Pelvic floor imaging

Reliability and validity of pelvic floor muscle displacement measurements during voluntary contractions

INTRODUCTION AND HYPOTHESIS

Understanding the functioning of pelvic floor muscles (PFM) is crucial in female PFM rehabilitation. The aim of this study was to determine the intra-session retest reliability and validity to evaluate the quantity of PFM displacement.

METHODS

This cross-sectional observational study examined the PFM displacement of 17 young healthy nulliparous women in the midsagittal plane. Three maximal voluntary contractions (MVCs) and five fast voluntary contractions (FVCs) were simultaneously examined with an electromagnetic tracking system (ETS) and transabdominal ultrasound (TAUS) and expressed in millimeters (mean, SD). To evaluate reliability and validity, the analysis of variance, intraclass coefficient (2,1), standard error of measurement (SEM), and minimal detectable difference (MDD) were calculated.

RESULTS

Maximal voluntary contractions and FVCs in supine position measured by an ETS (TAUS) showed a displacement of MVC: 3.5 ± 1.9 mm (7.8 ± 4.5 mm), FVC: 3.5 ± 2.4 mm (7.6 ± 5.3 mm), and during standing of MVC: 5.2 ± 1.6 mm (9.4 ± 3.8 mm) and FVC: 4.8 ± 2.5 mm (9.7 ± 4.1 mm). Intraclass correlation for the ETS (TAUS) measurement varied between 0.79 and 0.89 (0.61 and 0.74), SEM 0.52 and 1.03 mm (1.54 and 3.2 mm), and MDD 1.54 and 3.2 mm (6.64 and 7.53 mm). The correlation between an ETS and TAUS varied between 0.53 and 0.67.

CONCLUSIONS

For MVC and FVC, ETS measurements are highly reliable and TAUS measurements are moderately reliable for both contraction types. The correlation between the TAUS and ETS measurements is moderate. An ETS seems to be a reliable and valid measurement tool for evaluating PFM displacement during voluntary contractions. In future studies, the reproducibility and validity of ETS measurements need to be investigated in impact activities.

Laparoscopic inguinal ligament suspension with uterine preservation for pelvic organ prolapse: A retrospective cohort study

OBJECTIVE

To introduce an alternative surgical technique of laparoscopic inguinal ligament suspension (LILS) with uterine preservation and evaluate its efficacy and safety for patients with severe pelvic organ prolapse (POP).

METHODS

Between June 2014 and December 2015, 35 patients with symptomatic stage III or IV were treated by LILS with uterine preservation. The perioperative parameters including surgical time, blood loss, hospital stay and complications were recorded. The anatomical cure rate was evaluated according to the Pelvic Organ Prolapse Questionnaire (POP-Q) assessment. The anatomical points were analyzed by dynamic Magnetic Resonance Imaging (MRI). Validated questionnaire of the Pelvic Floor Distress Inventory (PFDI-20), the Pelvic Floor Impact Questionnaire (PFIQ-7) and the Pelvic organ prolapse urinary Incontinence Sexual Questionnaire (PISQ-12) were recorded to evaluate the symptom severity, quality of life and sexual activity.

RESULTS

The mean surgical time was 163.8 ± 42.3 min (range: 120-280 min), the mean estimated blood loss was 48.6 ± 60.5 ml (range: 10-200 ml), and the mean hospital stay was 5 days (range: 3-7 days). No intra-operative complications were encountered. The anatomical success rate at postoperative 6-month and 12-month was 97.1% and 94.3%, respectively. The postoperative anatomical points on straining showed a significant improvement on dynamic MRI as compared to baselines. The symptom severity, quality of life and sexual activity also presented significant improvement both 6-month and 12-month after surgery. After a minimal 12 months follow-up, no postoperative complications occurred and the recurrence prolapse were low.

CONCLUSION

LILS with uterine preservation is a feasible, effective and safe surgical alternative in the treatment of POP for patients who desire to reserve uterus. Longer follow-up data from larger studies are required to confirm the benefits of LILS with uterine preservation as a minimally invasive surgical approach.

A manometry classification to assess pelvic floor muscle function in women

OBJECTIVE

To develop a classification scale for manometry of pelvic floor muscles (PFM) in Brazilian women, according to the modified Oxford scale.

METHODS

A cross sectional study, with 288 women enrolled in the Maternity, Natal, Brazil. Manometry and PFM strength data were collected and classified according to the modified Oxford scale. A simple linear regression was performed to determine the classification scale of manometry using the modified Oxford scale as the explanatory variable and the arithmetic mean of the manometry measurements as the response variable.

RESULTS

The average age was 52.80 (±8.78; CI: 51.67-53.93) years. Manometry showed an average of 35.1 (±22.7; CI: 32.1-38.0) cmH2O and most women (29.7%) scored grade 3 on the modified Oxford scale. According to the proposed scale, values between 7.5 to 14.5 cmH2O correspond to very weak pressure; 14.6 to 26.5 cmH2O represent weak pressure; 26.6 to 41.5 cmH2O represent moderate pressure; 41.6 to 60.5 cmH2O represent good pressure, and values above 60.6 cmH2O correspond to strong pressure.

CONCLUSION

Manometry values were rated on a five-point scale. It is possible to rank the pressure levels performed by voluntary contraction of PFM with this new scale.

Evaluation of isolated urinary stress incontinence according to the type of levator ani muscle lesion using 3/4D transperineal ultrasound 36 months post-partum

INTRODUCTION

Vaginal delivery can lead to pelvic floor disorders. Many authors have described pelvic floor injuries that can predict future defects such as urinary incontinence and pelvic organ prolapse. We propose the assessment of urinary stress incontinence and its association with levator ani muscle (LAM) microtrauma (>20% in the levator hiatus area during Valsalva) and macrotraumas (avulsion) identified by 3/4D transperineal ultrasound (3D-TpUS) 36 months post-partum.

MATERIALS AND METHODS

This was a prospective observational study including 168 nulliparous women. All patients included were nulliparous with singleton gestation in cephalic presentation, at ≥37 weeks and were recruited on the first day after delivery. Thirty-six months after delivery, 3D-TpUS was carried out to identify LAM lesions (macro or micro). Clinical assessment of urinary stress incontinence (USI) was based on the ICIQ-UI-SF test; a simple stress test and urodynamic test were carried out in the same visit.

RESULTS

A total of 105 nulliparous women were studied (51 spontaneous deliveries [SpD] and 54 vacuum-assisted deliveries [VD]). Microtraumas were identified in 35.3% of SpD and 20.4% of VD. Macrotraumas (avulsion) were identified in 9.8% of SpD and 35.2% of VD (p = 0.006). No differences were found in USI between study groups or in relation to the identification of LAM defects (19.2% in the no lesion group, 25% in the macrotrauma and 13.8% in the microtrauma groups; p = not significant). Nor were significant differences found in the results from the different study groups in the International Consultation on Incontinence Modular Questionnaire Urinary Incontinence Short Form (ICIQ-UI SF) test (12.7±2.2 in the no lesion group, 12.5±4.2 in the macrotrauma and 13.25±4.8 in the microtrauma groups; p = NS).

CONCLUSION

No difference was observed in USI between patients with and without LAM lesions (microtrauma or macrotrauma) 36 months post-delivery.

Changes in the mean echogenicity and area of the puborectalis muscle during pregnancy and postpartum

Introduction and hypothesis

Three-dimensional (3D) and four-dimensional (4D) volume transperineal ultrasound imaging is increasingly used to assess changes in the dimensions of the pelvic floor during pregnancy and after delivery. Little is known with regard to the area of the puborectalis muscle and its structural changes. Echogenicity measurement, a parameter that provides information on the structure of muscles, is increasingly used in orthopaedics and neuromuscular disease evaluation. This study is aimed at assessing the changes in the mean echogenicity of the puborectalis muscle (MEP) and the puborectalis muscle area (PMA) during first pregnancy and after childbirth.

Methods

The MEP and PMA of 254 women during first pregnancy were measured at 12 and 36 weeks’ gestation and 6 months postpartum. To determine the effect of child-birth on MEP and PMA, the results at 6 months postpartum were separately analysed for vaginal deliveries, operative vaginal deliveries (ventouse) and caesarean section deliveries. Mean differences in MEP and PMA were analysed using ANOVA statistics.

Results

The MEP at 6 months postpartum was, independent of manoeuvre, significantly (p < 0.001) lower than MEP values during pregnancy. After caesarean delivery, the PMA was significantly smaller at maximum pelvic floor contraction than PMA after vaginal delivery (p = 0.003) or operative vaginal delivery (p = 0.002).

Conclusion

Our study indicates that structural changes in the puborectalis muscle during and after pregnancy, as measured by MEP, occur and can be analysed. In addition, the mode of delivery affects the area of the puborectalis during contraction after delivery. For true volume analysis, as part of an assessment of contractility of the puborectalis muscle we will need 3D volume analysis.

Effect of increasing awareness of pelvic floor muscle function on pelvic floor dysfunction: a randomized controlled trial

INTRODUCTION AND HYPOTHESIS

This randomized controlled study with blinding allocation evaluated pelvic floor knowledge (PFK) and the presence of pelvic floor dysfunction (PFD) in women office workers. The effects of receiving pelvic floor muscle (PFM) health education on PFK and PFD were also evaluated.

METHODS

Of 161 female volunteers, 145 (90.0 %, age range 18-69 years) responded. They were randomly allocated to three groups (group A 48, group B 48, group C 49). Online surveys were completed by all groups on three occasions using validated tools (Prolapse and Incontinence Knowledge Quiz, PFDI-20, PFIQ-7) and PFM exercise items. On completion of the baseline survey, groups A and B received an education intervention (group C was the control). Following this, all participants completed the second survey. Two months later, to allow time for the PFM exercises to have an effect, group A attended a re-education presentation, followed by the final survey administered to all groups. The results were analyzed using analysis of variance and Tukey's test.

RESULTS

Participants receiving both PFM exercise education interventions (group A) and those receiving only the first education intervention (group B) showed highly significant improvements in PFK compared with the control group (both p < 0.001). The groups receiving PFM exercise education also showed a highly significant decrease in PFD symptoms (p < 0.001), and a significant increase in quality of life (QoL; p < 0.05).

CONCLUSIONS

While the results of this study cannot be generalized to all women, low levels of PFK was associated with high a prevalence of PFD, and an increase in knowledge/awareness following education was significantly associated with an increase in QoL and a decrease in PFD symptoms.

Anorectal incontinence: a challenge in diagnostic and therapeutic approach

Anorectal incontinence is a symptom of a complex multifactorial disorder involving the pelvic floor and anorectum, which is a severe disability and a major social problem. Various causes may affect the anatomical and functional integrity of the pelvic floor and anorectum, leading to the anorectal continence disorder and incontinence. The most common cause of anorectal incontinence is injury of the sphincter muscles following delivery or anorectal surgeries. Although the exact incidence of anorectal incontinence is unknown, various studies suggest that it affects ~2.2-8.3% of adults, with a significant prevalence in the elderly (>50%). The successful treatment of anorectal incontinence depends on the accurate diagnosis of its cause. This can be achieved by a thorough assessment of patients. The management of incontinent patients involves conservative therapeutic procedures, surgical techniques, and minimally invasive approaches.

Postpartum translabial 2D and 3D ultrasound measurements of the anal sphincter complex in primiparous women delivering by vaginal birth versus Cesarean delivery

INTRODUCTION AND HYPOTHESIS

Consensus on normal translabial ultrasound (TL-US) anal sphincter complex measurements for postpartum women is lacking. We aimed to evaluate normative measurements in 2D and 3D TL-US for the anal sphincter complex (ASC) at 6 months postpartum and compare these measurements in women who had a vaginal birth (VB) and in those who had a Cesarean delivery (CD).

METHODS

A large, prospective cohort of primiparous women underwent 2D and 3D TL-US 6 months after their first delivery. For normative sphincter measurements, we excluded women with third- or fourth-degree lacerations or with sphincter interruption on TL-US. Measurements included the sphincter thickness at the 3, 6, 9, and 12 o'clock positions of the external anal sphincter (EAS) and the internal anal sphincter (IAS) at proximal, mid, and distal levels. We also measured the mean coronal diameter of the pubovisceralis muscle (PVM).

RESULTS

696 women consented to participate, and 433 women presented for ultrasound imaging 6 months later. Women who sustained a third- or fourth-degree laceration had significantly thicker EAS measurements at 12 o'clock. Sphincter asymmetry was common (69 %), but was not related to mode of delivery. Only IAS measurements at the proximal and distal 12 o'clock position were significantly thicker for CD patients. There were no significant differences in the EAS or PVM measurements between VB and CD women.

CONCLUSIONS

There appear to be few differences in normative sphincter ultrasound measurements between primiparous patients who had VB or CD.