Anatomie fonctionnelle du plancher pelvien

The importance of using 3D ultrasound during pelvic organ prolapse surgery in relation to pre- and post-operative quality of life questionnaires

AIM

The main aim of this study is to evaluate the interest of three-dimensional ultrasound perineal in the measurement of the levator hiatus area as an objective reflection of the surgical correction of pelvic organ prolapse (POP). Our hypothesis is that POP surgery decreases the size of the levator hiatus area.

MATERIALS AND METHODS

A longitudinal and prospective study was conducted between April and July 2017 in the Department of Gynaecology & Obstetrics at University Hospital of Angers. Surgery was performed either by laparoscopy (sacrocolpopexy) or vaginal surgery (with or without the use of mesh). All patients were handed an information letter and signed an informed consent before being included in the study. A questionnaire was fullfilled before and one month after surgery. A clinical evaluation using the simplified POP-Q classification and a perineal 3D ultrasound were carried out before and after surgery by the same professional. The levator hiatus area was assessed before and after surgery in order to evaluate the impact of surgery on the levator hiatus area. Simplified POP-Q measurements and responses to PFDI-20 and PFDI-7 questionnaires were also collected.

RESULTS

A total of 18 patients were included in the study and four were excluded. Seven underwent laparoscopic surgery and seven underwent vaginal surgery. The levator hiatus area decreased substantially from 20.87 to 16.55cm² on mean (p=0.0001) at rest. Regarding patient satisfaction, the PFDI-20 score improved after surgery from 89.36 to 37.87 on mean (p=0.006), but the PFIQ-7 score did not reveal any significant changes (p=0.096). For the clinical examination, we used the simplified POP-Q with Ba measurement from 2.3 to -1.92cm (p=0.005) or Bp from -1.5 to -2.46cm, which is not a significant change (p=0.14). Points C (or D in cases with a history of hysterectomy) changed from -3.1 to -6.15cm (p=0.03).

CONCLUSION

The levator hiatus area seems to decrease after POP surgery. 3D ultrasound seems a new and complementary procedure that allowed to evaluate objectively the levator hiatus area and thus the clinical findings of the surgery.

Clinical functional evaluation of female's pelvic floor: integrative review

Abstract Introduction: The effectiveness of pelvic floor muscle training (PFMT) depends on the correct prescription of intensity, repetition and endurance of muscle contractions, which are provided by an adequate assessment of pelvic floor muscle. Objective: Verify the techniques, resources and strategies used for clinical functional evaluation of female pelvic floor (PF) described in literature. Methods: It’s an integrative review of published studies and books from 2010 until December 2015. Relevant articles with complete description of PF evaluation were found through the use of Scielo, LILACS, PubMed and Medline databases. Results: 34 articles that fulfilled all the criteria were selected. Conclusion: The most used techniques, resources and strategies were: anamnesis, physical examination, measurement of pelvic floor muscle activity using Modified Oxford Scale or perineometry, and use of questionnaires to analyze patient's perspective of their own symptoms. Thus, we could use the parameters obtained in the evaluation to plan an ideal PFMT for each patient, so the physiotherapist would have a good database to analyze the evolution and define the end of therapy.

Determination of a cutoff value for pelvic floor distensibility using the Epi-no balloon to predict perineal integrity in vaginal delivery: ROC curve analysis. Prospective observational single cohort study

CONTEXT AND OBJECTIVE

Several risk factors are involved in perineal lacerations during vaginal delivery. However, little is known about the influence of perineal distensibility as a protective factor. The aim here was to determine a cutoff value for pelvic floor distensibility measured using the Epi-no balloon, which could be used as a predictive factor for perineal integrity in vaginal delivery.

DESIGN AND SETTING

Prospective observational single cohort study conducted in a maternity hospital.

METHODS

A convenience sample of 227 consecutive at-term parturients was used. All women had a single fetus in the vertex presentation, with up to 9.0 cm of dilation. The maximum dilation of the Epi-no balloon was measured using a tape measure after it had been inflated inside the vagina up to the parturients' maximum tolerance. The receiver operating characteristic (ROC) curve was used to obtain the Epi-no circumference measurement with best sensitivity and specificity.

RESULTS

Among the 161 patients who were included in the study, 50.9% underwent episiotomy, 21.8% presented lacerations and 27.3% retained an intact perineum. Age > 25.9 years; number of pregnancies > 3.4; number of deliveries > 2.2 and circumference measured by Epi-no > 21.4 cm were all directly correlated with an intact perineum. Circumference measurements using the Epi-no balloon that were greater than 20.8 cm showed sensitivity and specificity of 70.5% and 66.7% (area under curve = 0.713), respectively, as a predictive factor for an intact perineum in vaginal delivery.

CONCLUSION

Circumferences greater than 20.8 cm achieved using the Epi-no balloon are a predictive factor for perineal integrity in parturients.

Three-dimensional modeling of the pelvic floor support systems of subjects with and without pelvic organ prolapse

The purpose of this study was to develop three-dimensional finite element models of the whole pelvic support systems of subjects with and without pelvic organ prolapse (POP) that can be used to simulate anterior and posterior wall prolapses. Magnetic resonance imaging was performed in one healthy female volunteer (55 years old, para 2) and one patient (56 years old, para 1) with anterior vaginal wall prolapse. Contours of the pelvic structures were traced by a trained gynecologist. Smoothing of the models was conducted and attachments among structures were established. Finite element models of the pelvic support system with anatomic details were established for both the healthy subject and the POP patient. The models include the uterus, vagina with cavity, cardinal and uterosacral ligaments, levator ani muscle, rectum, bladder, perineal body, pelvis, obturator internus, and coccygeal muscle. Major improvements were provided in the modeling of the supporting ligaments and the vagina with high anatomic precision. These anatomically accurate models can be expected to allow study of the mechanism of POP in more realistic physiological conditions. The resulting knowledge may provide theoretical help for clinical prevention and treatment of POP.

Fiber type characterization of striated muscles related to micturition in female rabbits

Pelvic and perineal striated muscles are relevant for reproduction and micturition in female mammals. Damage to these muscles is associated with pelvic organ prolapse and stress urinary incontinence. The fiber type composition of skeletal muscle influences the susceptibility for damage and/or regeneration. The aim of the present study was to determine the fiber type composition of a perineal muscle, the bulbospongiosus, and a pelvic muscle, the pubococcygeus. Both muscles were harvested from adult female rabbits (8-10 months old). NADH-TR (nicotinamide adenine dinucleotide tetrazolium reductase) histochemistry was undertaken to identify oxidative and glycolytic muscle fibers. Alkaline (pH 9.4) ATP-ase (actomyosin adenosine triphosphatase) histochemistry was used to classify type I, type IIb or type IIa/IId muscle fibers. Results showed that the content of glycolytic fibers in the bulbospongiosus muscle was higher than that of oxidative fibers. Meanwhile, the opposite was true for the pubococcygeus. In the bulbospongiosus muscle, the content of type IIb muscle fibers was higher than that of type I, but was similar to that of type IIa/IId. In contrast, the content of each fiber type was similar in the pubococcygeus muscle. The relative proportion of fibers in bulbospongiosus and pubococcygeus muscles is consistent with their function during voiding and storage phases of micturition.