Postpartum pelvic floor trauma. Curr Opin Obstet Gynecol. 2009;21:474-479. [PMID: 19855276 DOI: 10.1097/gco.0b013e328332a84e]

Comparison of Cross-Sectional Area of Pubovisceral Muscle in Nulliparous and Primiparous Women

INTRODUCTION AND HYPOTHESIS

The main risk factor for pelvic floor disorders is vaginal delivery, which may cause levator ani muscle (LAM) injury and denervation. LAM includes pubovisceral muscle (PVM, pubococcygeus), puborectalis muscle (PRM), and iliococcygeus muscle. We hypothesize that primiparous women with low pelvic floor muscle contraction have a reduced PVM cross-sectional area (CSA) compared to nulliparous women.

METHODS (SAMPLE SIZE AND STATISTICAL APPROACHES)

This single-centre prospective observational study compared healthy nulliparous (n = 40) to primiparous (n = 40) women after vaginal delivery without LAM avulsion and Oxford score ≤ 3. Demographics, questionnaires (ICIQ-UI-SF, OAB-Q-SF, PISQ-12), POP-Q, Oxford score, ultrasound measurements (minimal anteroposterior and lateral diameters, hiatal area, PRM thickness, levator-urethra gap) and magnetic resonance imaging (MRI)-PVM CSA were evaluated. Normality was tested, and an appropriate test was used to compare the groups. Power calculation suggested 40 participants per group.

RESULTS

The primiparous group was older, had a higher BMI, and their hiatal area on ultrasound at contraction was larger compared to the nulliparous group. The CSA of the left-sided PVM (1.15 ± 0.50 cm2) was larger compared to the right side (1.03 ± 0.50 cm2), p = 0.02 in nulliparous women. The PVM CSA of primiparous women with low Oxford score was reduced compared to nulliparous (0.87 ± 0.30 versus 1.09 ± 0.50 cm2, p = 0.006). The intra-rater reliability for PVM CSA had an ICC of 0.90 and inter-rater ICC of 0.77.

CONCLUSIONS

Primiparous women after vaginal delivery with low pelvic floor contraction force had reduced PVM CSA on MRI images compared to nulliparous women.

Pelvic floor parameters predict postpartum stress urinary incontinence: a prospective MRI study

OBJECTIVE

To investigate the pelvic floor changes in primiparas with postpartum stress urinary incontinence (SUI) after vaginal delivery using pelvic floor MRI.

MATERIALS AND METHODS

Fifty-two women were enrolled in the primiparous stress urinary incontinent (PSUI) group and 51 in the primiparous continent (PC) group. Thirty nulliparas were also recruited as the nulliparous control (NC) group. Levator ani muscle (LAM) injury, levator hiatus area (LHA), H-line, M-line, the distance from the bladder neck and cervix to the pubococcygeal line (B-PCL and U-PCL), levator plate angle, the anterior angle of the urethra, bladder neck descent, retrovesicourethral angle, functional urethral length, and a bladder neck funnel were evaluated on MRI images. Univariate and multivariate logistic regression analyses were used to explore anatomical predictors for SUI.

RESULTS

The primiparas in the PSUI group showed more obvious LAM injuries than in the PC groups (p = 0.001). LAM function assessment: the PSUI group had larger LHA and shorter B-PCL and U-PCL than the other groups during straining. Assessment of urethral mobility and function: the PSUI group had larger anterior angle of the urethra, bladder neck descent, retrovesicourethral angle, and shorter functional urethral length than the other two groups (all p < 0.05). Up to 88.5% of primiparas in the PSUI group showed bladder funnel (p < 0.001). The logistic regression analysis showed that retrovesicourethral angle, functional urethral length, and the presence of bladder funnel were significantly associated with postpartum SUI (p < 0.05).

CONCLUSIONS

Increased retrovesicourethral angle, shortened functional urethral length, and the presence of bladder funnel may be anatomical predictors for SUI in the early postpartum period. Urethral sphincter dysfunction plays an essential role in developing postpartum SUI.

CRITICAL RELEVANCE STATEMENT

This study used several measurements to reflect the anatomical structure and functional changes of the pelvic floor to identify the best anatomical predictors associated with postpartum stress urinary incontinence (SUI), aiming to provide new insights into treatment strategies for postpartum SUI.

KEY POINTS

• Increased retrovesicourethral angle, shortened functional urethral length, and the presence of bladder funnel are more commonly seen in primiparas with SUI. • The combination of retrovesicourethral angle, functional urethral length, and bladder funnel had the highest diagnostic performance in predicting postpartum SUI (AUC=0.947). • Urethral sphincter dysfunction may be the main pathophysiological foundation in SUI development.

A Computational Procedure to Derive the Curve of Carus for Childbirth Computational Modeling

Computational modeling serves an important role in childbirth-related research. Prescribed fetal descent trajectory is a key characteristic in childbirth simulations. Two major types of fully prescribed fetal descent trajectory can be identified in the literature: straight descent trajectories and curve of Carus. The straight descent trajectory has the advantage of being simpler and could serve as a reasonable approximation for relatively small fetal movements during labor, but it cannot be used to simulate the entire childbirth process. Curve of Carus is the well-recognized fetal descent trajectory with physiological significance. However, no mathematical description of the curve of Carus can be found in the existing computational studies. This status of curve of Carus simulation in the literature hinders the direct comparison of results across different studies and the advancement of computational techniques built upon previous research. The goals of this study are: (1) propose a universal approach to achieve the curve of Carus for the second stage of labor, from the point when the fetal head engages the pelvis to the point when the fetal head is fully delivered. (2) demonstrate its utility when considering various fetal head sizes. The current study provides a detailed formulation of the curve of Carus, considering geometries of both the mother and the fetus. The maternal geometries were obtained from MRI data, and the fetal head geometries were based on laser scanning of a replica of a real fetal head.

Cumulative incidence of urinary incontinence and associated factors during pregnancy and after childbirth: a cohort study

INTRODUCTION AND HYPOTHESIS

This study examined the associated factors (i.e., obstetric and maternal-newborn factors) related to cumulative incidence of urinary incontinence and changes in urinary incontinence during pregnancy and the first year postpartum.

METHODS

This prospective, longitudinal, within-subject study included 501 women who completed the Incontinence Questionnaire-Urinary Incontinence Short Form during pre-pregnancy, early pregnancy, mid-pregnancy, and late pregnancy and at five time points during the first year postpartum. Data were analyzed by multivariate logistic regression, McNemar's and analysis of variance (ANOVA) tests.

RESULTS

According to the multivariate analysis, the gestational week and number of previous vaginal deliveries increased the risk of cumulative incidence of urinary incontinence (CIUI) during pregnancy (both p < 0.05). Full-time employment, higher body mass index, vaginal delivery and UI during early pregnancy and mid-pregnancy increased the risk of CIUI during the first year postpartum (all p < 0.05). CIUI tended to increase throughout the entire pregnancy (p < 0.001) and decrease from 3 to 5 days to 6 months postpartum (p = 0.028). The prevalence rates of UI at all postpartum visits were lower than those during late pregnancy (p < 0.001-0.009) but higher than those during pre-pregnancy (p < 0.001).

CONCLUSIONS

The results identified the change patterns in UI and the risk factors associated with CIUI during the entire pregnancy (i.e., gestational age and number of previous vaginal deliveries) and the first year postpartum (i.e., full-time work, higher body mass index, vaginal delivery and UI during early and mid-pregnancy). Appropriate counseling should be provided to women preparing for pregnancy and during the prenatal and postpartum periods.

Effects of yoga on the intervention of levator ani hiatus in postpartum women: a prospective study

[Purpose] This study aimed to explore the application value of yoga intervention in early postpartum recovery of the levator ani muscle hiatus (LAH) area. [Participants and Methods] Females in natural labor from May 2020 to November 2020 in the Third People’s Hospital of Sun Yat-sen University Ultrasound Research Center were prospectively included for a pelvic ultrasound examination. The control group received no intervention. The experimental group received 60-min yoga once a week from week 1 to week 12 postpartum. A pelvic ultrasound examination was performed on the week 6 and week 12 postpartum. The LAH area was measured at rest, during contraction and Valsalva maneuver. [Results] A total of 128 participants who met the inclusion criteria were selected and randomly assigned to the control group (n=66) and the experimental group (n=62) in pre and post intervention design. No significant differences were found in age, parity, body mass index, and fetal weight between the control and experimental groups. Further, no significant difference was observed in the LAH area between the control and experimental groups at rest, during contraction and Valsalva maneuver on the week 6 postpartum. However, the LAH area in experimental group significantly reduced at rest, during contraction and Valsalva maneuver on the week 12 postpartum. The differences of LAH area (date week 6 minus date week 12) in the control group at rest, during contraction and Valsalva maneuver were 0.12 ± 3.12 cm², 0.80 ± 2.29 cm², and 0.80 ± 4.22 cm², while in the control these were 1.95 ± 3.41 cm², 1.39 ± 1.91 cm², and 3.81 ± 5.49 cm², respectively. Compared with control group, the differences of LAH area significantly increased in experimental group at rest and during Valsalva maneuver. [Conclusion] Yoga intervention can help in the recovery of LAH.

Ultrasound analysis of the effect of second delivery on pelvic floor function in Chinese women

In our study, patients who had a second delivery were categorised into the following 4 groups. Pelvic floor ultrasound data were compared during the 6th week after the second delivery. The incidence of cystoceles was highest in group A and lowest in group D. In addition, groups A and B had a higher rate of rectoceles or perineum descent. Similarly, the areas of the levator hiatus were higher in Groups A and B during Valsalva manoeuvres. The area of the levator hiatus from the resting state to the Valsalva manoeuvre effect had the greatest change in Group A. A comparison of the PR thickening rates among the four groups did not reveal significant differences. All second delivery methods can cause varying degrees of pelvic organ prolapse and decreased pelvic floor function; however, vaginal delivery as the second delivery mode may have a more significant effect in Chinese women.Impact StatementWhat is already known on this subject? Different modes of delivery have significantly different effects on female pelvic floor function. Pregnancy beyond 35 weeks of gestation has an effect on female pelvic floor function, irrespective of the mode of delivery.What do the results of this study add? This study analysed the impact of different delivery modes on Chinese female pelvic floor function. Parous women who underwent different modes of second delivery all demonstrated different degrees of pelvic organ prolapse, as well as pelvic floor function decline.What are the implications of these findings for clinical practice and/or further research? Our study will provide basic research of Chinese female pelvic floor function after a second delivery, which will be of clinical significance around the world, as well as in China. China will keep promoting further delivery as the aging population is increasing. If the developing countries want to promote the second delivery around the women, they have basic research and data to instruct the females.

Changes in the Frequency of Cesarean Delivery in Nulliparous Women in Labor in a Canadian Population, 1992-2018

OBJECTIVE

To examine the relative contribution of changes in patient demographics and physician management to changes in the cesarean delivery rate in labor among nulliparous women.

METHODS

We conducted a retrospective cohort study of 485,451 births to nulliparous women who experienced labor at or beyond 35 weeks of gestation in Alberta, Canada, from 1992 to 2018. The data were from a province-wide perinatal database. The primary outcome was cesarean delivery. Multivariate logistic regression and calculation of population attributable risk for identified risk factors were performed.

RESULTS

The cesarean delivery rate increased from 12.5% in 1992 to 24% in 2018. The prevalence of maternal risk factors for cesarean delivery such as obesity, maternal age 35 years or older at delivery, and comorbidities increased over the study period. However, this did not account for the increase in cesarean delivery, because the frequency of cesarean delivery increased irrespective of risk status. Additionally, the population-attributable risk for each risk factor was stable across the study period. For example, for maternal age 35 years or older at delivery, the number of cesarean deliveries attributable to this factor (the population-attributable risk) was 0.9 per 100 deliveries in 1992-1998 and 1 per 100 in 2014-2018. The proportion of cesarean deliveries in which nonreassuring fetal status was the indication increased from 30.1% in 1992 to 51.1% in 2018. The absolute rate of cesarean delivery in the second stage of labor increased from 3.1% in 1992 to 5.9% in 2018. This was due to a significant increase, among those who entered the second stage, in cesarean delivery without a trial of forceps, from 2.5% in 1992 to 7.0% in 2018.

CONCLUSION

The observed doubling of the rate of cesarean delivery in labor in first-time mothers was not driven by patient risk factors. Increases in the rate of cesarean delivery for nonreassuring fetal status and decreased operative vaginal deliveries were important factors.

Childbirth Computational Models: Characteristics and Applications

The biomechanical process of childbirth is necessary to usher in new lives-but it can also result in trauma. This physically intense process can put both the mother and the child at risk of injuries and complications that have life-long impact. Computational models, as a powerful tool to simulate and explore complex phenomena, have been used to improve our understanding of childbirth processes and related injuries since the 1990s. The goal of this paper is to review and summarize the breadth and current state of the computational models of childbirth in the literature-focusing on those that investigate the mechanical process and effects. We first summarize the state of critical characteristics that have been included in computational models of childbirth (i.e., maternal anatomy, fetal anatomy, cardinal movements, and maternal soft tissue mechanical behavior). We then delve into the findings of the past studies of birth processes and mechanical injuries in an effort to bridge the gap between the theoretical, numerical assessment and the empirical, clinical observations and practices. These findings are from applications of childbirth computational models in four areas: (1) the process of childbirth itself, (2) maternal injuries, (3) fetal injuries, and (4) protective measures employed by clinicians during delivery. Finally, we identify some of the challenges that computational models still face and suggest future directions through which more biofidelic simulations of childbirth might be achieved, with the goal that advancing models may provide more efficient and accurate, patient-specific assessment to support future clinical decision-making.

Pelvic floor assessment using magnetic resonance imaging after vaginal delivery and elective caesarean delivery

INTRODUCTION AND HYPOTHESIS

We aimed to compare quantitative static and dynamic magnetic resonance imaging (MRI) measurements of pelvic floor changes during postpartum recovery from 1 week to 6 months after different modes of delivery.

METHODS

In this prospective study, 51 primiparous women (vaginal delivery group: 30 women; elective caesarean delivery group: 21 women) underwent static and dynamic MRI at 1 week, 6 weeks, 3 months, and 6 months postpartum to measure pelvic floor MRI values. Between-group differences in pelvic floor values at these time points were determined; subsequently, within-group comparisons according to time were performed. Analysis included independent samples t-tests and paired t-tests.

RESULTS

The puborectal hiatus line (H line), muscular pelvic floor relaxation line (M line), bladder-pubococcygeal line (B-PCL), and uterus-pubococcygeal line (U-PCL) differed significantly between groups during the Valsalva manoeuvre at 1 week postpartum (p < 0.05). The H line, M line, and B-PCL values differed significantly between groups during the Valsalva manoeuvre at 6 weeks postpartum (p < 0.05). There were few significant between-group differences in pelvic floor values at 3 months and 6 months postpartum. In the vaginal delivery group, the differences in the H line and M line at 1 week, 6 weeks, and 3 months postpartum were significant (p < 0.001). In the elective caesarean delivery group, U-PCL differed significantly at 6 weeks compared to 1 week postpartum during the Valsalva manoeuvre (p < 0.05).

CONCLUSIONS

Pelvic floor recovery primarily occurred during the early phase after delivery in both groups. Elective caesarean delivery had a non-significant protective effect on postpartum pelvic floor structure and function compared to vaginal delivery.

Factors involved in the persistence of stress urinary incontinence from postpartum to 12 years after first delivery

AIMS

The aim of this study was to investigate constitutional-, pregnancy-, labor-, and delivery-related factors involved in the long-term persistence of stress urinary incontinence (SUI) from 6 months postpartum to 12 years after first delivery. We also evaluated severity and impact on quality of life of persistent SUI.

METHODS

This was a longitudinal study including primigravid women who gave birth at our Public Health Hospital during 2007. Urinary symptoms were investigated at inclusion, 6 months and 12 years after delivery. Persistent SUI was defined as SUI reported both at 6 months postpartum and 12 years after first delivery. The International Consultation on Incontinence-Urinary Incontinence-Short Form (ICIQ-UI-SF) and the Incontinence Severity Index (ISI) were used to evaluate SUI.

RESULTS

During the inclusion period, 479 pregnant women were interviewed, 381 attended the 6-month follow-up visit, and 315 formed the study group. SUI persisted in 36 out of 44 (81.8%) women. With the ISI, 52.8% of these women were categorized as having slight, 41.7% moderate, and 5.6% severe incontinence. The mean ICIQ-UI-SF score was 7.13 (SD 3.51). Pregnancy SUI (odds ratio [OR], 4.54; 95% confidence interval [CI], 2.10-9.80) and active second stage of labor more than or equal to 1 hour (OR, 3.68; 95% CI, 1.21-11.14) were independently associated with persistent SUI.

CONCLUSIONS

Women who reported SUI during pregnancy, and those who had pushed for more than or equal to 1 hour in the second stage of labor were at greater risk of SUI persisting from 6 months postpartum to long after delivery. We found this independent association after controlling for several constitutional-, pregnancy-, labor-, and delivery-related variables.

Randomized controlled trial for improved recovery of the pelvic floor after vaginal delivery with a specially formulated postpartum supplement

Objective

To improve pelvic floor recovery after vaginal delivery with daily supplementation of a specially formulated postpartum recovery supplement.

Methods

Within 48 hours of vaginal delivery, primipara women were randomized in a 1:1 ratio to receive daily oral supplementation for 6 weeks with either a combination of regular prenatal vitamin (PNV), leucine (4 g/day), zinc (30 mg/day) and omega-3 fatty acid (900 mg/day) (treatment group), or only a PNV daily (control group). Co-primary outcomes were vaginal squeeze pressure as measured by perineometer and levator muscle injury as measured by transperineal 3-dimensional tomographic ultrasound at 6 weeks postpartum.

Results

Twenty-six women in the control group and 27 in the treatment group completed the trial. Weak pelvic floor muscle strength was significantly less frequent in the treatment group compared to the control group at 6 weeks after delivery (28% vs. 58%, P=0.03). Both right and left-sided levator-urethra gap was significantly larger in the control group compared to the treatment group indicating more levator injury being present in the control group at 6 weeks after delivery. Anterior vaginal wall prolapse at or beyond the hymenal ring was significantly more common in the control group compared to the treatment group (19% vs. 0%, P=0.02). Significantly more women reported bothersome bulge symptoms in the control group compared to the treatment group at 6 weeks postpartum (19% vs. 0%, P=0.02).

Conclusion

Postpartum women who received a specially formulated postpartum recovery supplement had improved recovery of the pelvic floor after vaginal delivery.

Relationship between transversus abdominis muscle thickness and urinary incontinence in females at 2 months postpartum

[Purpose] Urinary incontinence is a frequent postpartum complication. Thus, this study aimed to examine the associations of transversus abdominis muscle thicknesses at rest and during an abdominal drawing-in maneuver with urinary incontinence in females at 2 months postpartum. [Participants and Methods] The participants included 18 females at 2 months postpartum with or without urinary incontinence, and 10 nulliparous females as controls. Transversus abdominis thickness was measured at rest and during the abdominal drawing-in maneuver using diagnostic ultrasonography. The Japanese version of the International Consultation on Incontinence Questionnaire-Short Form was used to evaluate urinary incontinence. [Results] Females at 2 months postpartum were divided into groups with and without urinary incontinence according to questionnaire scores. The muscle thickness during the abdominal drawing-in maneuver contraction was significantly lower in those with urinary incontinence than in those without urinary incontinence and controls. [Conclusion] The results showed significantly reduced transversus abdominis thickness during contraction, which suggested reduced transversus abdominis strength in females with postpartum urinary incontinence. Thus, promoting synergistic contraction of the inner unit, including the transversus abdominis, in exercise therapy may be more effective for postpartum urinary incontinence.

Risk factors for postpartum urinary retention after vaginal delivery at term without epidural anesthesia

Objective: We performed a retrospective case-control study of vaginal delivery at term without epidural anesthesia to identify clinical predictions of postpartum urinary retention (PUR). Methods: We reviewed the obstetric records of all singleton vaginal deliveries at Japanese Red Cross, Katsushika Maternity Hospital form January 2016 through December 2017. Results: There were 58 women (2.4%) complicated by PUR and 2391 women without PUR. A multivariate analysis revealed nulliparity, instrumental delivery, and episiotomy as independent risk factors for PUR (nulliparity: adjusted OR 2.39, 95%CI 1.2-4.8, p = 0.01; instrumental delivery: 3.53, 95%CI 1.9-6.7, p < .01, episiotomy: adjusted OR 1.96, 95%CI 1.0-3.8, p = .04). While, urination (or urethral catheterization) within 1 hour before delivery revealed as independent prevention factor for PUR (adjusted OR 0.54, 95%CI 0.30-0.99, p = .048). Conclusions: The risk factors identified in our institute seemed to approximately similar to those observed in the institutes capable of performing epidural anesthesia. In addition, urination just before delivery seemed to be an independent prevention factor for PUR.

Degenerative Spondylolisthesis Is Related to Multiparity and Hysterectomies in Older Women

STUDY DESIGN

A case-control study.

OBJECTIVE

To determine whether parity and abdominal surgeries are associated with degenerative spondylolisthesis (DS).

SUMMARY OF BACKGROUND DATA

DS is considered to be a major cause of low back pain (LBP) in the older population, with greater prevalence of DS among women. Because LBP and impaired abdominal muscle function are common during pregnancy and post-partum, parity-related abdominal muscle deficiency, resulting in poor spinal mechanics, could be a factor in the development of DS in women. Indeed a relationship between the number of pregnancies and DS was reported in one study.

METHODS

A total of 322 women between the ages of 40 and 80 (149 with DS and 173 controls) filled out a questionnaire providing information about their demographics, the number of full-term pregnancies, the number and types of abdominal surgeries (including cesarean section and hysterectomies), and age at menopause among other items. A binary logistic regression was used as a multivariate model to identify the variables associated with DS.

RESULTS

Along with age and body mass index as covariates, the number of full-term pregnancies and the hysterectomy were significant predictors of DS. Other abdominal surgeries, cesarean section, or the number of years postmenopause were not significant predictors of DS in this regression model after adjusting for all other significant variables.

CONCLUSION

Each full-term pregnancy seems to be associated with the 22% increase in odds of developing DS. Hysterectomy nearly doubles the odds of DS as compared to women who did not have hysterectomy.

LEVEL OF EVIDENCE

4.

Outcome of vaginal mesh reconstructive surgery in multiparous compared with grand multiparous women: Retrospective long-term follow-up

We aimed to compare the long-term surgical outcome and complications of multiparous and grand multiparous women undergoing reconstructive surgery with vaginal mesh implants for repair of pelvic organ prolapse. This retrospective, long-term follow-up (28.17±20.7 months) comprised 113 women who underwent surgical reconstructive surgery with vaginal polypropylene mesh in a high parity rate population medical center. The women were divided into 2 groups (multiparous and grand multiparous) and each group was evaluated for objective and subjective surgical outcome. Patient demographics and surgical data were retrieved from electronic medical records. Outcome measure included POP-Q exam as objective outcome and validated Pelvic Floor Distress Inventory questionnaire (PFDI) to assess subjective outcome. Average age of patients was 62±7.9 (range 42–83) years. Average parity was 5.6±3.1 (range 1–14). There were 54 (47.7%) multiparous women and 59 (52.3%) grand multiparous women. The grand multiparous women were younger than the multiparous women and had a significantly higher degree of prolapse. At the last follow-up, the only significant difference was related to symptoms of an overactive bladder. In conclusion, long-term follow-up demonstrates that vaginal mesh surgery in grand multiparous women offers anatomical and subjective cure rates comparable to multiparous women.

Pelvic floor morphometry and function in women with and without puborectalis avulsion in the early postpartum period

BACKGROUND

Pelvic floor muscles are subject to considerable stretching during vaginal birth. In 13-36% of women, stretching results in avulsion injury whereby the puborectalis muscle disconnects from its insertion points on the pubis bone. Until now, few studies have investigated the effect of this lesion on pelvic floor muscles in the early postpartum period.

OBJECTIVE

The primary aim of this study was to compare pelvic floor muscle morphometry and function in primiparous women with and without puborectalis avulsion in the early postpartum period. Our secondary objective was to compare the 2 groups for pelvic floor disorders and impact on quality of life.

STUDY DESIGN

In all, 52 primiparous women diagnosed with (n = 22) or without (n = 30) puborectalis avulsion injury were assessed at 3 months postpartum. Pelvic floor muscle morphometry was evaluated with 3-/4-dimensional transperineal ultrasound at rest, maximal contraction, and Valsalva maneuver. Different parameters were measured in the midsagittal and axial planes: bladder neck position, levator plate angle, anorectal angle, and levator hiatus dimensions. The dynamometric speculum was used to assess pelvic floor muscle function including: passive properties (passive forces and stiffness) during dynamic stretches, maximal strength, speed of contraction, and endurance. Pelvic floor disorder-related symptoms (eg, urinary incontinence, vaginal and bowel symptoms) and impact on quality of life were evaluated with the International Consultation on Incontinence Questionnaire and the Pelvic Floor Impact Questionnaire-Short Form. Pelvic Organ Prolapse Quantification was also assessed.

RESULTS

In comparison to women without avulsion, women with avulsion presented an enlarged hiatus area at rest, maximal contraction, and Valsalva maneuver (P ≤ .013) and all other ultrasound parameters were found to be significantly altered during maximal contraction (P ≤ .014). They showed lower passive forces at maximal and 20-mm vaginal apertures as well as lower stiffness at 20-mm aperture (P ≤ .048). Significantly lower strength, speed of contraction, and endurance were also found in women with avulsion (P ≤ .005). They also presented more urinary incontinence symptoms (P = .040) whereas vaginal and bowel symptoms were found to be similar in the 2 groups. Pelvic Organ Prolapse Quantification revealed greater anterior compartment descent in women with avulsion (P ≤ .010). The impact of pelvic floor disorders on quality of life was found to be significantly higher in women with avulsion (P = .038).

CONCLUSION

This study confirms that pelvic floor muscle morphometry and function are impaired in primiparous women with puborectalis avulsion in the early postpartum period. Moreover, it highlights specific muscle parameters that are altered such as passive properties, strength, speed of contraction, and endurance.

3T magnetic resonance neurography of pudendal nerve with cadaveric dissection correlation

AIM: To evaluate the pudendal nerve segments that could be identified on magnetic resonance neurography (MRN) before and after surgical marking of different nerve segments.

METHODS: The hypothesis for this study was that pudendal nerve and its branches would be more easily seen after the surgical nerve marking. Institutional board approval was obtained. One male and one female cadaver pelvis were obtained from the anatomy board and were scanned using 3 Tesla MRI scanner using MR neurography sequences. All possible pudendal nerve branches were identified. The cadavers were then sent to the autopsy lab and were surgically dissected by a peripheral nerve surgeon and an anatomist to identify the pudendal nerve branches. Radiological markers were placed along the course of the pudendal nerve and its branches. The cadavers were then closed and rescanned using the same MRN protocol as the pre-marking scan. The remaining pudendal nerve branches were attempted to be identified using the radiological markers. All scans were read by an experienced musculoskeletal radiologist.

RESULTS: The pre-marking MR Neurography scans clearly showed the pudendal nerve at its exit from the lumbosacral plexus in the sciatic notch, at the level of the ischial spine and in the Alcock’s Canal in both cadavers. Additionally, the right hemorrhoidal branch could be identified in the male pelvis cadaver. The perineal and distal genital branches could not be identified. On post-marking scans, the markers were used as identifiable structures. The location of the perineal branch, the hemorroidal branch and the dorsal nerve to penis (in male cadaver)/clitoris (in female cadaver) could be seen. However, the visualization of these branches was suboptimal. The contralateral corresponding nerves were poorly seen despite marking on the surgical side. The nerve was best seen on axial T1W and T2W SPAIR images. The proximal segment could be seen well on 3D DW PSIF sequence. T2W SPACE was not very useful in visualization of this small nerve or its branches.

CONCLUSION: Proximal pudendal nerve is easily seen on MR neurography, however it is not possible to identify distal branches of the pudendal nerve even after surgical marking.

Pudendal nerve 3-dimensional illustration gives insight into surgical approaches

The pudendal nerve is located topographically in areas in which plastic surgeon reconstruct the penis, the vagina, the perineum, and the rectum. This nerve is at risk for either compression or direct injury with neuroma formation from obstetrical, urogynecologic, and rectal surgery as well as pelvic fracture and blunt trauma. The purpose of this study was to create a 3-dimensional representation based on magnetic resonance imaging of the pelvis supplemented with new anatomic dissections in men and women to delineate the location of the pudendal nerve and its branches, providing educational information both for surgical intervention and patient education. The results of this study demonstrated that most often there are at least 2, not 1, "pudendal nerves trunks" as they leave the pelvis to transverse the sacrotuberous ligament, and that there are most often 2, not 1, exit(s) from Alcock canal, one for the dorsal branch and one for the perineal branch of the pudendal nerve.

In vivo imaging of adipose-derived mesenchymal stem cells in female nude mice after simulated childbirth injury

The aim of the present study was to track in vivo the distribution and survival of adipose-derived mesenchymal stem cells (ASCs) transplanted into female BALB/c nude mice following simulated childbirth injury, using green fluorescent protein and luciferase dual labeling, bioluminescent imaging (BLI) and histological evaluation. The results demonstrated that the dually labeled ASCs could be detected for up to eight weeks in vivo. The number of implanted cells decreased during the first three weeks, and then stabilized until the end of the experiment. According to the linear regression plot, ~27,621 implanted cells survived until eight weeks after implantation. Transplanted ASCs predominantly existed at the inoculation site of the vagina, with little or no spread to other organs. Histological analysis confirmed the survival of the engrafted ASCs. The study provided basic evidence that BLI techniques can be used to monitor ASCs in vivo in real time and in the long term. Through local administration, ASCs could survive in the long term to facilitate repair following pelvic-floor injury.

Preventing urinary incontinence in women

PURPOSE OF REVIEW

This review examines the evidence to date, analyzes specific risk factors and assesses the ability to prevent urinary incontinence in women, while providing clinical recommendations. More extraordinary risk factors such as ethnicity and race, mixed and fecal incontinence, iatrogenic and neurogenic factors should be discussed in a follow-up report.

RECENT FINDINGS

Studies have revealed that certain factors place women at risk for developing urinary incontinence, including age, obesity, diabetes, pregnancy and delivery, high-impact physical exercise factors and estrogen deficiency.

SUMMARY

Healthcare providers should screen women who are at risk for developing urinary incontinence and institute specific interventions, specifically behavioral and even rehabilitative techniques, to prevent this prevalent and distressing condition.

Long-term effects of simulated childbirth injury on function and innervation of the urethra

AIMS

Pudendal nerve and external urethral sphincter (EUS) injury during vaginal delivery are risk factors for stress urinary incontinence (SUI). Although most patients with short-term postpartum SUI regain continence within 1 year, they have a higher predisposition to develop recurrent SUI years later, suggesting a possible mechanistic relationship. In contrast, animal models generally recover spontaneously and have not been studied much in the long term. The aim of this study was to investigate the long-term effects of simulated childbirth injury in rats.

METHODS

Thirty-four Sprague-Dawley female rats underwent sham injury or pudendal nerve crush and vaginal distension (PNC + VD), a simulated childbirth injury. Nine weeks later, leak point pressure (LPP) and EUS electromyography (EMG) were recorded simultaneously. The pudendal nerve was harvested for histological analysis. EUS neuromuscular junctions (NMJs) and their innervation were qualitatively assessed using immunofluorescence. A t-test was used to compare quantitative outcomes between groups, with P < 0.05 indicating a significant difference.

RESULTS

There was no significant difference in LPP or EUS EMG amplitude or firing rate between the two groups. Nonetheless after PNC + VD, NMJs in the EUS were diffuse and were innervated by tortuous and multiple axons, demonstrating that reinnervation of the EUS was still in progress.

CONCLUSIONS

Although continence function recovered 9 weeks after simulated childbirth injury, innervation of EUS was not complete at this time point, suggestive of persistent neurogenic deficiency which when compounded by the effects of aging may lead to a delayed recurrence of SUI in this animal model with increased age.

An insight into pelvic floor status in nulliparous women

INTRODUCTION AND HYPOTHESIS

Few studies have comprehensively investigated the prevalence of various types of pelvic floor Dysfunction (PFD) in women before their first pregnancy. However, no previous studies have investigated in detail all four compartments of PFD and the correlation between them.

METHODS

This was a cross-sectional study nested within a parent prospective study Screening for Pregnancy Endpoints (SCOPE) performed in a tertiary referral teaching hospital with approximately 9,000 deliveries per annum. Nulliparous women completed the validated Australian Pelvic Floor Questionnaire at 15 weeks' gestation, at the time of recruitment to the SCOPE study. The questionnaire contained four sections, with questions about urinary, faecal, prolapse and sexual dysfunction in the prepregnancy period.

RESULTS

A total of 1,484 participants completed the prenatal questionnaire. Urinary dysfunction was present in 61 % of participants, faecal in 41 %, prolapse in 5 % and sexual in 41 %; in 37 %, dysfunction was perceived as bothersome . At least one clinically significant symptom, defined as severity grade 2 or 3, or grade 1 associated with being bothersome, was reported by 58.2 % of participants. More than one type of PFD was present in 57.6 % of cases. The severity score of each symptom within a PFD section was associated with total section score.

CONCLUSIONS

We confirmed a high rate of PFD in nulliparous women. Clinically significant symptoms and associated bother were very common among symptomatic participants. The majority of affected women had more than one type of PFD. Postnatal follow-up is needed in order to elucidate the role of prepregnancy symptoms in the aetiology of postnatal pelvic floor pathology.

Magnetic resonance imaging of the pelvic floor: from clinical to biomechanical imaging

This article reviews the current role of magnetic resonance imaging in the study of the pelvic floor anatomy and pelvic floor dysfunction. The application of static and dynamic magnetic resonance imaging in the clinical context and for biomechanical simulation modeling is assessed, and the main findings are summarized. Additionally, magnetic resonance-based diffusion tensor imaging is presented as a potential tool to evaluate muscle fiber morphology. In this article, focus is set on pelvic floor muscle damage related to urinary incontinence and pelvic organ prolapse, sometimes as a consequence of vaginal delivery. Modeling applications that evaluate anatomical and physiological properties of pelvic floor are presented to further illustrate their particular characteristics. Finally, finite element method is described as a method for modeling and analyzing pelvic floor structures' biomechanical performance, based on material and behavioral properties of the tissues, and considering pressure loads that mimic real-life conditions such as active contraction or Valsalva maneuver.

Between suffering and hope: rehabilitation from urinary incontinence as an intervening component

This is a qualitative study seeking to understand Brazilian women's experience of urinary incontinence (UI) and design a representative theoretical model for the experience. Theoretical saturation occurred after analysis of the 18th non-directive interview in accordance with Grounded Theory. Two phenomena emerged: living with the challenges of UI and experiencing the hope and disappointment of rehabilitation from UI. Upon re-alignment of the components, the core category emerged, namely: between suffering and hope - rehabilitation from urinary incontinence as an intervening component. From the analysis in light of symbolic interactionism, pregnancy and vaginal birth were observed to be symbols of women's vulnerability to the suffering from living with the moral and physio-psychosocial challenges of UI. It is also inferred that the lack of consideration of the Unified Health System (SUS) in investing in the process of rehabilitation from UI may be having a negative effect on the incentive programs for promoting vaginal birth. Most of all, it reveals the ongoing suffering of women with UI, most of whom do not have access to rehabilitation due to the lack of programs geared to the real needs of these users of the Unified Health System.

The cube pessary: an underestimated treatment option for pelvic organ prolapse? Subjective 1-year outcomes

INTRODUCTION AND HYPOTHESIS

Pelvic organ prolapse (POP) is a common condition. The use of pessaries for conservative management of POP is widespread. However, there are little data on the use of cube pessaries. The aim of our study was to evaluate whether self-therapy with the use of vaginal cube pessaries in women with POP can be a well-tolerated, first-line treatment.

METHODS

In a prospective case series, 87 women who suffered from symptomatic POP, stages II-IV, were instructed in self-treatment with a vaginal cube pessary. Differences were analyzed using Wilcoxon's rank sum test or Fisher's exact test.

RESULTS

A pessary could be fitted in 84/87 patients (96.6%); 6 women were lost to follow-up. The remaining 78 patients (92.9%, median age 60 years) completed the study. Sixteen women (20.5%) chose not to continue with the pessary treatment. For these patients, general well-being decreased from a median numeric rating score (NRS) of 4.5 (3-6) to 2.0 (1-3, p < 0.001). In those who continued treatment, general well-being increased from a median NRS of 3.0 (2-5) to 8.0 (7-10, p < 0.001) after 1 year of use. The majority of patients (53) in the present study rated pessary self-care use as "very easy" or "easy" (85.5%). The Patient Global Impression of Improvement (PGI-I) was 2.0 (1-3) at follow-up examination. There were no complications or adverse effects of pessary use.

CONCLUSIONS

Conservative self-treatment with vaginal cube pessaries might be a feasible treatment option for women who suffer from POP.

Vulnerability of continence structures to injury by simulated childbirth

The goal of this study was to examine acute morphological changes, edema, muscle damage, inflammation, and hypoxia in urethral and vaginal tissues with increasing duration of vaginal distension (VD) in a rat model. Twenty-nine virgin Sprague-Dawley rats underwent VD under anesthesia with the use of a modified Foley catheter inserted into the vagina and filled with saline for 0, 1, 4, or 6 h. Control animals were anesthetized for 4 h without catheter placement. Urogenital organs were harvested after intracardiac perfusion of fixative. Tissues were embedded, sectioned, and stained with Masson's trichrome or hematoxylin and eosin stains. Regions of hypoxia were measured by hypoxyprobe-1 immunohistochemistry. Within 1 h of VD, the urethra became vertically elongated and displaced anteriorly. Edema was most prominent in the external urethral sphincter (EUS) and urethral/vaginal septum within 4 h of VD, while muscle disruption and fragmentation of the EUS occurred after 6 h. Inflammatory damage was characterized by the presence of polymorphonuclear leukocytes in vessels and tissues after 4 h of VD, with the greatest degree of infiltration occurring in the EUS. Hypoxia localized mostly to the vaginal lamina propria, urethral smooth muscle, and EUS within 4 h of VD. Increasing duration of VD caused progressively greater tissue edema, muscle damage, and morphological changes in the urethra and vagina. The EUS underwent the greatest insult, demonstrating its vulnerability to childbirth injury.

Transection of the pelvic or vagus nerve forestalls ripening of the cervix and delays birth in rats

Innervation of the cervix is important for normal timing of birth because transection of the pelvic nerve forestalls birth and causes dystocia. To discover whether transection of the parasympathetic innervation of the cervix affects cervical ripening in the process of parturition was the objective of the present study. Rats on Day 16 of pregnancy had the pelvic nerve (PnX) or the vagus nerve (VnX) or both pathways (PnX+VnX) transected, sham-operated (Sham) or nonpregnant rats served as controls. Sections of fixed peripartum cervix were stained for collagen or processed by immunohistochemistry to identify macrophages and nerve fibers. All Sham controls delivered by the morning of Day 22 postbreeding, while births were delayed in more than 75% of neurectomized rats by more than 12 h. Dystocia was evident in more than 25% of the PnX and PnX+VnX rats. Moreover, on prepartum Day 21, serum progesterone was increased severalfold in neurectomized versus Sham rats. Assessments of cell nuclei counts indicated that the cervix of neurectomized rats and Sham controls had become equally hypertrophied compared to the unripe cervix in nonpregnant rats. Collagen content and structure were reduced in the cervix of all pregnant rats, whether neurectomized or Shams, versus that in nonpregnant rats. Stereological analysis of cervix sections found reduced numbers of resident macrophages in prepartum PnX and PnX+VnX rats on Day 21 postbreeding, as well as in VnX rats on Day 22 postbreeding compared to that in Sham controls. Finally, nerve transections blocked the prepartum increase in innervation that occurred in Sham rats on Day 21 postbreeding. These findings indicate that parasympathetic innervation of the cervix mediates local inflammatory processes, withdrawal of progesterone in circulation, and the normal timing of birth. Therefore, pelvic and vagal nerves regulate macrophage immigration and nerve fiber density but may not be involved in final remodeling of the extracellular matrix in the prepartum cervix. These findings support the contention that immigration of immune cells and enhanced innervation are involved in processes that remodel the cervix and time parturition.

Perinatal urinary and fecal incontinence: suffering in silence

This article focuses on the prevention, identification, and management of urinary and fecal incontinence in the perinatal period. Both urinary and fecal incontinence are common concerns affecting women throughout pregnancy, intrapartum, and postpartum. These are the problems that are not approached by healthcare providers during the initial antepartal assessment, nor are they fully investigated after delivery. Many women hesitate to disclose this information. Women tend to consider this to be a minor discomfort of pregnancy and a consequence resulting from childbirth in the postpartum period. Intervention strategies and nursing care components in the perinatal period will be presented.