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Moser N, Skawran S, Steigmiller K, Röhrnbauer B, Winklehner T, Reiner CS, Betschart C. Quantitative 3D Analysis of Levator Ani Muscle Subdivisions in Nulliparous Women: MRI Feasibility Study. Diagnostics (Basel) 2024; 14:923. [PMID: 38732338 PMCID: PMC11083419 DOI: 10.3390/diagnostics14090923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 04/17/2024] [Accepted: 04/24/2024] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND The levator ani muscle (LAM) is crucial for pelvic floor stability, yet its quantitative MRI assessment is only a recent focus. Our study aims to standardize the quantitative analysis of the LAM morphology within the 3D Pelvic Inclination Correction System (3D-PICS). METHODS We analyzed 35 static MR datasets from nulliparous women examining the pubovisceral (PVM), iliococcygeal (ICM), coccygeal (COC), and puborectal muscle (PRM). The PVM consists of three origin-insertion pairs, namely the puboanal (PAM), puboperineal (PPM) and pubovaginal muscle (PVaM). The analysis included a quantitative examination of the morphology of LAM, focusing on the median location (x/y/z) (x: anterior-posterior, y: superior-inferior, z: left-right) of the origin and insertion points (a), angles (b) and lengths (c) of LAM. Inter-rater reliability was calculated. RESULTS Interindividual variations in 3D coordinates among muscle subdivisions were shown. In all, 93% of all origin and insertion points were found within an SD of <8 mm. Angles to the xz-plane range between -15.4° (right PRM) and 40.7° (left PAM). The PRM is the largest pelvic muscle in static MRI. The ICC indicated moderate-to-good agreement between raters. CONCLUSIONS The accurate morphometry of the LAM and its subdivisions, along with reliable inter-rater agreement, was demonstrated, enhancing the understanding of normal pelvic anatomy in young nulliparous women.
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Affiliation(s)
- Nathalie Moser
- Department of Gynecology, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland;
| | - Stephan Skawran
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
- Department of Nuclear Medicine, University Hospital Zurich, University of Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
| | - Klaus Steigmiller
- Institute of Epidemiology, Biostatistics and Prevention, University of Zurich, Hirschengraben 84, 8001 Zurich, Switzerland
| | - Barbara Röhrnbauer
- School of Engineering, IMES Institute of Mechanical Systems, ZHAW Zurich University of Applied Sciences, Technikumstrasse 71, 8401 Winterthur, Switzerland
| | - Thomas Winklehner
- SITEM Insel-Ability, University of Berne, Freiburgstrasse 3, 3010 Berne, Switzerland
| | - Cäcilia S. Reiner
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
| | - Cornelia Betschart
- Department of Gynecology, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland;
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Gong Q, Wang Y, Duan L, Lei L, Liu J, Yao J, Qi J, Xu Z, Nian Y, Wu Y. Comparative study of female pelvic floor among undeformed high-resolution thin-sectional anatomical (visible human) images and MRI and ultrasound images. JOURNAL OF CLINICAL ULTRASOUND : JCU 2024; 52:208-218. [PMID: 38108620 DOI: 10.1002/jcu.23616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 10/30/2023] [Accepted: 11/08/2023] [Indexed: 12/19/2023]
Abstract
PURPOSE Using visible human, MRI and ultrasound images, we aim to provide an anatomical basis for the identification and diagnosis of pelvic floor structure and disease by ultrasound imaging. METHODS One Chinese visible human (CVH) image, one American visible human image, 9 MRI images of normal volunteers, and 40 ultrasound images of normal volunteers or pelvic organ prolapse patients were used. Pelvic organs, pelvic floor muscles, and the connective tissue in CVH, VHP, MRI, and ultrasound images were selected for comparative study. RESULTS We successfully identified the boundary of the anal sphincter complex, including the subcutaneous, superficial, and deep parts of the external anal sphincter, conjoined longitudinal muscles and internal anal sphincter; the levator ani muscle (LAM), including the internal and external parts of the pubovisceral muscle and the superficial and deep parts of the puborectal muscle; the urethral sphincter complex, including the urethral sphincter proper and the urethral compressor; and the perineal body, the rectoperineal muscle and superficial transverse perineal muscle. CONCLUSIONS We successfully recognized and studied the location, subdivisions, 2D morphology and spatial relationships of the LAM, anal sphincter complex, urethral sphincter complex and perineal body in ultrasound images, thereby helping sonologists or clinicians accurately identify pelvic floor muscles and supporting structures in ultrasound images.
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Affiliation(s)
- Qingfang Gong
- Department of Digital Medicine, School of Biomedical Engineering and Imaging Medicine, Army Military Medical University (Third Military Medical University), Chongqing, China
| | - Yangyun Wang
- Department of Urology, Shanghai Fifth People's Hospital, Fudan University, Shanghai, China
| | - Li Duan
- Department of Ultrasound, Shanghai Fifth People's Hospital, Fudan University, Shanghai, China
| | - Ling Lei
- Department of Gynecology and Obstetrics, People's Hospital of Anshun, Anshun City, Guizhou Province, China
| | - Jia Liu
- Department of Digital Medicine, School of Biomedical Engineering and Imaging Medicine, Army Military Medical University (Third Military Medical University), Chongqing, China
| | - Jie Yao
- Department of Digital Medicine, School of Biomedical Engineering and Imaging Medicine, Army Military Medical University (Third Military Medical University), Chongqing, China
| | - Jing Qi
- Department of Digital Medicine, School of Biomedical Engineering and Imaging Medicine, Army Military Medical University (Third Military Medical University), Chongqing, China
| | - Zhou Xu
- Department of Digital Medicine, School of Biomedical Engineering and Imaging Medicine, Army Military Medical University (Third Military Medical University), Chongqing, China
| | - Yongjian Nian
- Department of Digital Medicine, School of Biomedical Engineering and Imaging Medicine, Army Military Medical University (Third Military Medical University), Chongqing, China
| | - Yi Wu
- Department of Digital Medicine, School of Biomedical Engineering and Imaging Medicine, Army Military Medical University (Third Military Medical University), Chongqing, China
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Yiasemidou M, Yates C, Cooper E, Goldacre R, Lindsey I. External rectal prolapse: more than meets the eye. Tech Coloproctol 2023; 27:783-785. [PMID: 37278904 DOI: 10.1007/s10151-023-02829-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 05/29/2023] [Indexed: 06/07/2023]
Affiliation(s)
- M Yiasemidou
- Pelvic Floor Unit, Department of Colorectal Surgery, Oxford University Hospitals NHS Trust, Oxford, England
| | - C Yates
- Pelvic Floor Unit, Department of Colorectal Surgery, Oxford University Hospitals NHS Trust, Oxford, England
| | - E Cooper
- Pelvic Floor Unit, Department of Colorectal Surgery, Oxford University Hospitals NHS Trust, Oxford, England
| | - R Goldacre
- Nuffield Department of Population Health, Big Data Institute, Oxford University, Oxford, England
| | - I Lindsey
- Pelvic Floor Unit, Department of Colorectal Surgery, Oxford University Hospitals NHS Trust, Oxford, England.
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Vereeck S, Pacquée S, Jacquemyn Y, Neels H, De Wachter S, Weeg N, Dietz HP. Does Cystocele Type Vary Between Vaginally Parous and Nulliparous Women? JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2023; 42:809-813. [PMID: 35766234 DOI: 10.1002/jum.16046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 06/05/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES To evaluate whether cystocele type varies with vaginal parity. METHODS Retrospective analysis of 464 vaginally nulliparous women seen at 2 urogynecology units between November 2006 and November 2019. A control group consisted of 871 vaginally parous women seen between July 2017 and November 2019. Patients underwent a standardized interview, POPQ, urodynamic testing, and translabial ultrasound. On imaging, significant cystocele was defined as bladder descent to ≥10 mm below symphysis pubis. Volume datasets were analyzed offline and blinded against clinical data. RESULTS Of 5266 women seen during the inclusion period, 464 were vaginally nulliparous. Three were excluded due to missing data, leaving 461. A control group of 871 parous women was generated from patients seen during the last 2.5 years of the inclusion period. Vaginally nulliparous women were presented at a younger age compared to vaginally parous women (P < .001). Symptoms of prolapse were reported in 104 (22%) nulliparae and 489 (56%) parous women (P < .0001). Vaginally parous women demonstrated more bladder descent (P < .0001) and more cystocele (418/871 versus 43/461, P < .0001), with a higher proportion of type III cystocele (cystocele with intact retrovesical angle) (20/43 versus 273/ 418, P < .0001). Cystourethrocele (Green type II) was more common in nulliparae and cystocele type III in parous women (P = .015). On multivariate analysis, these differences in proportions remained significant (P = .049). CONCLUSIONS Nulliparity was associated with a higher proportion of Green type II cystoceles. Green type III cystocele was more common in vaginally parous women, suggesting that the latter may be more likely to be due to childbirth-related pelvic floor trauma.
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Affiliation(s)
- Sascha Vereeck
- Department of Gynaecology, Antwerp University Hospital, Edegem, Belgium
- University of Antwerp, ASTARC, Antwerp, Belgium
| | - Stefaan Pacquée
- Department of Obstetrics, Gynaecology & Neonatology, University of Sydney, Sydney, NSW, Australia
- Sydney Medical School Nepean, University of Sydney, Sydney, NSW, 2747, Australia
| | - Yves Jacquemyn
- Department of Gynaecology, Antwerp University Hospital, Edegem, Belgium
- University of Antwerp, ASTARC, Antwerp, Belgium
| | - Hedwig Neels
- Department of Gynaecology, Antwerp University Hospital, Edegem, Belgium
- University of Antwerp, ASTARC, Antwerp, Belgium
| | - Stefan De Wachter
- University of Antwerp, ASTARC, Antwerp, Belgium
- Department of Urology, Antwerp University Hospital, Edegem, Belgium
| | - Natalie Weeg
- Department of Obstetrics, Gynaecology & Neonatology, University of Sydney, Sydney, NSW, Australia
- Sydney Medical School Nepean, University of Sydney, Sydney, NSW, 2747, Australia
| | - Hans Peter Dietz
- Department of Obstetrics, Gynaecology & Neonatology, University of Sydney, Sydney, NSW, Australia
- Sydney Medical School Nepean, University of Sydney, Sydney, NSW, 2747, Australia
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Bø K, Anglès-Acedo S, Batra A, Brækken IH, Chan YL, Jorge CH, Kruger J, Yadav M, Dumoulin C. International urogynecology consultation chapter 3 committee 2; conservative treatment of patient with pelvic organ prolapse: Pelvic floor muscle training. Int Urogynecol J 2022; 33:2633-2667. [PMID: 35980443 PMCID: PMC9477909 DOI: 10.1007/s00192-022-05324-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2022] [Indexed: 02/05/2023]
Abstract
INTRODUCTION AND HYPOTHESIS This manuscript from Chapter 3 of the International Urogynecology Consultation (IUC) on Pelvic Organ Prolapse (POP) describes the current evidence and suggests future directions for research on the effect of pelvic floor muscle training (PFMT) in prevention and treatment of POP. METHODS An international group of four physical therapists, four urogynecologists and one midwife/basic science researcher performed a search of the literature using pre-specified search terms on randomized controlled trials (RCTs) in Ovid Medline, EMBASE, CINAHL, Cochrane, PEDro and Scopus databases for publications between 1996 and 2021. Full publications or expanded abstracts in English or in other languages with abstracts in English were included. The PEDro rating scale (0-10) was used to evaluate study quality. Included RCTs were reviewed to summarize the evidence in six key sections: (1) evidence for PFMT in prevention of POP in the general female population; (2) evidence for early intervention of PFMT in the peripartum period for prevention and treatment of POP; (3) evidence for PFMT in treatment of POP in the general female population; (4) evidence for perioperative PFMT; (5) evidence for PFMT on associated conditions in women with POP; (6) evidence for the long-term effect of PFMT on POP. Full publications in English or in other languages with abstracts in English and expanded abstracts presented at international condition specific societies were included. Internal validity was examined by the PEDro rating scale (0-10). RESULTS After exclusion of duplicates and irrelevant trials, we classified and included 2 preventive trials, 4 trials in the post-partum period, 11 treatment trials of PFMT for POP in the general female population in comparison with no treatment or lifestyle interventions, 10 on PFMT as an adjunct treatment to POP surgery and 9 long-term treatment trials. Only three treatment studies compared PFMT with the use of a pessary. The RCTs scored between 4 and 8 on the PEDro scale. No primary prevention studies were found, and there is sparse and inconsistent evidence for early intervention in the postpartum period. There is good evidence/recommendations from 11 RCTs that PFMT is effective in reducing POP symptoms and/or improving POP stage (by one stage) in women with POP-Q stage I, II and III in the general female population, but no evidence from 9/10 RCTs that adding PFMT pre- and post -surgery for POP is effective. There are few long-term follow-up studies, and results are inconsistent. There are no serious adverse effects or complications reported related to PFMT. CONCLUSIONS There are few studies on prevention and in the postpartum period, and the effect is inconclusive. There is high-level evidence from 11 RCTs to recommend PFMT as first-line treatment for POP in the general female population. PFMT pre- and post-POP surgery does not seem to have any additional effect on POP. PFMT is effective and safe but needs thorough instruction and supervision to be effective.
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Affiliation(s)
- Kari Bø
- Department of Sports Medicine, The Norwegian School of Sport Sciences, PO Box 4014, Ullevål stadion, 0806, Oslo, Norway.
- Department of Obstetrics and Gynecology, Akershus University Hospital, Lørenskog, Norway.
| | | | - Achla Batra
- Department of Obstetrics & Gynaecology, VMMC & Safdarjung Hospital, New Delhi, India
| | - Ingeborg Hoff Brækken
- Kolbotn Physical Institute, Nordre Follo Municipality, Nordre Follo, Norway
- The Pelvic Floor Centre, Division of Surgery, Akershus University Hospital, Lørenskog, Norway
| | - Yi Ling Chan
- Department of Obstetrics and Gynaecology, Calderdale and Huddersfield NHS Foundation Trust, Huddersfield, UK
| | - Cristine Homsi Jorge
- Department of Health Science Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Jennifer Kruger
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Manisha Yadav
- Paropakar Maternity and women's hospital, Thapathali, Kathmandu, Nepal
| | - Chantale Dumoulin
- School of rehabilitation, Faculty of Medicine, Université de Montréal, Montréal, Canada
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