Maternal birth trauma: why should it matter to urogynaecologists?

Levator Ani Muscle Avulsion After Vaginal Delivery Comparing Routine Versus Restrictive Episiotomy: A Pilot Study

INTRODUCTION AND HYPOTHESIS

The objective was to compare the rate of levator ani muscle avulsion following vaginal birth after routine and restrictive episiotomy.

METHODS

This study consists of two cohorts of pregnant women prospectively enrolled between September 2015 and December 2017 at a university hospital. The pregnant women were subject to a randomized controlled trial, in which participants received a restrictive episiotomy protocol versus a routine episiotomy protocol for vaginal delivery. Levator ani avulsion was evaluated by four-dimensional ultrasound screening.

RESULTS

Sixty-one post-partum primipara women were enrolled in our study. Thirty-two women (52.5%) had undergone routine episiotomy whereas 29 women (47.5%) had gone through restrictive episiotomy. Right mediolateral episiotomies were performed in all cases. The rate of anal sphincter tear was 12.5% in the routine episiotomy group versus 13.8% in the restrictive episiotomy group (p = 1.00). Levator ani avulsion was detected in 9.4% of the routine episiotomy group (only on the right side) and in 10.3% of the restrictive episiotomy group (p = 1.00). No bilateral levator avulsion was detected in either of the groups. There were no statistical differences in the distances of the bladder neck descent, cystocele descent, uterine descent, rectocele descent, and the ballooning of the genital hiatus area between the groups.

CONCLUSIONS

In our pilot study, there was no reduction of the rate of levator ani avulsion in women with restrictive episiotomy compared with routine episiotomy. There were no differences in pelvic floor ultrasound parameters between the two groups.

Levator-urethra gap: is there a need for individualization of cut-offs?

OBJECTIVES

To determine whether height, weight and body mass index (BMI) are associated with the levator-urethra gap (LUG) measurement, and whether these factors confound the relationship between LUG and symptoms and signs of pelvic organ prolapse (POP).

METHODS

This was a retrospective study of women seen at a tertiary urogynecology unit between January 2020 and December 2021. Postprocessing of saved ultrasound volume data was used to measure the LUG, blinded against all other data. This measurement was tested for its association with organ descent and hiatal area, and height, weight and BMI were investigated for any potential confounding effect.

RESULTS

The 624 women seen during the inclusion period presented mostly with stress urinary incontinence (448/624 (72%)), urgency urinary incontinence (469/624 (75%)) and/or prolapse (338/624 (54%)). Mean age at assessment was 58 (range, 20-94) years, mean height was 163 (range, 142-182) cm, mean weight was 80 (range, 41-153) kg and mean BMI was 30 (range, 17-65) kg/m2. LUG measurements could be obtained in 613 women, resulting in 7356 (12 × 613) measurements. The average LUG in individual women measured 2.35 cm on the right and 2.32 cm on the left side (difference not significant), with a mean ± SD of 2.34 ± 0.63 cm overall. Mean LUG was associated with symptoms and signs of prolapse, both on clinical examination (POP quantification system) and on imaging, but not with height (P = 0.36), weight (P = 0.20) or BMI (P = 0.09).

CONCLUSIONS

Levator-urethra gap measurements do not seem to be significantly associated with height, weight or BMI in our population, obviating the need for individualization of LUG. However, this does not exclude interethnic variability of this biometric measure. © 2024 International Society of Ultrasound in Obstetrics and Gynecology.

Associated factors of vaginal laxity and female sexual function: a cross-sectional study

BACKGROUND

Female sexual dysfunction (FSD), including vaginal laxity (VL), can lead to a decrease in quality of life and affect partner relationships.

AIM

We aimed to investigate the associated factors of VL and FSD and their relationship with other pelvic floor disorders in a female population.

METHODS

This cross-sectional study was conducted at Chelsea and Westminster Hospital from July to December 2022. All women referred to clinical care at the urogynecology clinic were included. Participants were assessed according to sociodemographic and clinical aspects, the Pelvic Organ Prolapse Quantification system, sexual function, VL, sexual attitudes, sexual distress, sexual quality of life, vaginal symptoms, and pelvic floor disorders. Unadjusted and adjusted associated factors of VL and FSD were analyzed.

OUTCOMES

The primary outcome was the identification of the associated factors of VL and FSD in a female population, and secondary outcomes included the association between VL and pelvic organ prolapse (POP) with the questionnaire scores.

RESULTS

Among participants (N = 300), vaginal delivery, multiparity, perineal laceration, menopause, and gel hormone were significantly more frequent in those reporting VL (all P < .05). When compared with nulliparity, primiparity and multiparity increased the odds of VL by approximately 4 and 12 times, respectively (unadjusted odds ratio [OR], 4.26 [95% CI, 2.05-8.85]; OR, 12.77 [95% CI, 6.53-24.96]). Menopause and perineal laceration increased the odds of VL by 4 and 6 times (unadjusted OR, 4.65 [95% CI, 2.73-7.93]; OR, 6.13 [95% CI, 3.58-10.49]). In multivariate analysis, menopause, primiparity, multiparity, and POP remained associated with VL.

CLINICAL IMPLICATIONS

Parity, as an obstetric factor, and menopause and staging of POP, as clinical factors, were associated with VL.

STRENGTHS AND LIMITATIONS

The investigation of associated factors for VL will contribute to the understanding of its pathophysiology. The study design makes it impossible to carry out causal inference.

CONCLUSION

Menopause, primiparity, multiparity, and POP were highly associated with VL complaints in multivariate analysis.

[Vaginal laxity: Semiology, diagnosis and treatments]

OBJECTIVES

Vaginal laxity concerns 24 to 38% of women but it's still poorly understood and studied. The objective of this study is to do an inventory of current scientific knowledge about its definition, its diagnostic criteria, and treatments.

METHODS

We conducted a non systematic review of literature including original articles in French and English about the definition, diagnostic criteria and treatments of vaginal laxity using data bases such as Cochrane, Embase, Medline, PubMed et Science Direct.

RESULTS

It is a feeling of excessive looseness that can alter the quality of sexual intercourses. The main risk factor is vaginal delivery. The feeling of vaginal laxity appears to be linked to an excessive distensibility of the levator ani muscle that can be evaluated during physical examination by the measure of the genital hiatus and the perineal body (GH and PB measures from the POP-Q classification) during vasalva or by the measure of genital hiatus area by translabial sonography during valsalva. Although pelvic muscle training is currently prescribed as a first line treatment, data are limited to confirm its effectiveness in this affection. Colpoperineorraphy with levator ani myorraphy which was mostly evaluated in case of genital prolapse is associated with a high success rate but is at risk of dyspareunia. New nonsurgical treatments such as radiofrequency and vaginal laser seems to lead to lower success rate than surgical treatments but they are less invasive. Their effectiveness and long-term effects are still unknown which restrict their application in this condition.

CONCLUSION

Vaginal laxity is a frequent condition that impacts on the quality of life and sexual function. Further studies should be conducted to better understand its physiopathology and the optimal treatment.

Hyaluronic Acid and Radiofrequency in Patients with Urogenital Atrophy and Vaginal Laxity

Vaginal laxity (VL) and genitourinary syndrome of menopause (GSM), as well as aesthetic changes in the vulvar skin, often occur together and cause physical, psychological, and functional problems for women and their partners. The current study evaluated the efficacy of a nonsurgical radiofrequency device (RF) procedure combined with hyaluronic acid (HA) injection into the skin of the labia majora on clinical, histological, and aesthetic levels. Twenty women with GSM and VL, aged between 36 and 72 (mean age 53.4), were treated with bipolar RF SECTUM, vaginal and vulvar application, as well as with a hyaluronic acid (HA) injection into the skin of the labia majora. The Vaginal Laxity Questionnaire (VLQ), Vaginal Health Index (VHI), and Female Sexual Function Index (FSFI) were used to examine the clinical effects of the operations. The Global Aesthetic Improvement Scale was utilized to measure patient satisfaction. On a histochemical level, the concentrations of elastin and collagen in the vaginal wall and vulvar skin were examined. Results: There was significantly higher patient satisfaction and a considerable clinical improvement across all areas of analysis. On the histochemical level, elastin and collagen fiber concentration increased after the treatment protocol both in the vulvar skin and in the vaginal wall: elastin in the vaginal wall, 11.4%, and in the vulvar skin, 61%; collagen in the vaginal wall, 26%, and in the vulvar skin, 27%. The current study demonstrated the efficacy and safety of this nonsurgical RF procedure combined with a hyaluronic acid (HA) injection into the skin of the labia majora on clinical, histochemical, and aesthetic levels.

Micro-Focused Ultrasound Therapy in Patients with Urogenital Atrophy and Vaginal Laxity

Vaginal laxity (VL) and genitourinary syndromes of menopause (GSM) create physical, psychological, and functional problem for women and their partners. We aimed to evaluate the efficacy and safety of micro-focused ultrasound (MFU) therapy performed twice in the vaginal canal in a patients with VL and GSM. A total of 20 women with GSM and VL were treated with MFU Ultravera by Hironic. The treatment course consisted of two vaginal applications of MFU at an interval of 6 weeks. The clinical effects of the protocol were evaluated using the Vaginal Laxity Questionnaire (VLQ), the Vaginal Health Index (VHI), and the Female Sexual Function Index (FSFI). The overall values of the vaginal laxity evaluation for the total subject population showed a statistically significant improvement between the baseline and the findings at 3 and 6 months after treatment. The effect of therapy was consistent across all domains of FSFI. It peaked at the 6 week follow-up visit (from 26.5 to 32) and plateaued at 12 weeks and 6 months. There was a significant VHI improvement over time, with the greatest and most significant change between the study entry and 21 days after treatment; the VHI score leveled off up to 3 months after the procedures. MFU therapy, performed twice in the vaginal canal, showed promising efficacy and safety profiles, meriting further investigation.

Is age at menarche a predictor of maternal birth trauma?

OBJECTIVE

Age at menarche and the interval between menarche and age at first vaginal birth have been shown to be associated with reproductive performance; however, their association with maternal birth trauma has not been studied. We aimed to determine whether age at menarche, age at first vaginal birth and their interval are associated independently with levator ani muscle (LAM) avulsion and external anal sphincter (EAS) defect.

METHODS

This was a retrospective analysis of the ultrasound volume datasets of 466 vaginally parous patients attending one of two tertiary urogynecological units in Australia. All patients had undergone a standardized interview and clinical examination using the pelvic organ prolapse quantification staging system, followed by four-dimensional translabial ultrasound. Tomographic ultrasound imaging was used to evaluate the LAM for avulsion and the EAS for significant defect.

RESULTS

Of the 466 women analyzed, LAM avulsion was diagnosed in 121 (26.0%) and significant EAS defect in 55 (11.8%). Logistic regression analysis showed no association between age at menarche and LAM avulsion (P = 0.67). Weak but significant associations were noted between LAM avulsion and age at first vaginal birth (odds ratio (OR), 1.070 (95% CI, 1.03-1.11); P = 0.0007) and between LAM avulsion and menarche-to-first-vaginal-birth interval (OR, 1.064 (95% CI, 1.02-1.11); P = 0.0018). No significant associations were noted between significant EAS defect and any of the evaluated variables (all P ≥ 0.49).

CONCLUSIONS

Age at menarche is not predictive of maternal birth trauma i.e. LAM avulsion and EAS residual defect. There was a statistically significant association between LAM avulsion and menarche-to-first-vaginal-birth interval; however, this was not stronger than the previously established association between LAM avulsion and age at first vaginal birth, arguing against any distinct effect of prolonged prepregnancy hormonal stimulation on the biomechanical properties of the pelvic floor. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Translating the Pelvic Organ Prolapse Score into Samoan using a modified back translation methodology

Background

Although Samoan women have a high prevalence of obesity and multiple parity which are risk factors of pelvic organ prolapse, there is no prevalence data on this condition.

Aims

Translate the Pelvic Organ Prolapse-Symptoms Score (POP-SS) from English into Samoan,

Materials and methods

Standardised methods for translating questionnaires, individual face to face audio-recorded interviews in which women completed the POP-SS using a Think Aloud method, analysis using a Framework approach.

Results

The POP-SS was successfully translated in to Samoan, an additional information leaflet was developed to support women’s understanding of what prolapse is, 14 Samoan women were recruited of which 13 were interviewed and completed the POP-SS, results of POP-SS (scores), results of think aloud, results in terms of research experience.

Conclusions

A Samoan version of the POP-SS is now available for further evaluation of its psychometric properties prior to wider use. The team continue to collaborate on their work on establishing the prevalence of prolapse whilst building local research capacity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-022-01676-3.

Effect of radiofrequency and pelvic floor muscle training in the treatment of women with vaginal laxity: A study protocol

BACKGROUND

Vaginal laxity is an underreported condition that negatively affects women's sexual function and their relationships. Evidence-based studies are needed to better understand this complaint and to discuss its treatment options. Thus, we present a study protocol to compare the effect of radiofrequency and pelvic floor muscle training in the treatment of women with complaints of vaginal laxity.

METHODS/DESIGN

This is a prospective, parallel-group, two-arm, randomized clinical trial (Registry: RBR-2zdvfp-REBEC). Participants will be randomly assigned to one of the two groups of intervention (Radiofrequency or Pelvic Floor Muscle Training). The study will be performed in the Urogynecology outpatient clinic and in the physiotherapy outpatient clinic at the State University of Campinas-UNICAMP and will include women aged ≥ 18 years and with self-reported complaints of vaginal laxity. Participants will be assessed at baseline (pre-intervention period) and will be followed up in two periods: first follow-up (30 days after intervention) and second follow-up (six months after intervention).

EXPECTED RESULTS

The results of this randomized clinical trial will have a positive impact on the participants' quality of life, as well as add value to the development of treatment options for women with complaints of vaginal laxity.

TRIAL REGISTRATION

Registry: RBR-2zdvfp-Registro Brasileiro de Ensaios Clínicos-REBEC (19/02/2020).

Postpartum ultrasound for the diagnosis of obstetrical anal sphincter injury

This review presents the available data on the diagnosis of obstetrical anal sphincter injury by postnatal ultrasound imaging. There is increasing evidence that anal sphincter tears are often missed after childbirth and, even when diagnosed, often suboptimally repaired, with a high rate of residual defects after reconstruction. Even after postpartum diagnosis and primary repair, 25% to 50% of patients will have persistent anal incontinence. As clinical diagnosis may fail in the detection and classification of obstetrical anal sphincter injury, the use of imaging has been proposed to improve the detection and treatment of these lacerations. Notably, 3-dimensional endoanal ultrasound is considered the gold standard in the detection of obstetrical anal sphincter injury, and recently, 4-dimensional transperineal ultrasound, commonly available in obstetrical and gynecologic settings, has proven to be effective as well. Avoidance of forceps delivery when possible, performance of a rectal examination after vaginal delivery and before repair of any severe perineal tear, and offering sonographic follow-up at 10 to 12 weeks after vaginal delivery in high-risk women (maternal age of ≥35 years, vaginal birth after cesarean delivery, forceps, prolonged second stage of labor, overt obstetrical anal sphincter injury, shoulder dystocia, and macrosomia) may help reduce morbidity arising from anal sphincter tears.

Levator ani muscle avulsion: Digital palpation versus tomographic ultrasound imaging

OBJECTIVE

To determine the diagnostic performance of digital palpation of levator ani muscle (LAM) avulsion compared with translabial tomographic ultrasound imaging (TUI).

METHODS

A cross-sectional study, incorporating 195 women involved in a longitudinal cohort study. Palpation for levator integrity was performed, followed by a four-dimensional translabial ultrasound. LAM avulsion defects were diagnosed in the presence of puborectalis muscle detachment from its insertion. Post-processing analysis of ultrasound volumes for LAM integrity on TUI was performed blinded against palpation findings. Agreement between methods was assessed using Cohen's κ.

RESULTS

In all, 388 paired assessments of LAM bilaterally, were available. Sixteen (8.2%) unilateral avulsion defects were detected on palpation. Sonographically, 31 (16%) were diagnosed with avulsions: 4.6% bilateral and 11.3% unilateral. An overall agreement of 91% was observed between digital palpation and TUI, yielding a Cohen's κ of 0.32 (95% confidence interval 0.15-0.48) demonstrating "fair agreement": and implying 25% sensitivity, 98% specificity, 63% positive predictive value, and 92% negative predictive value. Analysis of the first and last 20 palpations showed no change in performance during the 13-day study period.

CONCLUSION

Assessment of LAM avulsion defects by digital palpation is feasible but may require substantial training. Confirmation by imaging is crucial, especially if the diagnosis of avulsion may influence clinical management.

The strategy for vaginal rejuvenation: CO2 laser or vaginoplasty?

Background

Vaginal laxity may result from trauma to the pelvic floor muscle, which may affect patients' sensation and quality of life. Vaginal rejuvenation, including surgical or nonsurgical interventions, aims to improve laxity. In this study, we aimed to establish a strategy for vaginal rejuvenation by comparing surgical and nonsurgical methods.

Methods

A retrospective clinical study was performed on patients who complained about vaginal laxity from 2017 to 2019. The degree of vaginal laxity severity was evaluated by vaginal examination in each patient. The patients were categorized as having a light, moderate or severe degree of vaginal laxity, and different correction methods were chosen accordingly. The Female Sexual Function Index (FSFI) questionnaire was administered to the patients preoperatively and at three months and one year after treatment.

Results

Seventeen patients with severe-degree vaginal laxity were treated with vaginoplasty. The total FSFI score was 23.21±2.57 before the operation and significantly increased to 29.36±1.84 (P<0.01) at one year after surgery. Eleven patients with moderate-degree vaginal laxity were treated with vaginoplasty and had a significant improvement in the total FSFI score at one year after surgery (29.86±1.74, P<0.01) compared with the FSFI score before surgery (23.41±2.84). Three patients with moderate-degree vaginal laxity were treated with a CO₂ laser and tended to have increased FSFI scores but did not show significant improvement after the operation. CO₂ laser treatment was performed on 16 patients with light-degree vaginal laxity. The total FSFI score improved from 23.76±2.35 to 26.16±2.58 at one year (P<0.05).

Conclusions

The strategy for vaginal rejuvenation should be selected based on the degree of vaginal laxity severity. Surgical treatment is suitable for severe- and moderate-degree vaginal laxity while nonsurgical treatment is suitable for light-degree vaginal laxity.

Prevalence of levator ani avulsion in a multicenter study (PAMELA study)

PURPOSE

The objective is to determine the prevalence of levator ani muscle (LAM) avulsion using four-dimensional ultrasound in primiparous women after vaginal delivery and according to delivery mode.

METHODS

This prospective, multicenter study included 322 women evaluated at 6-12 months postpartum by four-dimensional transperineal ultrasound to identify levator ani muscle avulsion. The researcher who performed the ultrasound was blinded to all clinical data. Meaningful data about the birth were also recorded: mode of delivery, mother's age and body mass index, duration of second stage, episiotomy, perineal tearing, anesthesia, assistant, head circumference and fetal weight.

RESULTS

303 volumes were valid for evaluation. The overall prevalence of levator ani muscle avulsion was 18.8% (95% CI 14.4-23.2%). In our multivariate analysis, only mode of delivery reached statistical significance as a risk factor for levator ani muscle avulsion (p < 0.001). The prevalence according to the different modes of delivery was 7.8% in spontaneous delivery, 28.8% in vacuum-assisted and 51.1% in forceps-assisted delivery. Compared with spontaneous delivery, the OR for LAM avulsion was 12.31 with forceps (CI 95% 5.65-26.80) and 4.78 with vacuum-assisted delivery (CI 95% 2.15-10.63).

CONCLUSIONS

Levator ani avulsion during vaginal delivery in primiparous women occurs in nearly one in every five deliveries. Delivery mode is a significant and modifiable intrapartum risk factor for this lesion. The incidence is lower in spontaneous delivery and significantly increases when an instrument is used to assist delivery, especially forceps.

Vaginal laxity: which measure of levator ani distensibility is most predictive?

OBJECTIVE

To assess the predictive value of measures of levator hiatal distension at rest and on maximum Valsalva maneuver for symptoms of vaginal laxity.

METHODS

This was a retrospective study of women seen at a tertiary urogynecological unit. All women underwent a standardized interview, clinical examination and four-dimensional translabial ultrasound examination. Area, anteroposterior diameter (APD) and coronal diameter (CD) of the levator hiatus were measured at rest and on maximum Valsalva maneuver in the plane of minimal hiatal dimensions using the rendered volume technique, by an operator blinded to all clinical data. The association between levator hiatal measurements and vaginal laxity was assessed, and receiver-operating-characteristics (ROC)-curve analysis was used to determine their predictive value.

RESULTS

Data from 490 patients were analyzed. Mean age was 58 (range, 18-88) years, and vaginal laxity was reported by 111 (23%) women. Measurements obtained on maximum Valsalva were significantly larger in women who reported vaginal laxity than in those who did not, with mean levator hiatal area, APD and CD of 30.45 ± 8.74 cm² , 7.24 ± 1.16 cm and 5.60 ± 0.89 cm, respectively, in the vaginal-laxity group, compared with 24.84 ± 8.63 cm² , 6.64 ± 1.22 cm and 5.01 ± 0.97 cm in the no-laxity group (P < 0.001 for all). Measurements obtained at rest were not significantly different between the groups. Multiple logistic regression analysis controlling for age, body mass index, vaginal parity and levator avulsion confirmed these results. The best regression model for the prediction of vaginal laxity included age, vaginal parity and levator hiatal area on maximum Valsalva. ROC-curve analysis of levator hiatal measurements on maximum Valsalva in the prediction of vaginal laxity demonstrated areas under the curve of 0.68 (95% CI, 0.63-0.73) for area, 0.63 (95% CI, 0.57-0.68) for APD and 0.68 (95% CI, 0.62-0.73) for CD.

CONCLUSIONS

Levator hiatal area on maximum Valsalva seems to be the measure of levator ani distensibility that is most predictive of symptoms of vaginal laxity. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

How Valid Is Tomographic Ultrasound Imaging in Diagnosing Levator and Anal Sphincter Trauma?

OBJECTIVES

Three-/four-dimensional translabial ultrasound (US) is increasingly used to image the levator ani and anal sphincters, especially in the form of tomographic US. The aim of the study was to evaluate the validity of these published methods.

METHODS

This work was a retrospective analysis of datasets of 172 nulliparous women who attended 2 tertiary urogynecologic centers for symptoms of pelvic floor dysfunction between June 2012 and September 2016. All patients had a standardized interview, clinical examination, and 4-dimensional translabial US examination. An evaluation of volume data was performed by the first author, who was blinded against all clinical data, including parity. An assessment for levator avulsion and anal sphincter defects was performed using stored US volume data.

RESULTS

Data sets of 162 and 153 nulliparous women were available for levator and anal sphincter assessments, respectively. On the assessment by the first author, a complete avulsion was diagnosed in 3 nulliparas. On a review by 2 senior authors, 1 was judged as positive and the other 2 as normal. On the sphincter assessment, 2 significant external anal sphincter defects were detected. On the review, 1 was judged as false-positive. The second was judged as highly abnormal by all authors. Therefore, 1 nullipara each was diagnosed with avulsion and a significant external anal sphincter defect.

CONCLUSIONS

Published diagnostic criteria for levator avulsion and external anal sphincter trauma on tomographic US imaging are highly unlikely to result in false-positive findings. This finding supports the clinical validity of this method.

Delivery mode, levator avulsion and obstetric anal sphincter injury: A cross-sectional study 20 years after childbirth

BACKGROUND

Levator ani muscle (LAM) and anal sphincter injuries are common after vaginal birth and are associated with pelvic organ prolapse and anal incontinence.

AIMS

Our objective was to investigate long-term association between delivery mode, LAM avulsion and obstetric anal sphincter injuries (OASIS) in women at least 20 years after their first birth.

METHODS

All women recruited at 'index birth' of the Dunedin (New Zealand) arm of ProLong (PROlapse and incontinence LONG-term research) Study, were invited to have translabial and transperineal ultrasound assessment of LAM and anal sphincters. Post-processing analysis of imaging data was performed blinded against delivery data. Statistical analysis was performed using the χ² test and results are expressed as odds ratios (OR).

RESULTS

Of the initial 1250 participants, 196 women returned for examination. Mean age was 50.8 years with a mean body mass index of 27.6 and median parity was three. They were seen on average 23 years after their first delivery. Four data sets were unavailable and one declined ultrasound assessment, leaving 191 for analysis. LAM avulsion was diagnosed in 29 (15.2%), and 24 women (12.6%) had significant anal sphincter defect. LAM avulsion was associated with forceps delivery (OR 2.45, 95% CI 1.04-5.80, P = 0.041). Forceps conveyed a greater risk of OASIS (21%) compared to a spontaneous vaginal delivery (11%) but did not reach statistical significance.

CONCLUSIONS

Forceps delivery is associated with long-term injurious effect on pelvic floor structures. Discussions of the long-term negative impact of pelvic floor structures and their functions are necessary to achieve an informed consent toward an operative vaginal delivery.

Contributing factors in forceps associated pelvic floor trauma

INTRODUCTION AND HYPOTHESIS

Levator avulsion occurs in 10-35% of women after a first vaginal delivery, with forceps being the main risk factor. Three mechanisms have been proposed to account for the high risk of trauma: the additional space requirement, increased speed of distension, and/ or greater force. This study examines the additional space requirements associated with forceps to determine any associated increase in avulsion risk.

METHODS

This was an in vitro simulation study of spatial requirements for delivery of a fetal head by forceps, with mathematical modelling of spatial requirements using data from a local observational study. A balloon device was used to model head circumferences through the range of expected measurements at term, with measurements taken after application of three different types of forceps. Each measurement was performed in triplicate.

RESULTS

On average, forceps increased the circumference of the fetal head by 1.01 cm for Wrigley's, 1.04 cm for Kielland's, and 1.64 cm for Neville-Barnes forceps, resulting in an estimated increase in the diameter of the fetal head by 0.32 cm, 0.33 cm, and 0.52 cm, respectively. This increase was linear throughout the tested range. In 534 singleton pregnancies at term, we determined an odds ratio (OR) of 1.11 per centimeter head circumference for avulsion. Hence, the additional space requirement due to forceps explains ORs of 1.11, 1.12, and 1.19 for avulsion, depending on forceps type.

CONCLUSIONS

The effect of forceps on avulsion risk is not fully explained by the increase in space requirement alone. Other factors, such as shortened time to maximum distension and/or increased peak force applied may contribute to the excess risk.

Levator Avulsion Is Associated With Pelvic Organ Prolapse 23 Years After the First Childbirth

OBJECTIVES

This study aimed to ascertain the association between levator avulsion and pelvic organ prolapse (POP).

METHODS

This was a cross-sectional study involving 195 women enrolled in a longitudinal cohort study and seen 20 years after an index birth. All had a standardized patient-administered questionnaire, the International Continence Society Pelvic Organ Prolapse Quantification assessment and 4D translabial ultrasound. Main outcome measures were objective POP clinically and on translabial ultrasound. Postimaging assessment of levator integrity and sonographically determined pelvic organ descent was done blinded against other data.

RESULTS

Of 195 women who were seen a mean of 23 (range, 19.4-46.2) years after their first birth, one declined ultrasound assessment and was excluded, leaving 194. Mean age was 50.2 (range 36.9-66.5) years with a mean body mass index (BMI) of 27.6 (range, 18.3-54.3) kg/m² . Median parity was 3 (range 1-14). Ninety-one percent (n = 176) had delivered vaginally. Eighteen percent (n = 34) were symptomatic of prolapse. Clinically, 36% (n = 69) had significant POP. Levator avulsion was diagnosed in 16% (n = 31). Mean levator avulsion defect score was 2.2 (range, 0-12). On univariate analysis, levator avulsion and levator avulsion defect score were associated with clinically and sonographically significant POP, that is, odds ratio 2.6 (1.2-5.7), P = .01; and odds ratio 3.3 (1.4-7.7); P = .003, respectively; Ba (P < .001); bladder (P < .001); uterine (P < .001) and rectal ampulla (P = .009) descent, but not POP symptoms, C, and Bp. Multivariate analysis controlling for potential confounders confirmed our findings.

CONCLUSIONS

Levator avulsion is associated with female pelvic organ prolapse, especially of the anterior and central compartments. This association may become stronger with aging.

Association between pelvic organ prolapse types and levator-urethra gap as measured by 3D transperineal ultrasound

OBJECTIVES

To evaluate the association between pelvic organ prolapse (POP) types and levator-urethra gap (LUG) as measured by 3-dimensional transperineal tomographic ultrasound.

METHODS

A retrospective study was carried out on 98 women with symptomatic POP. Three-dimensional transperineal tomographic ultrasound images and POP quantification coordinates were reviewed. Each vaginal compartment was staged for the degree of prolapse, and total number of involved compartments identified. LUG was measured on 3-dimensional tomographic sonograms as the distance between the center of the urethra and the levator insertion bilaterally. Based on prior studies, an abnormal LUG of 25 mm or greater indicated levator avulsion. The LUG and the presence or absence of unilateral/bilateral avulsions was analyzed with reference to the clinical diagnosis of prolapse (single versus multicompartment, and mild [stage II] versus severe [stage III-IV]). Generalized logit models were used to evaluate the association between avulsion and prolapse type and stage.

RESULTS

The LUG was substantially larger in women with multicompartment compared to single-compartment POP (28.9 ± 4.1 mm versus 22.7 ± 4.1 mm, P < .01). Similarly, LUG was substantially larger in women with severe (stage III-IV) compared to mild (stage II) POP (28.8 ± 4.7 mm versus 23.3 ± 4.5 mm, P < .01). Women with severe prolapse were 32 times more likely than women with mild prolapse to have bilateral levator avulsion. Those with POP involving all 3 vaginal compartments were 76 times more likely than single-compartment POP to have bilateral levator avulsions.

CONCLUSIONS

Bilateral levator ani avulsion as diagnosed by LUG measurements of 25 mm or greater at rest is associated with multicompartment, severe prolapse.

Prevalence of Maternal Birth Trauma in Nepali Women

OBJECTIVES

Pelvic organ prolapse is very common among women in Nepal, especially uterine prolapse. This would suggest a high rate of levator trauma, which is a strong predictor of such prolapse in the Western world. Hence, we decided to study the prevalence of maternal birth trauma in Nepali women.

METHODS

In November 2016, we offered an interview, clinical examination, and 4-dimensional translabial sonography to women attending a gynecology clinic. Of 129 women seen, 5 were excluded due to previous pelvic surgery. Translabial sonography volume data sets were obtained and analyzed by tomographic imaging for levator ani and anal sphincter trauma at a later date, blinded against all clinical data.

RESULTS

Mean age was 39 (21-74) years, median vaginal parity was 2 (0-9), mean age at first delivery 21 (14-40). Seventeen (14%) had not given birth vaginally; of these, 14 (11%) delivered by cesarean only, and 3 (2%) were nulliparous. Tomographic assessment for levator avulsion and anal sphincter trauma was possible in 124 women and performed as previously described. We found 2 (2%) unilateral avulsions and significant external anal sphincter defects in another 2 women.

CONCLUSIONS

Levator and anal sphincter trauma are significantly less prevalent in Nepali women in comparison to Western populations. This is intriguing, especially in view of the high prevalence of prolapse in Nepali women.

Ultrasound in the assessment of pelvic organ prolapse

Imaging is increasingly being used in urogynaecology. Because of low cost and universal availability, ultrasound (US) is the most commonly used diagnostic modality, which allows the observation of manoeuvres such as Valsalva and pelvic floor muscle contraction in real time. The ability to see beyond surface anatomy is particularly important in the posterior compartment and in obstructed defecation where this method may replace defecation proctography. Imaging is especially useful in the form of 3D/4D multiplanar and tomographic translabial US, as these modalities give access to the axial plane and the levator ani. This allows assessment of both avulsion, i.e. major maternal birth trauma, and hiatal overdistension, i.e. ballooning. Both are major risk factors for both prolapse and prolapse recurrence. This review will outline current clinical utility, introduce recent research in the respective field and provide an overview of likely future utility of imaging in the investigation of pelvic organ prolapse.

Can We Evaluate Hiatal Ballooning by Measuring the Anteroposterior Diameter With 2-Dimensional Translabial Ultrasonography?

OBJECTIVES

To analyze the association between the anteroposterior hiatal diameter and pelvic organ prolapse and to determine whether 2-dimensional translabial ultrasonography can evaluate hiatal ballooning by measuring the anteroposterior diameter.

METHODS

This study was a retrospective analysis of 312 women seen for lower urinary tract symptoms or pelvic organ prolapse between December 2014 and July 2016. All women had an International Continence Society (ICS) Pelvic Organ Prolapse Quantification (POP-Q) system examination and 4-dimensional translabial ultrasonography. The anteroposterior hiatal diameter was measured in the midsagittal plane, and the hiatal area was measured in the minimal axial plane during the maximal Valsalva maneuver.

RESULTS

Valid data from 294 patients were analyzed. International Continence Society POP-Q stage 0 was found in 121 women, stage 1 in 49, stage 2 in 78, stage 3 in 42, and stage 4 in 4. The anteroposterior diameter had an excellent linear correlation (r = 0.814; P < .001) with the hiatal area during the Valsalva maneuver and was strongly related to ICS POP-Q stages (P < .01). A receiver operating characteristic curve analysis proposed a cutoff of 6.0 cm for the anteroposterior diameter against ICS POP-Q stage 2 and higher (sensitivity, 73%; specificity, 52%) and prolapse symptoms (sensitivity, 74%; specificity, 64%).

CONCLUSIONS

The anteroposterior hiatal diameter, which represents hiatal distensibility in the midsagittal plane, can be used to evaluate hiatal ballooning. "Mild" ballooning was defined as an anteroposterior diameter measurement of 6.0 to less than 6.5 cm, "moderate" ballooning as 6.5 to less than 7.0 cm, and "marked" ballooning as 7.0 cm or greater.

Impact of subsequent pregnancies on pelvic floor functional anatomy

INTRODUCTION AND HYPOTHESIS

Vaginal childbirth clearly has an effect on pelvic floor anatomy, and pregnancy itself also likely plays a role. This study investigated the effects of consecutive pregnancies by comparing pelvic organ support and function in urogynecological patients delivered by cesarean section (CS) only.

METHODS

This was a retrospective study using 161 archived data sets of urogynecological patients delivered exclusively by CS presenting with symptoms of pelvic floor dysfunction between 2007 and 2015. Patients had undergone an interview, clinical examination using the Pelvic Organ Prolapse Quantification (POP-Q) system, and 3D/4D translabial ultrasound (TLUS) using Voluson systems. Measures of functional pelvic floor anatomy were obtained from stored ultrasound (US) volumes at a later date, using proprietary software, and blinded against all other data.

RESULTS

One hundred and sixty-one women delivered exclusively by CS were seen in a urogynecological clinic. Volume data analysis was possible in 151 patients. Mean age was 52 (26-82) years, with a mean body mass index (BMI) of 29.5 (18.4-48.7) kg/m². Forty-three (28.5%) women had one CS, 67 (44.4%) had two, and 41 (27.1%) had three or more. On multivariate analysis, adjusting for age, BMI, history of hysterectomy, and incontinence or prolapse surgery, there were no significant differences between groups.

CONCLUSIONS

On comparing women with one, two, or three or more CS, we found no significant differences in any measured sonographic parameters of pelvic organ descent and pelvic floor muscle function. This implies that subsequent pregnancies after the first are unlikely to exert significant additional effects on pelvic floor functional anatomy.

Association between vaginal parity and rectocele

INTRODUCTION AND HYPOTHESIS

Rectocele is common in parous women but also seen in nulliparae. This study was designed to investigate the association between vaginal parity and descent of the rectal ampulla/rectocele depth as determined by translabial ultrasound (TLUS).

METHODS

This retrospective observational study involved 1296 women seen in a urogynaecological centre. All had undergone an interview, clinical examination and 4D ultrasound (US) imaging supine and after voiding. Offline analysis of volume data was undertaken blinded against other data. Rectal ampulla position and rectocele depth were measured on Valsalva. A pocket depth of 10 mm was used as a cutoff to define rectocele on imaging.

RESULTS

Most women presented with prolapse (53%, n = 686); 810 (63%) complained of obstructed defecation (OD). Clinically, 53% (n = 690) had posterior-compartment prolapse with a mean Bp of -1 [standard deviation (SD)1.5; -3 to 9 cm]. Mean descent of the rectal ampulla was 10 mm below the symphysis (SD 15.8; -50 to 41). A rectocele on imaging was found in 48% (n = 618). On univariate analysis, OD symptoms were strongly associated with rectal descent, rectocele depth and rectocele on imaging (all P < 0.001). The prevalence of a rectocele seen on imaging increased with vaginal parity (P < 0.001). One-way analysis of variance (ANOVA) of vaginal parity against rectal descent and rectocele depth showed a dose-response relationship (both P < 0.001).

CONCLUSIONS

Vaginal parity was strongly associated with descent of the rectal ampulla and rectocele depth. This relationship approximated dose-response characteristics, with the greatest effect due to the first vaginal delivery.