that similar to prostate radiotherapy, spacers may potentially reduce doses to surrounding healthy rectal or bladder tissues. However, guidance on spacer injections for gynecologic brachytherapy is scarce, and the optimal anatomical location for spacer placement remains undefined. We discuss maximizing the effects of spacers from an anatomical perspective.

FINDINGS

As vesicovaginal and rectovaginal septa form part of the endopelvic fascia and are not uniform tissues, spacer injection resistance varies. In pelvic organ prolapse surgery, saline is injected into the anterior and posterior vaginal walls as a spacer, and the vagina, vesicovaginal septum, and bladder can be fluidly dissected. Relatively firm vesicovaginal septum tissue is used as a reconstructive organ, whereas rectovaginal septum tissue is less dense. Cervical cancer is invasive, involving surrounding fascia and ligaments. Ideally, the vesicovaginal and rectovaginal septa should be resected in radical hysterectomy. Here, spacer adaptation and the technical details of injection are described. When using ultrasound guidance for spacer injection, the target site should be adequately magnified, and the spacer ideally injected into the incision layer during radical hysterectomy. Finally, posthysterectomy, the intestinal tract may adhere to the vaginal cuffs. Therefore, artificial ascites may be useful; however, the spread depends on perioperative manipulation.

CONCLUSIONS

Anatomical and surgical viewpoints are advantageous for safe, therapeutic, and replicable spacer injection administration.

Prevalence and Normalization of Stress Urinary Incontinence in Female Strength Athletes

ABSTRACT

Mahoney, K, Heidel, RE, and Olewinski, L. Prevalence and normalization of stress urinary incontinence in female strength athletes. J Strength Cond Res 37(9): 1877-1881, 2023-Strength training is increasing in popularity in women but is also a potential risk factor for stress urinary incontinence (SUI). There is potential for normalization of SUI in sports with high rates of SUI. Pelvic floor physical therapy is an effective treatment for SUI in both athletes and nonathletes, but female strength athletes may not be aware of this option. Our study sought to assess prevalence, normalization, rates of treatment, and preferred sources of information about SUI in female strength athletes. A novel cross-sectional survey was distributed online through social media groups dedicated to female strength athletes with 425 women responding within 4 days. Statistical significance of results was assumed at a 2-sided alpha value of 0.05. 43.5% of athletes experienced incontinence with daily tasks, 59.1% experienced incontinence with normal strength training, and 50.2% experienced incontinence during competition. Of the athletes who experienced incontinence, 61.4% did not have incontinence before starting their sport and only 9.4% had ever sought treatment. 67.9% of all athletes surveyed believed that urinary incontinence was a normal part of their sport. Our findings indicate that SUI is common in female strength athletes and may be a consequence of the sport itself. Normalization of SUI is common, and few athletes seek treatment.

Impact of parity and delivery mode on pelvic floor function in young women: a 3D ultrasound evaluation

INTRODUCTION AND HYPOTHESIS

The objectives were to evaluate clinical and anatomical parameters assessed by three-dimensional pelvic floor ultrasound (3D ultrasound) in parous and nulliparous women of childbearing age and to assess underreported symptoms of sexual dysfunction (SD), urinary incontinence (UI) and flatus incontinence (FI).

METHODS

Women without complaints of pelvic floor dysfunction, aged 20-50 years, were eligible for this prospective cross-sectional study. They completed the King's Health Questionnaire, Female Sexual Function Index and St Mark's Incontinence Score adapted for this study. Next, a physical examination and 3D ultrasound were performed. The scores obtained in the questionnaires were compared with the 3D ultrasound data.

RESULTS

In total, 326 women were invited to participate. Of these, 203 women met the inclusion criteria, and their cases were classified as nulliparity (NU, 59), vaginal delivery (VD, 80), forceps delivery (FD, 18) and caesarean section (CS, 48). These groups were homogeneous regarding age (p=0.096), parity (p=0.051) and body mass index (p=0.06). The hiatal dimension (HD; p=0.003) and transverse diameter (TD) (p=0.001) were significantly different among the groups. Compared with the NU and CS groups, the VD and FD groups had an increased HD and TD. The frequencies of underreported symptoms identified by questionnaires were as follows: SD (46.3%), UI (35%) and FI (28%). After VD and FD, women were more likely to present UI (p<0.001), FI (p<0.001) and SD (p=0.002) than the women with NU and those who had undergone a CS. UI was related to a greater HD (p=0.002) and anteroposterior diameter (p=0.022), FI was associated with a thinner left pubovisceral muscle (p=0.013), and SD was related to a greater HD (p=0.026).

CONCLUSIONS

Three-dimensional ultrasound can identify mild morphological changes in young women with apparently normal physical examinations, mainly after VD and FD. In such individuals, these findings are associated with higher incidences of underreported sexual, urinary and anal symptoms.

Pelvic floor and perineal muscles: a dynamic coordination between skeletal and smooth muscles on pelvic floor stabilization

The purpose of this review is to present our researches on the pelvic outlet muscles, including the pelvic floor and perineal muscles, which are responsible for urinary function, defecation, sexual function, and core stability, and to discuss the insights into the mechanism of pelvic floor stabilization based on the findings. Our studies are conducted using a combination of macroscopic examination, immunohistological analysis, 3D reconstruction, and imaging. Unlike most previous reports, this article describes not only on skeletal muscle but also on smooth muscle structures in the pelvic floor and perineum to encourage new understanding. The skeletal muscles of the pelvic outlet are continuous, which means that they share muscle bundles. They form three muscle slings that pass anterior and posterior to the anal canal, thus serving as the foundation of pelvic floor support. The smooth muscle of the pelvic outlet, in addition to forming the walls of the viscera, also extends in three dimensions. This continuous smooth muscle occupies the central region of the pelvic floor and perineum, thus revising the conventional understanding of the perineal body. At the interface between the levator ani and pelvic viscera, smooth muscle forms characteristic structures that transfer the lifting power of the levator ani to the pelvic viscera. The findings suggest new concepts of pelvic floor stabilization mechanisms, such as dynamic coordination between skeletal and smooth muscles. These two types of muscles possibly coordinate the direction and force of muscle contraction with each other.

Iatrogenic Ureteral Injuries Associated with Gynecological and Surgical Procedures: Our Experience About 18 Cases and Literature Review

Aim

To describe the epidemiological aspects, etiology and outcome of iatrogenic ureteral injury repair at the urology division of Souro Teaching Hospital of Bobo Dioulasso (Burkina-Faso).

Patients and Methods

This was a retrospective descriptive study of consecutive patients with iatrogenic ureteric injuries who were referred and managed in the urology division of Souro Sanou Teaching Hospital (Bobo-Dioulasso) from January 2012 to December 2017. Variables studied were age, the time at the diagnosis, the causative event, the method of repair, and the outcome of the management.

Results

The mean age was 37.72±3.5 years coming from the rural population in most cases. The mean time at the diagnosis was 15 days. The injuries were due to gynecologic surgeries with hysterectomy (66%) and caesarian section (33%). Ureteric reimplantation with anti-reflux system was performed in seventeen patients. The rate of treatment success was 94% and the postoperative course was uneventful for all the patients.

Conclusion

Iatrogenic ureteric lesions at the department of urology of Sanou Sourou teaching hospital of Bobo Dioulasso were mainly caused by gynecologic and obstetric surgeries like hysterectomy and caesarian section.

Reliability of the PERFECT scheme assessed by unidigital and bidigital vaginal palpation

INTRODUCTION AND HYPOTHESIS

The aim of the present study was to evaluate the inter- and intra-rater reliability of the PERFECT scheme assessed by uni- and bidigital vaginal palpation in young nulligravid women.

METHODS

Forty healthy women [median age 22 (19-34) years] were evaluated by unidigital vaginal palpation by both Examiners A and C, while the other 40 participants [median age 23.5 (19-35) years] were assessed by Examiners B and C by bidigital vaginal palpation. Inter- and intra-rater reliability of all items of the PERFECT scheme were evaluated: P = power (Modified Oxford Scale); E = endurance; R = repetitions; F = fast contractions. Cohen's linear weighted kappa (κw) was used to assess the reliability of the power, while the intraclass correlation coefficient (ICC) was applied for the other items. A priori sample size calculation found that 40 participants would be adequate.

RESULTS

Inter-rater reliability of unidigital palpation was considered fair for power (κw = 0.34) and poor for other items (ICC < 0.50); bidigital inter-rater reliability was considered moderate (power: κw = 0.57; endurance: ICC = 0.53; fast contractions: ICC = 0.65, respectively) and low (repetitions: ICC = 0.27). Intra-rater reliability was substantial for power (κw = 0.73 and 0.62), moderate for fast contractions (ICC = 0.63 and 0.51) and poor for repetitions (ICC < 0.50), respectively, for uni- and bidigital palpation. Endurance showed poor (ICC < 0.50) and moderate (ICC = 0.61) reliability for uni- and bidigital palpation.

CONCLUSIONS

The PERFECT scheme carried out by bidigital vaginal palpation presents higher reliability when two examiners carry out the physical examination. When one examiner is responsible for PFM assessment, both types of palpation are recommended for evaluation of power and fast contraction; endurance should be evaluated using bidigital palpation. Examiners should be careful during the assessment of repetition of sustained contractions because inter- and intra-reliabilities for both types of palpation were classified as poor.

Pelvic floor physical therapy in the treatment of pelvic floor dysfunction in women

PURPOSE OF REVIEW

To describe the principles of pelvic floor physical therapy (PFPT), review the evidence for PFPT as a treatment for pelvic floor dysfunction, and summarize the current recommendations for PFPT as a first-line conservative treatment option for pelvic floor disorders.

RECENT FINDINGS

Pelvic floor dysfunction can cause voiding and defecation problems, pelvic organ prolapse (POP), sexual dysfunction, and pelvic pain. PFPT is a program of functional retraining to improve pelvic floor muscle strength, endurance, power, and relaxation in patients with pelvic floor dysfunction. Based on the available evidence, PFPT with or without supplemental modalities can improve or cure symptoms of urinary incontinence, POP, fecal incontinence, peripartum and postpartum pelvic floor dysfunction, and hypertonic pelvic floor disorders, including pelvic floor myofascial pain, dyspareunia, vaginismus, and vulvodynia. Currently, there is conflicting evidence regarding the effectiveness of perioperative PFPT before or after POP and urinary incontinence surgery.

SUMMARY

PFPT has robust evidence-based support and clear benefit as a first-line treatment for most pelvic floor disorders. Standards of PFPT treatment protocols, however, vary widely and larger well designed trials are recommended to show long-term effectiveness.

The histological microstructure and in vitro mechanical properties of the human female postmenopausal perineal body

OBJECTIVE

The perineal body connects muscles from the pelvic floor and is critical for support of the lower part of the vagina and proper function of the anal canal. We determined mechanical parameters and volume fractions of main components of the human female postmenopausal perineal body.

METHODS

The specimens were taken from 15 fresh female cadavers (age 74 ± 10, mean ± standard deviation). Seventy-five specimens from five regions of the perineal body were processed histologically to assess volume fractions of tissue components using stereological point testing grid. Fifteen specimens taken from the midline region were loaded uniaxially with 6 mm/min velocity until tissue rupture to determine Young's modulus of elasticity, ultimate stresses, and strains.

RESULTS

The perineal body was composed of collagen (29%), adipose cells (27%), elastin (7%), smooth muscle (11%), and skeletal muscle (3%). The residual tissue (19%) constituted mostly peripheral nerves, lumina of blood vessels, fibroblasts, and fibrocytes. Young's modulus of elasticity at midline region was 18 kPa (median) at small and 232 kPa at large deformations, respectively. The ultimate stress was 172 kPa and the ultimate strain was 1.4.

CONCLUSIONS

We determined the structural and mechanical parameters of the perineal body. The resultant data could be used as input for models simulating pelvic floor prolapse or dysfunction.

Clinical Significance of Neuropeptide Y Expression in Pelvic Tissue in Patients with Pelvic Floor Dysfunction

OBJECTIVES

To investigate the neuropeptide Y (NPY) expression in the tissue of pelvic floor ligament and anterior vaginal wall in female patients with pelvic organ prolapse (POP) and stress urinary incontinence (SUI).

METHOD

Seventeen patients with POP, 6 with SUI, 13 with POP and SUI (POP&SUI), and 10 controls were included in this study from First Affiliated Hospital of JiNan University. Immunohistochemical assay was used to examine NPY expression in the tissue of round ligament, cardinal ligament of uterus, uterosacral ligament, and anterior vaginal wall. NPY expression were compared between POP, SUI, POP&SUI and controls.

RESULTS

NPY was positive expressed in the round ligament, cardinal ligament of uterus, uterosacral ligament, and anterior vaginal subepithelial connective tissue. Compared with the control group, NPY expression in the round, cardinal, and uterosacral ligaments in patients with POP&SUI group was decreased with significant statistical difference (p<0.05). NPY expression in anterior vaginal wall was significantly decreased in POP, SUI, and POP&SUI groups compared to normal group (p<0.05). Compared to POP group, NPY expression in SUI and POP&SUI groups were significantly decreased (p<0.05), however the difference was not statistical different between SUI and POP&SUI groups (p>0.05). In POP and POP&SUI groups, the NPY expression in the cardinal ligament of uterus, uterosacral ligament, and anterior vaginal wall were negatively correlated with age (p<0.05), however, was not correlated with number of pregnancy, number of delivery, and BMI (p>0.05).

CONCLUSIONS

NPY expression was reduced in the round ligament, cardinal ligament of uterus, Uterosacral ligament, and vaginal anterior wall of the patients with POP and SUI. The decreased NPY expression may play an important role in the development of pelvic floordysfunction.

Translabial Ultrasound in Midurethral Sling (Mesh) Visualization and Erosion Detection in Women With Stress Urinary Incontinence: A Retrospective Pilot Study

Sling erosion is a significant complication of midurethral sling (mesh) placement for stress urinary incontinence, a common pelvic floor disorder. The goal of this retrospective case-control pilot study was to evaluate the performance of translabial ultrasound (TLUS) and magnetic resonance imaging in diagnosing mesh erosion. Therefore, women who underwent surgery in the setting of prior failed midurethral sling for stress urinary incontinence were identified from the hospital database. The case subcohort comprised all women with intraoperatively documented erosion, and the control subcohort comprised an equal number of randomly selected patients without erosion. The data consisted of selected clinical parameters, the presence of erosion at surgery (reference standard) and at cystourethroscopy, and dual-reader preoperative TLUS consensus interpretation for mesh location (intraluminal, mural, and extramural) and erosion (defined as intraluminal or mural mesh location). Odds ratios were calculated for the selected clinical parameters. Of the 198 women identified, 15 (8%) had mesh erosion at surgery into the lower urinary tract. The sensitivity, specificity, and accuracy of TLUS and cystourethroscopy in detecting erosion in the combined group of cases and controls (30 women) were 93%, 88%, and 90%, as well as 67%, 100%, and 83%, respectively (TLUS Cohen κ = 0.85). Thus, TLUS may be a good diagnostic tool in diagnosing mesh erosion. Only 7 of 30 women had pelvic magnetic resonance examination, and mesh fragments were not visualized. Case-control comparison of the selected clinical parameters was not statistically significant.

Translabial US: Preoperative Detection of Midurethral Sling Erosion in Stress Urinary Incontinence

Purpose To evaluate the performance of translabial (TL) US in preoperative detection of sling erosion into pelvic organs with cystourethroscopic and surgical correlation. Materials and Methods The study cohort included women who underwent surgery at a subspecialty center (from 2008 to 2016) for suspected mesh complications in the setting of previous midurethral sling placement for stress urinary incontinence (from 1999 to 2012) with available preoperative TL US imaging. Clinical information, the finding of sling erosion identified intraoperatively and at cystourethroscopy, and blinded dual-reader radiologic analysis of the TL US studies for mesh location (intraluminal, mural, or extramural) relative to pelvic organs (bladder, urethra, vagina, or rectum) were evaluated. The diagnostic performance of TL US was correlated with the reference standard of surgical findings. The consensus of two radiologists was recorded, and interobserver agreement was evaluated with the κ statistic. Results Of the 124 women who were suspected of having sling erosion (mean age, 57.5 years ± 11.1 [standard deviation]), 15 women (12.1%) had sling erosion into the urethra or bladder at surgery. Sensitivity and specificity for erosion at TL US were 53% (95% confidence interval: 45%, 62%) and 100% (95% confidence interval: 97%, 100%), respectively, when erosion was defined as only intraluminal mesh products. Sensitivity and specificity for erosion at TL US were 93% (95% confidence interval: 89%, 98%) and 72% (95% confidence interval: 65%, 80%), respectively, when erosion was defined as visualizing either intraluminal or intramural mesh products. Interobserver agreement (κ value) was 0.95. Cystourethroscopy had 67% sensitivity and 100% specificity for sling erosion. Conclusion Preoperative translabial US can be used to detect sling erosion into the lower urinary tract, with sensitivity up to 93% and specificity up to 100%. © RSNA, 2018 Online supplemental material is available for this article. See also the editorial by Benson and Phillips in this issue.

Pelvic Floor Physical Therapy and Women's Health Promotion

Pelvic floor dysfunction is defined as abnormal function of the pelvic floor and includes conditions that can have significant adverse impacts on a woman's quality of life, including urinary incontinence (stress, urge, and mixed), fecal incontinence, pelvic organ prolapse, sexual dysfunction, diastasis recti abdominis, pelvic girdle pain, and chronic pain syndromes. Women's health care providers can screen for, identify, and treat pelvic floor dysfunction. This article examines the case of a woman with multiple pelvic-floor-related problems and presents the evidence for the use of pelvic floor physical therapy (PFPT) for pregnancy-related pelvic floor dysfunction. PFPT is an evidence-based, low-risk, and minimally invasive intervention, and women's health care providers can counsel women about the role that PFPT may play in the prevention, treatment, and/or management of pelvic floor dysfunction.

Modelling of Soft Connective Tissues to Investigate Female Pelvic Floor Dysfunctions

After menopause, decreased levels of estrogen and progesterone remodel the collagen of the soft tissues thereby reducing their stiffness. Stress urinary incontinence is associated with involuntary urine leakage due to pathological movement of the pelvic organs resulting from lax suspension system, fasciae, and ligaments. This study compares the changes in the orientation and position of the female pelvic organs due to weakened fasciae, ligaments, and their combined laxity. A mixture theory weighted by respective volume fraction of elastin-collagen fibre compound (5%), adipose tissue (85%), and smooth muscle (5%) is adopted to characterize the mechanical behaviour of the fascia. The load carrying response (other than the functional response to the pelvic organs) of each fascia component, pelvic organs, muscles, and ligaments are assumed to be isotropic, hyperelastic, and incompressible. Finite element simulations are conducted during Valsalva manoeuvre with weakened tissues modelled by reduced tissue stiffness. A significant dislocation of the urethrovesical junction is observed due to weakness of the fascia (13.89 mm) compared to the ligaments (5.47 mm). The dynamics of the pelvic floor observed in this study during Valsalva manoeuvre is associated with urethral-bladder hypermobility, greater levator plate angulation, and positive Q-tip test which are observed in incontinent females.

Myotonometry Reliably Measures Muscle Stiffness in the Thenar and Perineal Muscles

Purpose: The authors investigated the reliability of myotonometry-measured muscle tone in the thenar and perineal muscles. Methods: Participants were women aged 18-50 years who were asymptomatic for thumb and pelvic floor dysfunction (interrater study n=20; intrarater study n=43) or who were symptomatic for vulvodynia (interrater study n=14; intrarater study n=32). Mechanical properties (stiffness, frequency, decrement, relaxation time, and creep) of the muscles were measured using a myotonometer (MyotonPRO) while the muscles were in a relaxed state. Measures were performed twice by two assessors. Intra- and interrater reliability were determined using intra-class correlation coefficients (ICCs) and absolute reliability using the standard error of measurement and a minimum detectable change. Results: The primary property of interest, muscle stiffness, showed very good interrater (ICC 0.85-0.86) and intrarater (ICC 0.82-0.88) reliability in the thenar eminence. In the perineal muscles, reliability results ranged from good to very good for interrater (ICC 0.70-0.86) and intrarater (ICC 0.80-0.91) reliability for muscle stiffness. Absolute reliability was confirmed, with all measures showing minimal variance. Conclusions: Muscle stiffness of the smaller muscles of the body can be reliably measured using the MyotonPRO. The device could be used as a reference standard in the development of a digital palpation scale that would facilitate accurate diagnosis of muscle tone.

Early results of a novel technique for anterior vaginal wall prolapse repair: anterior vaginal wall darn

BACKGROUND

The aim of this study was to describe the results of a 1-year patient follow-up after anterior vaginal wall darn, a novel technique for the repair of anterior vaginal wall prolapse.

METHODS

Fifty-five patients with anterior vaginal wall prolapse underwent anterior vaginal wall darn. The anterior vaginal wall was detached using sharp and blunt dissection via an incision beginning 1 cm proximal to the external meatus and extending to the vaginal apex. The space between the tissues that attach the lateral vaginal walls to the arcus tendineus fasciae pelvis was then darned. Cough Stress Test, Pelvic Organ Prolapse Quantification, seven-item Incontinence Impact Questionnaire, and six-item Urogenital Distress Inventory scores were performed 1-year postoperatively to evaluate recovery.

RESULTS

One-year postoperatively, all patients were satisfied with the results of the procedure. No patient had vaginal mucosal erosion or any other complication.

CONCLUSIONS

One-year postoperative findings for patients in this series indicate that patients with stage II-III anterior vaginal wall prolapse were successfully treated with the anterior vaginal wall darn technique.

The role of smooth muscle cells in the pathophysiology of pelvic organ prolapse

Pelvic organ prolapse (POP) is a prevalent and disabling condition. The pathophysiology of prolapse is multifactorial, and no single mechanism adequately explains all aspects of its development. The pathophysiology of POP is complex and incompletely understood. Smooth muscle (SM), an integral part of the vaginal wall and endopelvic structures that support the pelvic viscera, has also been implicated in the pathophysiology of POP. In this article, we review the role of smooth muscle cells (SMC) in the pathophysiology of POP, also addressing the anatomy of SM in pelvic floor, morphometric analysis, biomechanical properties, and potential mechanisms.

A novel technique for anterior vaginal wall prolapse repair: anterior vaginal wall darn

AIM

The aim of this study is to introduce a new technique, anterior vaginal wall darn (AVWD), which has not been used before to repair the anterior vaginal wall prolapse, a common problem among women.

MATERIALS AND METHODS

Forty-five women suffering from anterior vaginal wall prolapse were operated on with a new technique. The anterior vaginal wall was detached by sharp and blunt dissection via an incision beginning from the 1 cm proximal aspect of the external meatus extending to the vaginal apex, and the space between the tissues that attach the lateral walls of the vagina to the arcus tendineus fascia pelvis (ATFP) was then darned. Preoperation and early postoperation evaluations of the patients were conducted and summarized.

RESULTS

Data were collected six months after operation. Cough stress test (CST), Pelvic Organ Prolapse Quantification (POP-Q) evaluation, Incontinence Impact Questionnaire (IIQ-7), and Urogenital Distress Inventory (UDI-6) scores indicated recovery. According to the early postoperation results, all patients were satisfied with the operation. No vaginal mucosal erosion or any other complications were detected.

CONCLUSION

In this initial series, our short-term results suggested that patients with grade II-III anterior vaginal wall prolapsus might be treated successfully with the AVWD method.

Normal vulvovaginal, perineal, and pelvic anatomy with reconstructive considerations

A thorough insight into the female genital anatomy is crucial for understanding and performing pelvic reconstructive procedures. The intimate relationship between the genitalia and the muscles, ligaments, and fascia that provide support is complex, but critical to restore during surgery for correction of prolapse or aesthetic reasons. The external female genitalia include the mons pubis, labia majora and minora, clitoris, vestibule with glands, perineal body, and the muscles and fascia surrounding these structures. Through the perineal membrane and the perineal body, these superficial vulvar structures are structurally related to the deep pelvic muscle levator ani with its fascia. The levator ani forms the pelvic floor with the coccygeus muscle and provides vital support to all the pelvic organs and stability to the perineum. The internal female genital organs include the vagina, cervix, uterus, tubes, and ovaries with their visceral fascia. The visceral fascia also called the endopelvic fascia, surrounds the pelvic organs and connects them to the pelvic walls. It is continuous with the paraurethral and paravaginal fascia, which is attached to the perineal membrane. Thus, the internal and external genitalia are closely related to the muscles and fascia, and work as one functioning unit.