Levator ani muscle avulsion and subsequent vaginal delivery: 8-year longitudinal follow-up

OBJECTIVES

To assess the evolution of levator ani muscle (LAM) avulsion from 1 year to 8 years after first delivery in women with and those without subsequent vaginal delivery. In addition, to assess whether women with full or partial avulsion 8 years after first delivery have larger LAM hiatal area and more symptoms of pelvic organ prolapse compared to women with normal LAM insertion.

METHODS

In this single-center longitudinal study, 195 women who were primiparous at the start of the study were included and underwent transperineal ultrasound examination 1 year and 8 years after first delivery. Muscle insertion was assessed by tomographic ultrasound imaging in the axial plane. Full LAM avulsion was defined as abnormal muscle insertion in all three central slices. Partial LAM avulsion was defined as abnormal muscle insertion in one or two central slices. Eight years after the first delivery, LAM hiatal area was assessed at rest, during maximum pelvic floor muscle contraction and on maximum Valsalva maneuver. To assess symptoms of pelvic organ prolapse, the vaginal symptoms module of the International Consultation on Incontinence Questionnaire was used.

RESULTS

At 1-year follow-up, 25 (12.8%) women showed signs of LAM avulsion, of whom 20 fulfilled the sonographic criteria of full avulsion and five of partial avulsion. Eight years after the first delivery, 35 (17.9%) women were diagnosed with avulsion, of whom 25 were diagnosed with full avulsion and 10 with partial avulsion. No woman with partial or full avulsion at 1 year had improved avulsion status at 8-year follow-up. Of the 150 women who had subsequent vaginal delivery, 21 (14.0%) women were diagnosed with partial or full LAM avulsion 1 year after first delivery, and 31 (20.7%) women were diagnosed with partial or full avulsion 8 years after first delivery. Of the 45 women without subsequent vaginal delivery, one woman with partial avulsion 1 year after first delivery was diagnosed with full avulsion at 8-year follow-up. All women with full avulsion at 1-year follow-up were diagnosed with full avulsion at 8-year follow-up regardless of whether they had subsequent vaginal delivery. At 8-year follow-up, women with full avulsion had statistically significantly larger LAM hiatal area compared to women with normal muscle insertion. Mean ± SD vaginal symptom scores ranged between 5.5 ± 5.7 and 6.0 ± 4.0 and vaginal symptom quality of life scores ranged between 0.9 ± 1.4 and 1.5 ± 2.2 and did not differ significantly between women with normal muscle insertion and women with partial or full avulsion at 8-year follow-up.

CONCLUSIONS

More LAM avulsions were present 8 years compared with 1 year after first delivery in women with subsequent vaginal delivery. Except for one primipara, all women without subsequent vaginal delivery had unchanged LAM avulsion status between 1 year and 8 years after their first delivery. Larger LAM hiatal area was found in women with full avulsion compared to those with normal muscle insertion at 8-year follow-up. Vaginal symptoms scores were low and did not differ between women with normal muscle insertion and those with partial or full avulsion at 8-year follow-up. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Overactive Bladder in Late Pregnancy to 1 Year After First Vaginal Delivery

IMPORTANCE

Understanding overactive bladder (OAB) during pregnancy and postpartum may increase our knowledge of pathophysiology.

OBJECTIVES

The purpose of this study was to understand the prevalence and severity of OAB during pregnancy through 1 year postpartum as well as the associated factors.

STUDY DESIGN

This is a secondary analysis of a prospective cohort study evaluating primiparous women with a singleton term vaginal delivery assessed at the third trimester, 8 weeks postpartum, and 1 year postpartum. Overactive bladder was defined as urinary urgency plus nocturia or frequency, or urgency urinary incontinence (UUI). Overactive bladder severity was defined using average visual analog scores (0-100) from OAB symptoms on the Epidemiology of Prolapse and Incontinence Questionnaire. We evaluated associations with OAB at each time point using logistic regression.

RESULTS

Among 579 participants, mean age was 29 years. Overactive bladder prevalence was higher at 8 weeks postpartum (23%) than at the third trimester (18%, P = 0.03) and 1 year postpartum (19%, P = 0.03). Overactive bladder severity was higher at the third trimester (42.2) than at 8 weeks postpartum (23.3, P = 0.008), but not at 1 year postpartum (29.1, P = 0.1). In those with OAB, UUI severity was higher at 1 year postpartum compared with that at the third trimester ( P = 0.02). Younger age was associated with third trimester OAB. At 8 weeks postpartum, OAB was associated with older age, urinary tract infection after delivery, birth weight ≥3,500 g, and third trimester OAB. At 1 year postpartum, OAB was associated with birth weight ≥3,500 g and third trimester OAB.

CONCLUSIONS

Overactive bladder affects 1 in 5 primiparous women during pregnancy or after vaginal delivery. The increased severity of UUI postpartum and the association between higher birth weight and OAB postpartum suggest an effect of delivery.

Effect of Perineal Massage and Warm Compresses Technique in Postpartum Pelvic Floor Dysfunction. A Secondary Analysis from a Randomised Controlled Trial

Pelvic floor dysfunction (PFD) is common to be associated with pregnancy and birth. To date, no research has been done to understand whether the perineal massage and warm compresses technique has an impact on pelvic floor dysfunction. To assess the impact of perineal massage and warm compresses technique during the second stage of labor in pelvic floor dysfunction at 3 and 6 months postpartum. Of the 800 women recruited to randomised controlled trial to prevent perineal trauma, 496 were included in the study, with 242 (48.8%) assigned to the Perineal Massage and Warm Compresses (PeMWaC) group and 254 (51.2%) to the control group (hands-on). Used the Pelvic Floor Distress Inventory-20 (PFDI-20). The questionnaire is divided into three subscales: Urinary (UDI), Colorectal-Anal (CRADI), and Pelvic Organ Prolapse Distress Inventory (POPDI). The PeMWaC group had a significantly higher frequency of intact perineum (p < 0.001) and low-severity vaginal tears (tears without any other degree of perineal trauma) (p = 0.031) compared to the control group, while the control group had significantly more patients who suffered high-severity vaginal/perineal trauma (second degree perineal tears) (p = 0.031) and patients without spontaneous perineal trauma or vaginal tears who underwent episiotomy (p < 0.001). In addition, at 3 months postpartum, women in the control group had a higher Urinary Distress Inventory (UDI) score and global score, compared to the PeMWaC group, and after controlling for confounding variables, the perineal massage and warm compresses technique was associated with lower UDI scores at 3 months postpartum compared to control group. At 6 months postpartum, there were no differences in the UDI or global scores, indicating general recovery from perineal trauma. In addition to reducing perineal trauma during birth, the perineal massage and warm compresses technique was associated with a lower prevalence of early PFD symptoms, mainly urinary distress, at 3 months.Trial registration http://www.ClinicalTrials.gov NCT05854888, retrospectively registered.

Knowledge Mapping Analysis of Research on Pregnancy-Related Pelvic Girdle Pain (PPGP) from 2002 to 2022 Using Bibliometrics

Background

Pregnancy-related Pelvic Girdle Pain (PPGP) is a prevalent condition characterized by various physiological and pathological processes in the female body. The objective of this study is to offer a comprehensive understanding of the current research landscape, key areas of interest, and potential future directions in the field of PPGP.

Methods

Using Web of Science, we explored PPGP literature from 2002 to 2022. VOSviewer and CiteSpace facilitated a quantitative analysis, revealing co-authorship patterns, co-occurring themes, citations, and co-citations.

Results

We identified, peaking at 99 publications in 2021. The United States led with 138 publications and the highest citation count (3160). The Karolinska Institute boasted the highest tally of publications (n = 21). Regarding the volume of publications, the esteemed journal of BMC Pregnancy and Childbirth attained the foremost position. Notably, Gutke, Annelie emerged as the most prolific and highly cited author. The analysis of keyword co-occurrence and co-citation clustering unveiled an intricate tapestry of PPGP studies, spanning various domains including risk factors, mechanistic intricacies, diagnostic benchmark, treatment modalities, and far-reaching ramifications on one's quality of life.

Conclusion

Research endeavors exploring PPGP have unveiled an enduring trajectory of growth in contemporary times. The existing body of research primarily focuses on delving into the intricate interplay of epidemiological factors and the profound implications of interventions encompassing physical therapy, exercise protocols, and diverse modes of pain management within the domain of PPGP. Multidisciplinary integration encapsulates a prevailing trajectory of progress within this domain, while the focal point of future inquiries into PPGP may revolve around subjects pertaining to standardized outcome reporting.

Management of levator ani avulsion: a systematic review and narrative synthesis

PURPOSE

Levator ani muscle (LAM) avulsion affects up to 35% of women. Unlike obstetric anal sphincter injury, LAM avulsion is not diagnosed immediately after vaginal delivery, however, has a profound impact on quality of life. The management of pelvic floor disorders is in growing demand yet the significance of LAM avulsion in the context of pelvic floor dysfunction (PFD) is poorly understood. This study collates information on success of treatment for LAM avulsion to establish the best options for management of women.

METHODS

MEDLINE®, MEDLINE® In-Process, EMBASE, PubMed, CINAHL and The Cochrane Library were searched for articles that evaluated the management techniques used to treat LAM avulsion. The protocol was registered with PROSPERO (CRD42021206427).

RESULTS

Natural healing of LAM avulsion occurs in 50% of women. Conservative measures, including pelvic floor exercises and pessary use are poorly studied. Pelvic floor muscle training for major LAM avulsions was of no benefit. Post-partum pessary use was only of benefit in the first three months for women. Surgeries for LAM avulsion are poorly researched but studies suggest they may provide benefit for 76-97% of patients.

CONCLUSIONS

Whilst some women with PFD secondary to LAM avulsion improve spontaneously, 50% continue to have pelvic floor symptoms 1 year following delivery. These symptoms result in a significant negative impact on quality of life, however, it is not clear whether conservative or surgical methods are helpful. There is a pressing need for research to find effective treatments and explore appropriate surgical repair techniques for women with LAM avulsion.

Three-dimensional endovaginal ultrasound assessment using the levator ani deficiency score in primiparas: A replication study

INTRODUCTION

It is essential to assess the levator ani properly as part of clinical care in patients presenting with pelvic floor dysfunction. The levator ani deficiency scoring system is a previously published method to assess levator ani defects with three-dimensional endovaginal ultrasound. The primary aim of this study was to determine the intra- and interrater reliability of the levator ani deficiency score in a cohort of non-instrumentally delivered primiparas.

MATERIAL AND METHODS

Primiparas (n = 141) were examined at least 1 year after vaginal birth. Three-dimensional endovaginal ultrasound volumes were acquired by a single examiner using two different automated ultrasound probes. The volumes were analyzed by two separate raters who were blinded to each other's assessments. Descriptive statistics were calculated for levator ani deficiency score and categorized into three levels (mild, moderate, severe). Kendall's tau-b was calculated for intra- and interrater comparisons.

RESULTS

Intrarater comparisons of levator ani deficiency score and levator ani deficiency category were high (Kendall's tau-b ≥0.80 for Rater 1; >0.79 for Rater 2). Interrater comparisons of levator ani deficiency score and levator ani deficiency category were also high (Kendall's tau-b >0.9 for assessment 1 and >0.78 for assessment 2). Varying by rater, probe and assessment, 75.9%-80.1% of the study population had no/mild deficiency, 6.4%-9.2% had moderate deficiency, and 4.3%-6.4% had severe levator ani deficiency.

CONCLUSIONS

The levator ani deficiency scoring system is a feasible method to assess defects of the levator ani muscle and can be reproduced with high intra- and interrater correlations. Using the scoring system in clinical practice may facilitate concordant assessment between different examiners. However, the system should be used to support clinical findings and symptomatology and not as a screening tool, as the score is lacking the category of no levator ani deficiency.

Proregenerative extracellular matrix hydrogel mitigates pathological alterations of pelvic skeletal muscles after birth injury

Pelvic floor disorders, including pelvic organ prolapse and urinary and fecal incontinence, affect millions of women globally and represent a major public health concern. Pelvic floor muscle (PFM) dysfunction has been identified as one of the leading risk factors for the development of these morbid conditions. Childbirth, specifically vaginal delivery, has been recognized as the most important potentially modifiable risk factor for PFM injury; however, the precise mechanisms of PFM dysfunction after parturition remain elusive. In this study, we demonstrated that PFMs exhibit atrophy and fibrosis in parous women with symptomatic pelvic organ prolapse. These pathological alterations were recapitulated in a preclinical rat model of simulated birth injury (SBI). The transcriptional signature of PFMs after injury demonstrated an impairment in muscle anabolism, persistent expression of genes that promote extracellular matrix (ECM) deposition, and a sustained inflammatory response. We also evaluated the administration of acellular injectable skeletal muscle ECM hydrogel for the prevention of these pathological alterations. Treatment of PFMs with the ECM hydrogel either at the time of birth injury or 4 weeks after injury mitigated PFM atrophy and fibrosis. By evaluating gene expression, we demonstrated that these changes are mainly driven by the hydrogel-induced enhancement of endogenous myogenesis, ECM remodeling, and modulation of the immune response. This work furthers our understanding of PFM birth injury and demonstrates proof of concept for future investigations of proregenerative biomaterial approaches for the treatment of injured pelvic soft tissues.

Diagnosis of maternal birth trauma by pelvic floor ultrasound

BRIEF SUMMARY

Maternal somatic birth trauma due to vaginal delivery is more common than generally assumed and an important cause of future morbidity. Maternal birth trauma may involve both psychological and somatic morbidity, some of it long-term and permanent. Somatic birth trauma is now understood to encompass not just episiotomy, perineal tears and obstetric anal sphincter injuries (OASI), but also trauma to the levator ani muscle, termed 'avulsion'. This review will focus on recent developments in the imaging diagnosis of maternal birth trauma, discuss the most important risk factors and strategies for primary and secondary prevention. Translabial and exo-anal ultrasound allow the assessment of maternal birth trauma in routine clinical practice and enable the use of levator avulsion and anal sphincter trauma as key performance indicators of maternity services. This is likely to lead to a greater awareness of maternal birth trauma amongst maternity caregivers and improved outcomes for patients, not the least due to an increasing emphasis on patient autonomy and informed consent in antenatal and intrapartum care.

Multicenter study of the evolution of different types of avulsion over the 12 months after delivery

OBJECTIVE

To perform a multicenter study of muscle recovery in levator ani muscle (LAM) avulsion during the first 12 months postpartum according to the type of LAM avulsion suffered.

METHODS

This was a multicenter prospective observational study including 242 primiparas. Transperineal ultrasound was performed at 6 months and 12 months after delivery. Type I LAM avulsion was present when most of the lateral fibers of the pubovisceral muscle were observed at the muscle's insertion at the pubic level. Type II LAM avulsion was defined as complete detachment of the pubovisceral muscle from its insertion at the pubic level.

RESULTS

Among the 56 patients who completed the study (with ultrasound at 6 and 12 months after delivery), 76 avulsions (10 cases of bilateral avulsion) were identified at 6 months after delivery, and the total number of avulsions had decreased to 58 at 12 months after delivery (P < 0.001; 95% confidence interval [CI] 13.9%-33.5%). This decrease was due to the disappearance of 69.2% of the cases of Type I LAM avulsions (P < 0.001; 95% CI: 50.2%-88.2%). However, the number of Type II LAM avulsions remained constant at 6 months and 12 months after delivery.

CONCLUSION

The spontaneous resolution of LAM avulsion during the first 12 months postpartum occurs in cases of Type I LAM avulsion but is not observed in Type II LAM avulsion.

Two year follow-up and comparison of pelvic floor muscle electromyography after first vaginal delivery with and without episiotomy and its correlation with urinary incontinence: A prospective cohort study

INTRODUCTION

Few prospective studies have revealed the long-term neuromuscular alterations of pelvic floor after vaginal delivery. The aim of this study was to evaluate the impact of episiotomy on the electrical activity of pelvic floor muscle 2 years following vaginal delivery, and explore the relation between surface electromyography (sEMG) amplitudes and urinary incontinence.

MATERIAL AND METHODS

A total of 427 primiparous women with full-term singleton vaginal delivery were included in the cohort and 362 with no further births within the 2 year follow-up completed observations. Of these, 200 underwent episiotomy and 162 underwent nonepisiotomy. Clinical demographic characteristics, vaginal EMG variables and urinary incontinence-specific questionnaire scores were collected at 6 weeks, 6, 12 and 24 months after childbirth, respectively. Primary outcomes were the comparison of sEMG values between the episiotomy and nonepisiotomy groups throughout 2 years. Secondary outcomes were the correlation between sEMG of both groups and the incidence and severity of urinary incontinence. Spearman's correlation analysis, Kruskal-Wallis test and ANOVA with Bonferroni correction were used to analyze the variables.

RESULTS

Amplitude of maximal fast and endurance contractions on sEMG in the episiotomy group was significantly lower than the nonepisiotomy counterpart. Such difference of sEMG persisted for a long period after birth: endurance contraction, 33.12 ± 8.92 vs 35.085 ± 9.98, p < 0.01 at 24 months, and fast contraction, 36.53 ± 8.87 vs 39.05 ± 9.98, p = 0.01 at 12-month. Although there was no significant difference in incidence and severity of urinary incontinence between both groups, a negative correlation existed between EMG values of muscle contraction and urinary incontinence symptoms throughout.

CONCLUSIONS

Primiparous women delivered with episiotomy demonstrated lower contractile sEMG activity of pelvic floor muscle in the long term. The lower sEMG values of fast contraction were associated with urinary incontinence symptoms.

All or nothing? A second look at partial levator avulsion

OBJECTIVE

To define associations between partial levator trauma and symptoms and signs of pelvic organ prolapse (POP).

METHODS

This was a retrospective study of 3484 women attending a tertiary urogynecology unit for symptoms of pelvic floor dysfunction between January 2012 and February 2020. All women underwent a standardized interview, clinical pelvic organ prolapse quantification (POP-Q) examination and tomographic ultrasound imaging of the pelvic floor. Women with full levator avulsion were excluded from analysis. Partial levator avulsion was quantified using the tomographic trauma score (TTS), in which slices 3-8 are scored bilaterally for abnormal insertions. Binomial multiple logistic regression was analyzed independently for the outcome variables prolapse symptoms, symptom bother and objective prolapse on clinical examination and imaging, with age and body mass index as covariates. Two continuous outcome variables, prolapse bother score and hiatal area on Valsalva, were analyzed using multiple linear regression.

RESULTS

Of the 3484 women, ultrasound data were missing or incomplete in 164 due to lack of equipment, clerical error and/or inadequate image quality. Full levator avulsion was diagnosed in 807 women, leaving 2513 for analysis. TTS ranged from 0-10, with a median of 0. Partial trauma (TTS > 0) was observed in 667/2513 (26.5%) women. All subjective and objective measures of POP were associated significantly with TTS, most strongly for cystocele. Associations were broadly linear and similar for all slice locations but disappeared after accounting for hiatal area on Valsalva.

CONCLUSION

Partial avulsion is associated with POP and prolapse symptoms. This association was strongest for cystocele, both on POP-Q and ultrasound imaging. The effect of partial avulsion on POP and prolapse symptoms is explained fully by its effect on hiatal area. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Diagnostic test accuracy of magnetic resonance imaging and pelvic floor ultrasound for diagnosis of levator ani muscle avulsion

OBJECTIVE

To estimate the diagnostic test accuracy of magnetic resonance imaging (MRI) and pelvic floor ultrasound for levator ani muscle (LAM) avulsion in a general parous population, with view to establishing if ultrasound could substitute for MRI to diagnose LAM avulsion.

METHODS

This was a cross-sectional study of 135 women 4 years after their first delivery. Signs and symptoms of pelvic floor dysfunction were assessed using validated methods. All women underwent four-dimensional transperineal ultrasound (TPUS), three-dimensional endovaginal ultrasound (EVUS) and MRI. Images were acquired at rest, on pelvic floor muscle contraction (PFMC) and on maximum Valsalva maneuver, and analyzed by two blinded observers. Predefined cut-off values were used to diagnose LAM avulsion. In the absence of a reference standard, latent class analysis (LCA) was used to establish diagnostic test characteristics for LAM avulsion as the primary outcome measure. Secondary outcomes were kappa (κ) agreement between imaging techniques, intraclass correlation coefficients (ICC) for hiatal measurements at rest, on PFMC and on maximum Valsalva maneuver, and the association of LAM avulsion with signs and symptoms of pelvic floor dysfunction.

RESULTS

The prevalence of LAM avulsion was 23.0% for MRI, 11.1% for TPUS and 17.8% for EVUS. The prevalence of LAM avulsion using LCA was 15.7%. The sensitivity for LAM avulsion of TPUS (71% (95% CI, 50-90%)) and EVUS (91% (95% CI, 74-100%)) was lower than that of MRI (100% (95% CI, 84-100%)). The specificity of TPUS (100% (95% CI, 97-100%)) and EVUS (95% (95% CI, 91-99%)) was higher than that of MRI (91% (95% CI, 85-97%)). MRI and EVUS had high predictive values for the assessment of major LAM avulsion (positive predictive value (PPV), 95% and negative predictive value (NPV), 100%; PPV, 100% and NPV, 98%, respectively), while TPUS had high predictive values for minor LAM avulsion (PPV, 100% and NPV, 95%). Major LAM avulsion on MRI and EVUS was associated with anterior vaginal wall prolapse, which was not found for TPUS. The agreement in the diagnosis of LAM avulsion (κ, 0.69) and hiatal measurements (ICC, 0.60-0.81) was highest between MRI and EVUS.

CONCLUSIONS

Pelvic floor ultrasound can be implemented as a triage test to assess parous women for LAM avulsion because of its high specificity. Ultrasound cannot substitute for MRI because of its lower sensitivity. The predictive ability of ultrasound is moderate for the presence, and very good for the absence, of LAM avulsion. A positive test should be confirmed by a different observer or imaging technique. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

The evolution of levator ani muscle trauma over the first 9 months after vaginal birth

INTRODUCTION AND HYPOTHESIS

The objective was to investigate the evolution of levator ani muscle (LAM) trauma over the first 9 months after birth and to evaluate their agreement between different assessment periods.

METHODS

From March 2017 to April 2019 we prospectively evaluated LAM states (intact, hematoma, partial or complete avulsion) of primiparous women after vaginal birth by using 4D translabial ultrasound (TLUS) at three different assessment periods. All women were examined 1-4 days (A1) and 6-10 weeks (A2) postpartum, and women with a trauma additionally 6-9 months postpartum (A3). Cohen's Kappa analysis was performed to evaluate the test agreement between the assessment periods.

RESULTS

Thirty-two percent of the women at A1 had a LAM trauma and 24% at A2. The higher number of LAM injuries at A1 can be explained by hematomas (14%), of which 51% spontaneously resolved at A2, 35% revealed themselves as partial, and 12% as complete avulsions. At A3, we observed anatomical improvement from complete to partial avulsions (23%) and few partial avulsions changed into an intact LAM (3%); none of the complete avulsions changed into an intact LAM. The agreement of 4D TLUS between A1 and A2 was moderate to good (0.64 for the right-sided LAM/0.60 for the left-sided LAM) and between A2 and A3 good to very good (0.76 right-sided/0.84 left-sided).

CONCLUSIONS

Levator ani muscle trauma can reliably be diagnosed during all assessment periods. However, the agreement between A1 and A2 was only moderate to good. This can be explained by hematomas inside the LAM that were only observed early postpartum. We observed some anatomical improvement at A3, but no complete avulsion improved to an intact LAM.

Prevalence of Planned Abdominal Binder Use after Vaginal Delivery

OBJECTIVES

Pregnancy and vaginal delivery are risk factors for pelvic floor dysfunction. Abdominal binder use may increase intraabdominal pressure, affecting pelvic floor healing or function in recently traumatized postpartum pelvic floor muscle. This study assesses the prevalence of postpartum abdominal binder use, timing, and reasons for use.

METHODS

In this cross-sectional observational survey study, women who underwent a vaginal delivery at our institution were enrolled. Participants were excluded if they did not speak Spanish or English. Participants were recruited on the postpartum unit. Data were deidentified and analyzed as appropriate for each variable.

RESULTS

In total, 673 surveys were completed. Seven were excluded because they had cesarean deliveries. The average age was 26 years. Median gravidity and parity were 2 and 2. In total, 549 women (82%) planned to wear an abdominal binder postpartum. In all, 335 women provided a specific time when they would start use: 240 women (71%) would start at ≤2 days postpartum, 60 women (18%) would start at 3 to 7 days postpartum, and 35 women (11%) would start after 1 week postpartum. Common reasons reported for use included appearance, support, pain, swelling, weight loss, and recommendation.

CONCLUSIONS

Among women delivering at our institution, planned abdominal binder use postvaginal delivery is common. The reasons cited include health and desire to return to prior body shape. The effects of using an abdominal binder in the postpartum period are unknown. More research is needed to better elucidate how increased postpartum intraabdominal pressure affects healing in traumatized pelvic floor muscles.

Natural history of levator ani muscle avulsion 4 years following childbirth

OBJECTIVES

The primary aim was to evaluate prospectively the natural history of levator ani muscle (LAM) avulsion 4 years following first delivery and its correlation with signs and symptoms of pelvic floor dysfunction (PFD). The secondary aim was to investigate the effect of a second vaginal delivery on the incidence of LAM avulsion and PFD.

METHODS

This was a prospective longitudinal study of nulliparous women recruited antenatally, who were assessed at 36 weeks' gestation and 3 months, 1 year and 4 years postpartum for signs and symptoms of PFD and presence of LAM avulsion. Pelvic floor muscle strength was assessed by digital palpation, and pelvic organ prolapse (POP) was assessed using the POP quantification (POP-Q) system. Validated questionnaires were used to evaluate urinary, bowel and sexual function and symptoms of POP. Transperineal ultrasound was performed to assess LAM integrity and hiatal biometry. Differences in signs and symptoms of PFD over time were evaluated using a linear mixed model, separately in women who had had one delivery and in those who had two or more deliveries during the study period.

RESULTS

Of 269 women recruited, 147 (55%) attended the 4-year follow-up and were examined at a mean interval of 3.8 ± 0.4 years after their first delivery. Of these, 74 (50%) had a subsequent delivery. The prevalence of LAM avulsion 4 years after a first vaginal delivery was 13%, with no difference between women who had one and those who had two or more vaginal deliveries. Women with an intact LAM and one or more deliveries showed no change in signs and symptoms of PFD at 4 years compared with the previous assessments. Of women with one vaginal delivery who were diagnosed with LAM avulsion 3 months or 1 year postpartum, those in whom the LAM avulsion was no longer evident at 4 years (42%) showed worsening of POP-Q measurements, whereas those with persistent LAM avulsion (58%) showed significant worsening in pelvic floor muscle strength and hiatal area on ultrasound. After a second vaginal delivery, no new avulsions were diagnosed, however, previous LAM avulsion became more extensive in 44% of women and hiatal area increased in women with persistent LAM avulsion.

CONCLUSIONS

The first vaginal delivery carries the greatest risk for LAM avulsion, with impact on signs of PFD 4 years later. A second vaginal delivery could result in deterioration of LAM avulsion, but no new avulsions were found. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Habitus and Pelvic Floor Symptoms and Support 1 Year Postpartum

OBJECTIVE

To estimate the association between habitus measures and pelvic floor support and symptoms in primiparous women 1 year after term vaginal delivery.

METHODS

In this cross-sectional study including women enrolled at seven academic and community sites, we assessed pelvic floor support, weight, height, waist circumference, and percent fat using air displacement plethysmography and participants completed questionnaires, all at one year postpartum. We tested the association of quintiles of habitus measure, including body mass index (BMI), waist circumference, percent body fat, and waist/height ratio, with the primary outcomes: anatomic support, dichotomized as maximal vaginal descent less than 0 cm (better support) compared with 0 cm or more (worse support) per the pelvic organ prolapse quantification examination and symptom burden (positive with bothersome symptoms in two or more of six symptom domains), and on five secondary outcomes. The sample size provides 90% power to detect odds ratios (ORs) of 1.78 or greater between women at mean compared with mean+1 SD of habitus measure.

RESULTS

Of 592 participants, 55 (9.3%) demonstrated worse support and 321 (54.2%) symptom burden. In multivariable analyses, habitus measures were not significantly associated with anatomic support or, except for the highest waist/height ratio quintile, with symptom burden. Compared with women in the first quintile of each habitus measure, those in most higher quintiles demonstrated elevated odds of moderate to severe urinary incontinence (UI); increased odds for stress urinary incontinence (SUI) were mainly limited to the highest quintile. After adjusting for percent body fat, the increased odds for BMI on SUI (OR 2.47, 95% CI 1.43-4.28) were no longer significant (OR 1.38, 95% CI 0.54, 3.51).

CONCLUSION

Habitus in primiparous patients at 1 year postpartum was not associated with anatomic support or symptom burden. Habitus was more associated with moderate to severe UI than mild UI. The association of higher BMI with SUI was attenuated by fitness, reflected by fat percentage.

Trajectories of Pelvic Floor Symptoms and Support After Vaginal Delivery in Primiparous Women Between Third Trimester and 1 Year Postpartum

OBJECTIVES

The objectives of this study were to describe trajectories of pelvic floor symptoms and support from the third trimester to 1 year postpartum in primiparous women after vaginal delivery and to explore factors associated with their resolution between 8 weeks postpartum and 1 year postpartum.

METHODS

Five hundred ninety-seven nulliparous women 18 years or older who gave birth vaginally at term completed the Epidemiology of Prolapse and Incontinence Questionnaire and the Pelvic Organ Prolapse Quantification examination at the third trimester, 8 weeks postpartum, and 1 year postpartum.

RESULTS

At 1 year postpartum, 41%, 32%, and 23% of participants reported stress urinary incontinence, nocturia, and flatus incontinence, respectively, and 9% demonstrated maximal vaginal descent (MVD) ≥ 0 cm. For more common symptoms, incidence rates between the third trimester and 8 weeks postpartum ranged from 6% for urinary frequency to 22% for difficult bowel movements, and resolution rates between 8 weeks postpartum and 1 year postpartum ranged from 23% for stress urinary incontinence to 73% for pain. Between the third trimester and 8 weeks postpartum, 13% demonstrated de novo MVD ≥ 0 cm. For most symptoms, the presence of the same symptom before delivery decreased the probability of resolution between 8 weeks postpartum and 1 year. However, the sensitivities of predelivery vaginal bulge and MVD of 0 cm or greater for those outcomes at 1 year postpartum was overall low (10-12%).

CONCLUSIONS

One year postpartum, urinary and bowel symptoms are common in primiparous women who gave birth vaginally. A substantial portion of this burden is represented by symptoms present before delivery, while most of the prevalence of worse anatomic support is accounted for by de novo changes after delivery.

Levator ani avulsion: a Systematic evidence review (LASER)

BACKGROUND

There is variation in the reported incidence rates of levator avulsion (LA) and paucity of research into its risk factors.

OBJECTIVE

To explore the incidence rate of LA by mode of birth, imaging modality, timing of diagnosis and laterality of avulsion.

SEARCH STRATEGY

We searched MEDLINE, EMBASE, CINAHL, AMED and MIDIRS with no language restriction from inception to April 2019.

STUDY ELIGIBILITY CRITERIA

A study was included if LA was assessed by an imaging modality after the first vaginal birth or caesarean section. Case series and reports were not included.

DATA COLLECTION AND ANALYSIS

RevMan v5.3 was used for the meta-analyses and SW SAS and STATISTICA packages were used for type and timing of imaging analyses.

RESULTS

We included 37 primary non-randomised studies from 17 countries and involving 5594 women. Incidence rates of LA were 1, 15, 21, 38.5 and 52% following caesarean, spontaneous, vacuum, spatula and forceps births, respectively, with no differences by imaging modality. Odds ratio of LA following spontaneous birth versus caesarean section was 10.69. The odds ratios for LA following vacuum and forceps compared with spontaneous birth were 1.66 and 6.32, respectively. LA was more likely to occur unilaterally than bilaterally following spontaneous (P < 0.0001) and vacuum-assisted (P = 0.0103) births but not forceps. Incidence was higher if assessment was performed in the first 4 weeks postpartum.

CONCLUSIONS

LA incidence rates following caesarean, spontaneous, vacuum and forceps deliveries were 1, 15, 21 and 52%, respectively. Ultrasound and magnetic resonance imaging were comparable tools for LA diagnosis.

TWEETABLE ABSTRACT

Levator avulsion incidence rates after caesarean, spontaneous, vacuum and forceps deliveries were 1, 15, 21 and 52%, respectively.

Levator Morphology and Strength After Obstetric Avulsion of the Levator Ani Muscle

OBJECTIVES

Obstetric levator avulsion may be an important risk factor for prolapse. This study compares the size of the levator hiatus, the width of the genital hiatus, and pelvic muscle strength between vaginally parous women with or without levator avulsion, 5 to 15 years after delivery.

METHODS

Parous women were assessed for levator ani avulsion, using 3-dimensional transperineal ultrasound. Women with and without levator ani avulsion were compared with respect to levator hiatus areas (measured on ultrasound), genital hiatus (measured on examination), and pelvic muscle strength (measured with perineometry). Further analysis also considered the association of forceps-assisted birth.

RESULTS

At a median interval of 11 years from first delivery, levator avulsion was identified in 15% (66/453). A history of forceps-assisted delivery was strongly associated with levator avulsion (45% vs 8%; P < 0.001). Levator avulsion was also associated with a larger levator hiatus area (+7.3 cm; 95% confidence interval [CI], 4.1-10.4, with Valsalva), wider genital hiatus (+0.6 cm; 95% CI, 0.3-0.9, with Valsalva), and poorer muscle strength (-14.5 cm H2O; 95% CI, -20.4 to -8.7, peak pressure). Among those with levator avulsion, forceps-assisted birth was associated with a marginal increase in levator hiatus size but not genital hiatus size or muscle strength.

CONCLUSIONS

Obstetric levator avulsion is associated with a larger levator hiatus, wider genital hiatus, and poorer pelvic muscle strength. Forceps-assisted birth is an important marker for levator avulsion but may not be an independent risk factor for the development of pelvic muscle weakness or changes in hiatus size in the absence of levator avulsion.

The effect of the birth method on changes of the prepartum and postpartum dimensions of perineal body

OBJECTIVE

The perineal body is critical for maintaining the integrity of the pelvic floor, especially in females as it can be injured during vaginal delivery. This study aimed to evaluate the effect of childbirth on perineal body dimensions by using a transperineal 2D ultrasound.

STUDY DESIGN

This prospective cohort study was performed in a tertiary obstetric care center. A total of 172 term pregnant women who delivered either by cesarean section or vaginal delivery were enrolled in the study. All demographic data and information were collected prospectively. The perineal body was measured in length, height, perimeter, and area. Mode of delivery was classified into four categories, including prelabor cesarean section, cesarean section during the first stage of labor, the first vaginal delivery, and more than one previously vaginal delivery. A postpartum evaluation was performed after 6 weeks.

RESULTS

Among the 172 women, 40 (23.3 %) had a history of cesarean section (CS) and they delivered with scheduled CS, 40 (23.3 %) women delivered by primary CS during active labor, 48 (27.9 %) women had the first vaginal delivery, 44 (25.6 %) women who delivered vaginally had a history of at least one vaginal delivery. The postpartum perineal body measurements were significantly lower in terms of length, perimeter, and area in all pregnancy groups.

CONCLUSION

Pregnancy and delivery change perineal body dimensions, significantly. Cesarean section does not completely protect against changes in perineal body morphology.

Early postpartum physical activity and pelvic floor support and symptoms 1 year postpartum

BACKGROUND

Risks of pelvic organ prolapse and urinary incontinence increase after the first vaginal delivery. During the early postpartum period, a time of active regeneration and healing of the pelvic floor, women may be particularly vulnerable to greater pelvic floor loading.

OBJECTIVE

This prospective cohort study aimed to determine whether objectively measured moderate to vigorous physical activity in the early postpartum period predicts pelvic floor support and symptoms 1 year after the first vaginal birth.

STUDY DESIGN

We enrolled nulliparous women in the third trimester, later excluding those who had a cesarean or preterm delivery. Participants wore triaxial wrist accelerometers at 2 to 3 weeks and 5 to 6 weeks postpartum for ≥4 days. Primary outcomes, assessed 1 year postpartum, included (1) pelvic floor support on Pelvic Organ Prolapse Quantification examination, dichotomized as maximal vaginal descent of <0 cm (better support) vs ≥0 cm (worse support); and (2) pelvic floor symptom burden, considered positive with report of ≥1 bothersome symptom in ≥2 of 6 domains, assessed using the Epidemiology of Prolapse and Incontinence Questionnaire. The primary predictor was average daily moderate to vigorous physical activity. Because we could not eliminate women with pelvic floor changes before pregnancy, we modeled prevalence, rather than risk, ratios for each outcome using modified Poisson regression.

RESULTS

Of 825 participants eligible after delivery, 611 completed accelerometry and 1-year follow-up; 562 completed in-person visits, and 609 completed questionnaires. The mean age was 28.9 years (standard deviation, 5.01). The mean for moderate to vigorous physical activity measured in minutes per day was 57.3 (standard deviation, 25.4) and 68.1 (standard deviation, 28.9) at 2 to 3 weeks and 5 to 6 weeks, respectively. One year postpartum, 53 of 562 participants (9.4%) demonstrated worse vaginal support and 330 of 609 participants (54.2%) met criteria for pelvic floor symptom burden. In addition, 324 (53.1%), 284 (46.6%), 144 (23.6%), and 25 (4.1%) reported secondary outcomes of stress urinary incontinence, overactive bladder, anal incontinence, and constipation, respectively, and 264 (43.4%), 250 (41.0%), and 89 (14.6%) reported no, mild, or moderate to severe urinary incontinence, respectively. The relationship between moderate to vigorous physical activity and outcomes was not linear. On the basis of plots, we grouped quintiles of moderate to vigorous physical activity into 3 categories: first and second quintiles combined, third and fourth quintiles combined, and fifth quintile. In final multivariable models, compared with women in moderate to vigorous physical activity quintiles 3 and 4, those in the lower 2 (prevalence ratio, 0.55; 95% confidence interval, 0.31-1.00) and upper quintile (prevalence ratio, 0.70; 95% confidence interval, 0.35-1.38)) trended toward lower prevalence of worse support. However, we observed the reverse for symptom burden: compared with women in quintiles 3 and 4, those in the lower 2 (prevalence ratio, 1.20; 95% confidence interval, 1.02-1.41) and upper quintile prevalence ratio 1.34 (95% confidence interval, 1.11-1.61) demonstrated higher prevalence of symptom burden. Moderate to vigorous physical activity did not predict any of the secondary outcomes. The presence of a delivery factor with potential to increase risk for levator ani muscle injury did not modify the effect of moderate to vigorous physical activity on outcomes.

CONCLUSION

Except for support, which was worse in women with moderately high levels of activity, early postpartum moderate to vigorous physical activity was either protective or had no effect on other parameters of pelvic floor health. Few women performed substantial vigorous activity, and thus, these results do not apply to women performing strenuous exercise shortly after delivery.

Association Between Measures of Trunk Recovery 5 to 10 Weeks Postpartum and Pelvic Floor Support and Symptoms 1 Year Postpartum in Primiparas Delivered Vaginally

OBJECTIVE

To determine whether 2 aspects of trunk recovery after childbirth, intraabdominal pressure (IAP) generation and trunk flexor endurance (TFE), predict measures of pelvic floor health 1 year postpartum.

METHODS

In this prospective cohort study, we enrolled nulliparas in their third trimester and followed up those delivered vaginally for 1 year. We measured IAP while lifting a weighted car seat (IAPLIFT), IAP during TFE testing (IAPTFE), and TFE duration 5 to 10 weeks postpartum and assessed pelvic floor support and symptoms 1 year postpartum.

RESULTS

Mean age of the 624 participants was 28.7 years. At 5 to 10 weeks postpartum, mean (SD) maximal IAPLIFT and IAPTFE were 47.67 (11.13) and 51.57 (12.34) cm H2O, respectively. Median TFE duration was 126 seconds (Interquartile range, 74-211). At 1 year postpartum, 9.3% demonstrated worse support (maximal vaginal descent at or below hymen) and 54% met criteria for symptom burden (bothersome symptoms in ≥2 domains of Epidemiology of Prolapse and Incontinence Questionnaire). In multivariable models, neither IAPLIFT nor IAPTFE were associated with worse support or symptom burden (P = 0.54-1.00). Trunk flexor endurance duration increased prevalence of worse support (prevalence ratio, 1.05; 95% confidence interval, 1.01-1.08) per 60-second increase, P = 0.005) but not symptom burden (prevalence ratio, 1.00; 95% confidence interval, 0.98-1.03; P = 0.92).

CONCLUSIONS

These results provide some reassurance to early postpartum women, who are unlikely to perform routine activities that generate IAP far outside the range tested. Further research is needed to understand why women with long TFE durations have increased prevalence of worse support.

Type of levator ani muscle avulsion as predictor for the disappearance of avulsion

OBJECTIVES

The objective of our study was to establish whether the type of levator ani muscle (LAM) avulsion diagnosed 6 months after delivery influences the integrity of the LAM at 1 year after delivery and determine its influence on the levator hiatus area.

STUDY DESIGN

This observational prospective cohort study included 192 primiparous women with vaginal delivery. Transperineal ultrasound examinations were performed at 6 months and 1 year postpartum. Levator hiatus measurements (anteroposterior diameter, transverse diameter, and area) were performed in the plane of minimal dimensions. Complete avulsion was defined based on maximum contraction in multislice mode. Type I LAM avulsion was present when most lateral fibers of the pubovisceral muscle were observed at its insertion at the pubic level (the arch of the elevator remained intact). Type II LAM avulsion was defined as a complete detachment of the pubovisceral muscle from its insertion at the pubic level.

RESULTS

In total, 192 patients were recruited after delivery; 48 patients were diagnosed with complete LAM avulsion, and 13 patients with avulsion did not attend the second ultrasound follow-up at 1 year after delivery. Thirty-five patients with complete LAM avulsion were included in the study. At 6 months after delivery, 51 LAM avulsions were observed in 35 patients (including bilateral LAM avulsion in 16 cases), of which 54.9% were right avulsions and 45.1% left avulsions. Furthermore, 11 (five right and six left) were type I LAM avulsions at the 6-month assessment, and all of these had disappeared 1 year after delivery. However, none of the type II LAM avulsions (23 right and 17 left) observed at 6 months had disappeared at the second ultrasound examination. There were no differences between the LAM areas detected at the first and second ultrasound examinations (10.2 ± 3.3 vs 9.3 ± 1.8; P = .404).

CONCLUSIONS

The type of LAM avulsion observed at 6 months after childbirth predicts LAM persistence at 1 year postpartum.

Pelvic floor ultrasound finds after episiotomy and severe perineal tear: systematic review and meta-analysis

AIM

Vaginal delivery is a well-known risk factor for pelvic floor muscle (PFM) injuries, mainly when associated to prolonged labor, instrumental birth and perineal trauma such as episiotomy and perineal tears. The purpose of this meta-analysis was to test the hypothesis that episiotomy and severe perineal tear may increase the risk of pelvic floor damage.

METHODS

We performed a systematic literature search through electronic databases including MEDLINE via PubMed, LILACS via BVS, Embase via Elsevier and Cochrane Library up to January 2019. We included articles that reported as outcome one or more morphological aspects of the PFM evaluated by ultrasonography in primiparous women three to 24 months postpartum. This review is registered in the PROSPERO database (registration number: CRD42017075750).

RESULTS

the final selection was composed of 18 articles for the systematic review, and 10 for the meta-analysis. Women with levator ani muscle (LAM) avulsion were 1.77 times more likely to have undergone episiotomy (OR = 1.77, CI 95% 1.25-2.51, five trials), 4.31 times more likely to have severe perineal tear (OR = 4.31, CI 95% 2.34-7.91, two trials). Women with defects in the anal sphincters were 2.82 times more likely to have suffered severe perineal tear (OR = 2.82, 95% CI 1.71-4.67, three trials).

CONCLUSIONS

Both episiotomy and severe perineal tear are risk factors for LAM avulsion and anal sphincter injury, and this can be useful for identifying women who are at greater risk of developing PFM dysfunctions.

Change in prevalence of major levator ani muscle defects from 6 weeks to 1 year postpartum, and maternal and obstetric risk factors: A longitudinal ultrasound study

INTRODUCTION

The present study aimed first to investigate the change in prevalence of major levator ani muscle (LAM) defects, also called avulsions, from 6 weeks to 1 year postpartum, and second to assess maternal and obstetric risk factors for having persistent major LAM defects/avulsions at 1 year postpartum.

MATERIAL AND METHODS

This is a secondary analysis of data from a prospective cohort study including 300 nulliparous women at 17-19 weeks of gestation. Major LAM defects were diagnosed at 6 weeks and 1 year postpartum using transperineal ultrasonography. We defined persistent major LAM defects as a defect diagnosed both at 6 weeks and 1 year postpartum. Maternal and obstetric data were obtained from the hospital's electronic birth records. Pelvic floor muscle function was measured vaginally by manometer at 21 weeks of gestation. The main outcome measurement was change in prevalence of major LAM defects. Maternal and obstetric risk factors for having persistent major LAM defect were also assessed.

RESULTS

Prevalence of major LAM defects was 19.4% at 6 weeks and 10.4% at 1 year postpartum. No new major LAM defects were diagnosed at 1 year postpartum. Persisting major LAM defects were associated with longer second stage of labor (median 74.5 minutes vs median 48.0 minutes, P = .012) and higher neonatal birthweight (mean difference of 232.3 g, 95% confidence interval [CI] 21.5-443.1). Vacuum delivery was independently associated with persistent major LAM defects, adjusted OR 3.0 (95% CI 1.0-9.0).

CONCLUSIONS

There was a 50% reduction of sonographically diagnosed major LAM defects from 6 weeks to 1 year postpartum. This finding suggests that assessment of the major LAM 6 weeks postpartum may be too early to diagnose defects/avulsions. Long second stage of labor, high neonatal birthweight and vacuum delivery were associated with persistent major LAM defects/avulsions.

Association between the side of levator Ani muscle trauma and fetal position at birth - a prospective observational study

INTRODUCTION

Trauma of the levator ani muscle (LAM) is common after vaginal birth and can most reliably be diagnosed by 3-dimensional (3D) translabial ultrasound (TLUS). Multiple risk factors are known in general, but not in association to a specific side of the body. Therefore, our aim was to evaluate different impact factors which cause LAM trauma on either side of the body or bilateral by focusing on the fetal position at birth.

MATERIAL AND METHODS

As part of a prospective cohort study between 3/2017 and 4/2019, we analyzed vaginal births of nulliparous women with singletons in vertex presentation≥36+0 gestational weeks. We evaluated their pelvic floor for hematomas, partial and complete LAM avulsions by 3D TLUS 2-4 days postpartum and searched for an association between the affected body side and different fetal, maternal and obstetrical factors.

RESULTS

71 out of 213 women (33.3%) suffered from LAM trauma - 17 (23.9%) on the right side, 20 (28.2%) on the left side and 34 (47.9%) bilateral. No association between the different evaluated factors and the affected body side could be identified, except for the quality of fetal heart rate tracing.

CONCLUSIONS

No significant impact factors of LAM trauma could be associated with a specific side of the body. Other possible mechanisms need investigation in the future, such as the time of the birth canal and the fetus to adapt to each other, including adequate time for the tissue to stretch and the fetus to rotate into the ideal position within the LAM hiatus.

EINLEITUNG

Levatormuskelverletzungen sind häufig nach Vaginalgeburten und können zuverlässig mittels translabialem 3D-Ultraschall diagnostiziert werden. Diverse Risikofaktoren sind hierfür bekannt, allerdings keine hinsichtlich der Assoziation zu einer der beiden Körperseiten. Daher war das Ziel dieser Arbeit, verschiedene Einflussfaktoren im Rahmen vaginaler Geburten zu evaluieren, welche eine Levatorverletzung auf einer der beiden Körperseiten bzw. beidseitig begünstigen, v. a. hinsichtlich der Kindsposition im Geburtskanal.

MATERIAL UND METHODIK

In einer prospektiven Kohortenstudie analysierten wir von 3/2017-4/2019 Erstgebärende mit vaginalen Einlingsgeburten aus Schädellage≥36+0 SSW. Wir evaluierten 2-4 Tage postpartal ihren Beckenboden mittels 3D-Ultraschall hinsichtlich Hämatomen sowie partiellen und kompletten Levatoravulsionen und suchten nach Assoziationen zwischen der betroffenen Körperseite und fetalen, maternalen und geburtshilflichen Einflussfaktoren.

ERGEBNISSE

Von 213 Frauen erlitten 71 (33.3%) eine Levatorverletzung - 17 (23.9%) rechtsseitig, 20 (28.2%) linksseitig und 34 (47.9%) beidseitig. Es wurden keine Assoziationen zwischen den untersuchten Einflussfaktoren und der betroffenen Körperseite gefunden, bis auf die Qualität der fetalen Herzfrequenz.

DISKUSSION

Es konnten keine signifikanten Einflussfaktoren für das Auftreten einer Levatorverletzung einer spezifischen Körperseite eruiert werden. Daher bedarf es in Zukunft der Untersuchung weiterer Mechanismen, wie der Adaptationsvorgänge von Geburtskanal und Fet und der adäquaten Zeit für das Gewebe zur notwendigen Dehnung, v. a. im Bereich der Levatoröffnung.

Prediction of levator ani muscle avulsion by genital tears after vaginal birth-a prospective observational cohort study

INTRODUCTION

Visible birth tears and levator ani muscle (LAM) trauma are common after birth. For the diagnosis of LAM trauma ultrasound evaluation is advisable. As ultrasound equipment and trained personnel are not available everywhere at all times, we aimed to evaluate whether specific overt birth tears are an indicator for LAM trauma.

METHODS

In a prospective cohort study at our center from March 2017-April 2019, we evaluated vaginal births of nulliparous women with singletons in vertex presentation ≥ 36 + 0 gestational weeks for LAM trauma by translabial ultrasound and for overt birth tears by inspection. We then calculated the association of overt birth tears with complete LAM avulsion.

RESULTS

Of 213 women, 23.9% had any kind of LAM trauma, with 14.1% being complete avulsions. In univariate analysis, solely high-grade perineal tears (OASIS) were significantly associated with complete LAM avulsions.

CONCLUSIONS

Fourteen percent of women suffered a complete LAM avulsion after vaginal birth, with OASIS being the only associated parameter of significance. The occurrence of such trauma might be an indicator for a mismatch between the size of the fetus and the structures of the birth canal, leading to birth trauma. Assessing for LAM trauma by translabial ultrasound in women with OASIS might be worthwhile.

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.

Postpartum sexual function; the importance of the levator ani muscle

Introduction and hypothesis

Pelvic floor muscle function plays an important role in female sexual functioning. Smaller genital hiatal dimensions have been associated with sexual dysfunction, mainly dyspareunia. On the other hand, trauma of the levator ani muscle sustained during childbirth is associated with increased genital hiatus, which potentially can affect sexual functioning by causing vaginal laxity. This study aims to determine the association between levator hiatal dimensions and female sexual dysfunction after first vaginal delivery.

Methods

This is a secondary analysis of a prospective observational study. Two hundred four women who had a first, spontaneous vaginal delivery at term between 2012 and 2015 were recruited at a minimum of 6 months postpartum. Thirteen pregnant women were excluded. We analyzed the association of total PISQ-12 score, as well as individual sexual complaints (desire, arousal, orgasm and dyspareunia), with levator hiatal dimensions at rest, with maximum Valsalva and during pelvic floor muscle contraction as measured by 4D transperineal ultrasound. Statistical analysis was performed using linear regression analysis and Mann-Whitney U test.

Results

One hundred ninety-one women were evaluated at a median of 11 months postpartum. There was no significant association between total PISQ-12 score and levator hiatal dimensions. Looking at individual sexual complaints, women with dyspareunia had significantly smaller levator hiatal area and anterior-posterior diameter on maximum Valsalva. By using multivariate logistic regression analysis however we found dyspareunia was not independently associated with levator hiatal dimensions.

Conclusions

After first vaginal delivery sexual dysfunction is not associated with levator hiatal dimensions as measured by 4D transperineal ultrasound.

Device-assisted pelvic floor muscle postpartum exercise programme for the management of pelvic floor dysfunction after delivery

Background: Pelvic floor dysfunction (PFD) is a multifactorial condition that clinically manifests as the pelvic prolapse, urinary and/or rectal incontinence, and sexual dysfunction.Aim: We aimed to evaluate the efficacy of two pelvic floor trainers for the prevention of PFD in women during the postpartum period.Materials and methods: This was a prospective, randomized, open-label study in 70 women in the postpartum period. Participants were randomized to complete a daily, 20-min set of pelvic floor muscle exercises using the EmbaGYN (UK; Group 1, n = 40) or the Magic Kegel Master device (China; Group 2, n = 40) for 4 weeks. All participants anonymously completed the PFDI-20 questionnaire and FSFI form at baseline and last visit. Pelvic floor muscle strength was measured using the XFT-0010 device.Results: After the completion of the 4-week pelvic floor muscle exercise program, there was a significant decrease in the rates of all PFD symptoms including pelvic organ prolapse and urinary and/or fecal incontinence in both groups. The rates of sexual dysfunction after the exercise program decreased significantly only in Group II (69.4 versus 25.0%; р =.001). After the program, Group I showed a significant reduction in the number of women with symptoms of urgent urinary incontinence versus baseline (35.3 versus 8.8% p = .009). Similarly, the rates of urine loss associated with coughing, sneezing or laughing in Group I decreased from 41.2% at baseline to 11.8% after the program (р =.006) and the rates of urine leakage independent of physical activity from 23.5 to 5.9% (p = .040), respectively.Conclusion: The 4-week postpartum pelvic floor muscle exercise program utilizing the EmbaGYN or Magic Kegel Master device has significantly increased the pelvic floor muscle strength and decreased the symptoms of pelvic organ prolapse, urinary and fecal incontinence. The use of the Magic Kegel Master device significantly reduced the symptoms of sexual dysfunction. The use of the EmbaGYN device was effective in addressing the individual symptoms of urinary incontinence.

Ultrasound imaging of the perineal body: a useful clinical tool

Introduction and hypothesis

The perineal body is a fibromuscular pyramidal structure located between the vagina and the anus. It has been difficult to image because of its small size and anatomical location. This study used 2D transperineal ultrasound to measure the perineal body and assess whether there is an association with prolapse.

Methods

An observational, cross-sectional study was carried out in a tertiary level Urogynaecology department and included prolapse patients and healthy nulliparous volunteers (control group). This was a clinical assessment, including POP-Q and trans-perineal 2D ultrasound measurement of the perineal body height, length, perimeter, and area. Parametric tests were used, as the data were normally distributed. Results are reported as mean and 95% confidence interval (±95% CI).

Results

A total of 101 participants were recruited of which 22 were nulliparous healthy volunteers. Mean perineal body measurements in controls were height 22.5 ± 3.3 mm, length 17.4 ± 2.7 mm, perimeter 7.5 ± 0.9 mm, and area 2.8 ± 0.38 cm². Perineal body measurements in 79 prolapse patients: height 16.9 ± 1.7 mm, length 16.0 ± 1.4 mm, perimeter 6.5 ± 0.5 mm and area 2.1 ± 0.5 cm². A small perineal body was strongly associated with posterior compartment prolapse (paired t test, p < 0.0001) and wider POP-Q GH (paired t test, p = 0.0003). Surprisingly, Pelvic Organ Prolapse Quantification Perineal Body (POP-Q PB) of the two groups was not significantly different. A perineal body mid-sagittal area of less than 2.4 cm² has been shown to be associated strongly with posterior compartment prolapse.

Conclusions

It is possible to measure the perineal body on 2D ultrasound. This technique facilitates the objective diagnosis of perineal deficiency. POP-Q PB does not predict the length or area of the perineal body.

Defining "normal recovery" of pelvic floor function and appearance in a high-risk vaginal delivery cohort

INTRODUCTION AND HYPOTHESIS

Childbirth pelvic floor trauma leads to pelvic floor disorders. Identification of significant injuries would facilitate intervention for recovery. Our objectives were to identify differences in pelvic floor appearance and function following delivery and patterns of normal recovery in women sustaining high-risk labor events.

METHODS

We completed a prospective cohort study comparing women undergoing vaginal births involving risk factors for pelvic floor injury with women undergoing cesareans. Data were collected on multidimensional factors including levator ani muscle (LA) tears. Descriptive and bivariate statistics were used to compare the groups. We identified potential markers of pelvic floor injury based on effect size.

RESULTS

Eighty-two women post-vaginal delivery and 30 women post-cesarean enrolled. The vaginal group had decreased perineal body length between early postpartum, 6 weeks (p < 0.001), and 6 months (p = 0.001). POP-Q points did not change between any time point (all p > 0.05). Measures of strength improved between each time point (all p < 0.002). When compared with cesarean delivery, women post-vaginal birth had longer genital hiatus and lower anterior and posterior vaginal walls (all p < 0.05). Based on theoretical considerations and effect sizes, those with Bp ≥0 cm, Kegel force ≤1.50 N, and/or an LA tear on imaging were considered to have significant pelvic floor injury. Using this definition, at 6 weeks, 27 (46.4%) women were classified as injured. At 6 months, 13 (29.6%) remained injured.

CONCLUSIONS

We propose that pelvic floor muscle strength, posterior vaginal wall support, and imaging consistent with LA tear are potential indicators of abnormal or prolonged recovery in this cohort with high-risk labor events.

New Method for Assessment of Levator Avulsion Injury: A Comparative Elastography Study

OBJECTIVE

The aim of this study was to introduce elastography as a new method for sonographic assessment of postpartum pelvic floor trauma.

METHODS

We examined 86 postpartum primiparous women, of whom 43 had undergone primary caesarean section (group_CS) and 43 vaginal delivery (group_VD). In a puborectal-symphysis plane, B-mode and elastographic ultrasonography were used to evaluate pelvic floor trauma. The strain value of left and right puborectal muscle was assessed close to the symphysis (Trauma_Elastography). The strain ratio maximum of this measurement was stored (Trauma_Index).

RESULTS

The elastographic evaluation revealed more trauma-suspicious lesions than the B-mode investigation (60.5% versus 39.5%; P < .001). The median Trauma_Index was higher in group_VD compared to group_CS (1.63 versus 1.18; P < .001).

CONCLUSION

Sonographic elastography assessment in a new examination plane shows postpartum trauma of the pelvic floor in women after vaginal delivery. This new method may help to identify women with a higher risk of postpartum pelvic floor disorders.

Association of levator injury and urogynecological complaints in women after their first vaginal birth with and without mediolateral episiotomy

BACKGROUND

Pelvic organ prolapse is a common health problem in women and has a negative influence on quality of life. A major cause of pelvic organ prolapse is levator injury.

OBJECTIVE

The objective of the study was to evaluate the association of mediolateral episiotomy with levator injury (levator avulsion, ballooning, or combined) and urogynecological complaints.

STUDY DESIGN

A prospective observational cohort study was performed in 204 primiparous women with a spontaneous vaginal delivery without anal sphincter tear in a general hospital between 2012 and 2015. One hundred three of these women had had a mediolateral episiotomy. Validated urogynecological questionnaires and transperineal 3-dimensional/4-dimensional ultrasound were completed after delivery. Outcome measures were levator avulsion, ballooning (hiatal area of more than 25 cm²), and urogynecological questionnaire scores. Statistical analysis was performed using univariate and multiple logistic regression analysis.

RESULTS

The median time at investigation after vaginal delivery was 13 months (range 6-33). Levator injury (avulsion, ballooning, or combined) was identified in 35 of the 103 women who had undergone mediolateral episiotomy (40.0%) and 33 of the 101 women without episiotomy (32.7%) (P = .69). No differences were found in the incidence of levator avulsion 27 (26.7%) vs 23 (22.8%) (P = .53) or in levator ballooning (20 [19.4%] vs 23 [22.8%] (P = .58) between both groups. There was an association between longer duration of the second stage of labor and the incidence of levator avulsion (odds ratio, 1.24 [95% confidence interval, 1.01-1.52]). Nonocciput anterior fetal position increased the risk of levator ballooning and levator injury (odds ratio, 10.19 [95% confidence interval, 1.89-54.91] and odds ratio, 12.16 [95% confidence interval, 1.41-104.38], respectively). No differences in urogynecological complaints were found.

CONCLUSION

Mediolateral episiotomy is not associated with the occurrence of levator injury or urogynecological complaints in women with a spontaneous vaginal delivery who did not obtain an anal sphincter injury. Levator injury was associated with a prolonged second stage of labor and a nonocciput anterior fetal position.

Questionnaires to evaluate pelvic floor dysfunction in the postpartum period: a systematic review

Background

Pelvic floor dysfunctions (PFDs) affect the female population, and the postpartum period can be related to the onset or aggravation of the disease. Early identification of the symptoms and the impact on quality of life can be achieved through assessment instruments.

Objective

The purpose of this systematic review is to evaluate questionnaires used to assess PFD in the postpartum period.

Methods

A systematic review study was conducted, following Preferred Reporting Items for the Systematic Reviews and Meta-Analyses (PRISMA) criteria, using the databases: PubMed, Biblioteca Virtual de Saúde (BVS), Web of Science, and Scopus, and the keywords PFD or pelvic floor disorders, postpartum or puerperium, and questionnaire. Articles published up till May 2018 were included, searching for articles using validated questionnaires for the evaluation of PFDs in postpartum women. The articles included were evaluated according to a checklist, and the validation studies and translated versions of the questionnaires were identified.

Results

The search of the databases resulted in 359 papers, and 33 were selected to compose this systematic review, using nine validated questionnaires to assess PFDs in the postpartum period: International Consultation on Incontinence Questionnaire – Vaginal Symptoms (ICIQ-VS), Pelvic Floor Distress Inventory 20 (PFDI-20), Pelvic Floor Impact Questionnaire (PFIQ-7), PFDI-46, Pelvic Floor Impact Questionnaire (PFIQ-31), Pelvic Floor Bother Questionnaire (PFBQ), Female Pelvic Floor Questionnaire, electronic Personal Assessment Questionnaire – Pelvic Floor, and PFD questionnaire specific for pregnancy and postpartum. The most frequently reported questionnaires included PFDI-20, PFIQ-7, and ICIQ-VS and are recommended by ICI. In addition, the review identified a specific questionnaire, recently developed, to access PFD during pregnancy and postpartum.

Conclusion

The questionnaires used to evaluate PFD during postpartum period are developed for general population or urology/gynecology patients with incontinence and reinforce the paucity of highly recommended questionnaires designed for postpartum, in order to improve early and specific approach for this period of life.

Pelvic muscles' mechanical response to strains in the absence and presence of pregnancy-induced adaptations in a rat model

BACKGROUND

Maternal birth trauma to the pelvic floor muscles is thought to be consequent to mechanical demands placed on these muscles during fetal delivery that exceed muscle physiological limits. The above is consistent with studies of striated limb muscles that identify hyperelongation of sarcomeres, the functional muscle units, as the primary cause of mechanical muscle injury and resultant muscle dysfunction. However, pelvic floor muscles' mechanical response to strains have not been examined at a tissue level. Furthermore, we have previously demonstrated that during pregnancy, rat pelvic floor muscles acquire structural and functional adaptations in preparation for delivery, which likely protect against mechanical muscle injury by attenuating the strain effect.

OBJECTIVE

We sought to determine the mechanical impact of parturition-related strains on pelvic floor muscles' microstructure, and test the hypothesis that pregnancy-induced adaptations modulate muscle response to strains associated with vaginal delivery.

STUDY DESIGN

Three-month-old Sprague-Dawley late-pregnant (N = 20) and nonpregnant (N = 22) rats underwent vaginal distention, replicating fetal crowning, with variable distention volumes. Age-matched uninjured pregnant and nonpregnant rats served as respective controls. After sacrifice, pelvic floor muscles, which include coccygeus, iliocaudalis, and pubocaudalis, were fixed in situ and harvested for fiber and sarcomere length measurements. To ascertain the extent of physiological strains during spontaneous vaginal delivery, analogous measurements were obtained in intrapartum rats (N = 4) sacrificed during fetal delivery. Data were compared with repeated measures and 2-way analysis of variance, followed by pairwise comparisons, with significance set at P < .05.

RESULTS

Gross anatomic changes were observed in the pelvic floor muscles following vaginal distention, particularly in the entheseal region of pubocaudalis, which appeared translucent. The above appearance resulted from dramatic stretch of the myofibers, as indicated by significantly longer fiber length compared to controls. Stretch ratios, calculated as fiber length after vaginal distention divided by baseline fiber length, increased gradually with increasing distention volume. Paralleling these macroscopic changes, vaginal distention resulted in acute and progressive increase in sarcomere length with rising distention volume. The magnitude of strain effect varied by muscle, with the greatest sarcomere elongation observed in coccygeus, followed by pubocaudalis, and a smaller increase in iliocaudalis, observed only at higher distention volumes. The average fetal rat volume approximated 3 mL. Pelvic floor muscle sarcomere lengths in pregnant animals undergoing vaginal distention with 3 mL were similar to intrapartum sarcomere lengths in all muscles (P > .4), supporting the validity of our experimental approach. Vaginal distention resulted in dramatically longer sarcomere lengths in nonpregnant compared to pregnant animals, especially in coccygeus and pubocaudalis (P < .0001), indicating significant attenuation of sarcomere elongation in the presence of pregnancy-induced adaptations in pelvic floor muscles.

CONCLUSION

Delivery-related strains lead to acute sarcomere elongation, a well-established cause of mechanical injury in skeletal muscles. Sarcomere hyperelongation resultant from mechanical strains is attenuated by pregnancy-induced adaptations acquired by the pelvic floor muscles prior to parturition.

Longitudinal pelvic floor biometry: which factors affect it?

OBJECTIVES

To evaluate pelvic floor biometry of women 3-5 years after their first delivery. The effect of a subsequent delivery and the mode of delivery on pelvic floor biometry were also studied.

METHODS

Three-hundred and twenty-eight women who had been examined by translabial ultrasound during their first singleton pregnancy and at 8 weeks and 1 year postpartum, were invited for a follow-up 3-5 years later. The positions of the bladder neck, cervix, anorectal junction and hiatal area (HA) were evaluated using translabial ultrasound. The effects of parity, mode of delivery and levator ani muscle avulsion were studied.

RESULTS

A total of 240 women completed the study. Of these, 179 had one or more vaginal deliveries (VD) (VD-only group), 52 had one or more Cesarean sections (CS) (CS-only group) and nine had both VD and CS at follow-up. The mean interval between the first delivery and follow-up was 3.8 years. A significantly lower bladder neck and anorectal junction on Valsalva, a lower cervix at rest, on Valsalva and pelvic floor muscle contraction, and a greater HA were observed in the VD-only group at follow-up, compared with findings at 1 year of follow-up or in the first pregnancy. The findings were similar in the CS-only group, except without a lower anorectal junction on Valsalva. Compared with the primiparous VD-only group, a greater HA at rest was observed in the multiparous VD-only group (P = 0.027). The VD-only group had a greater HA than the CS-only group.

CONCLUSIONS

At 3-5 years after first delivery, a lower bladder neck, cervix and anorectal junction, and a greater HA were observed compared with findings in the first trimester and at 1 year of follow-up, regardless of parity or mode of delivery. Women with two or more VDs had a greater HA compared with those who had only one VD, and women with at least one VD had a greater HA compared with those who delivered by CS only. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Longitudinal follow-up of levator ani muscle avulsion: does a second delivery affect it?

OBJECTIVES

To evaluate the morphological outcome of levator ani muscle (LAM) avulsion 3-5 years after a first delivery and to assess the effect of a second delivery on this condition. The impact of LAM avulsion on pelvic floor disorders was also studied.

METHODS

Six hundred and sixty-six women who had been assessed for LAM avulsion 8 weeks after their first delivery were invited for a follow-up examination 3-5 years later. Women completed the Pelvic Floor Distress Inventory including the Urinary Distress Inventory (UDI) and Pelvic Organ Prolapse Distress Inventory (POPDI) questionnaires to explore symptoms of pelvic floor disorders, and the pelvic floor was examined using three-dimensional translabial ultrasound and assessed using the pelvic organ prolapse quantification system.

RESULTS

Three hundred and ninety-nine women completed the study, of whom 151 were multiparous. Mean interval between first delivery and follow-up was 42.3 ± 7.6 months. Among 69 women who had LAM avulsion 8 weeks after their first delivery, nine (13.0%) had no LAM avulsion at follow-up. One (0.9%) woman had a new LAM avulsion after her second vaginal delivery. A greater proportion of women with LAM avulsion reported symptoms of stress urinary incontinence (SUI) (adjusted odds ratio, 2.09 (95% CI, 1.18-3.70); P = 0.01) and symptoms of prolapse than did women without avulsion; however, this difference did not reach statistical significance (P = 0.61). Women with LAM avulsion had higher UDI and POPDI scores than did women without avulsion (median UDI score, 17.7 (interquartile range (IQR), 5.0-32.4) vs 9.2 (IQR, 0.0-22.1); P = 0.045 and median POPDI score, 20.8 (IQR, 8.8-40.5) vs 10.7 (IQR, 0.0-32.8); P = 0.021).

CONCLUSIONS

The risk of developing new LAM avulsion after a second vaginal delivery is low (0.9%). Healing of LAM avulsion was observed in 13% of women who had at least one vaginal delivery. At 3-5 years after delivery, women with LAM avulsion reported symptoms of SUI more often than did those without, and had higher UDI and POPDI scores, implying more bothersome symptoms. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Recent Advances in Understanding Pelvic-Floor Tissue of Women With and Without Pelvic Organ Prolapse: Considerations for Physical Therapists

Pelvic organ prolapse is a fairly common condition that imposes significant symptoms, diminished quality of life, social burden, financial expense, and surgical risk on women. As evidence supporting the benefit of pelvic-floor muscle training in nonsurgical management of pelvic organ prolapse grows, physical therapists are becoming a provider of choice interacting with women affected by pelvic organ prolapse. This perspective article will review recent research on tissue characteristics of 3 key components of pelvic organ support: skeletal muscle, ligament, and vaginal wall. This information will be summarized as implications for physical therapists. An improved understanding of pelvic-floor tissue in women with and without pelvic organ prolapse will provide a more comprehensive appreciation of the interaction of multiple systems in the disorder.

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.

The Epidemiology of Pelvic Floor Disorders and Childbirth: An Update

Using a lifespan model, this article presents new scientific findings regarding risk factors for pelvic floor disorders (PFDs), focusing on the role of childbirth in the development of single or multiple coexisting PFDs. Phase I of the model includes predisposing factors, such as genetic predisposition and race. Phase II includes inciting factors, such as obstetric events. Prolapse, urinary incontinence (UI), and fecal incontinence (FI) are more common among vaginally parous women, although the impact of vaginal delivery on risk of FI is less dramatic than prolapse and UI. Phase III includes intervening factors, such as age and obesity.

Agreement and reliability of pelvic floor measurements during rest and on maximum Valsalva maneuver using three-dimensional translabial ultrasound and virtual reality imaging

OBJECTIVES

Imaging of the levator ani hiatus provides valuable information for the diagnosis and follow-up of patients with pelvic organ prolapse (POP). This study compared measurements of levator ani hiatal volume during rest and on maximum Valsalva, obtained using conventional three-dimensional (3D) translabial ultrasound and virtual reality imaging. Our objectives were to establish their agreement and reliability, and their relationship with prolapse symptoms and POP quantification (POP-Q) stage.

METHODS

One hundred women with an intact levator ani were selected from our tertiary clinic database. Information on clinical symptoms were obtained using standardized questionnaires. Ultrasound datasets were analyzed using a rendered volume with a slice thickness of 1.5 cm, at the level of minimal hiatal dimensions, during rest and on maximum Valsalva. The levator area (in cm(2) ) was measured and multiplied by 1.5 to obtain the levator ani hiatal volume (in cm(3) ) on conventional 3D ultrasound. Levator ani hiatal volume (in cm(3) ) was measured semi-automatically by virtual reality imaging using a segmentation algorithm. Twenty patients were chosen randomly to analyze intra- and interobserver agreement.

RESULTS

The mean difference between levator hiatal volume measurements on 3D ultrasound and by virtual reality was 1.52 cm(3) (95% CI, 1.00-2.04 cm(3) ) at rest and 1.16 cm(3) (95% CI, 0.56-1.76 cm(3) ) during maximum Valsalva (P < 0.001). Both intra- and interobserver intraclass correlation coefficients were ≥ 0.96 for conventional 3D ultrasound and > 0.99 for virtual reality. Patients with prolapse symptoms or POP-Q Stage ≥ 2 had significantly larger hiatal measurements than those without symptoms or POP-Q Stage < 2.

CONCLUSIONS

Levator ani hiatal volume at rest and on maximum Valsalva is significantly smaller when using virtual reality compared with conventional 3D ultrasound; however, this difference does not seem clinically important. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.