Paravaginal defects: a comparison of clinical examination and 2D/3D ultrasound imaging

The usual suspect: cross-sectional study of fundal pressure at second stage of delivery and the association with pelvic floor damage

INTRODUCTION AND HYPOTHESIS

Uterine fundal pressure is applied to accelerate birth by increasing the expulsive force of the uterus in the second stage of delivery. The aim of the study was to evaluate the effect of using uterine fundal pressure during the second stage of delivery on the rate of pelvic floor damage among primiparous women using three-dimensional transperineal ultrasonography.

METHODS

The women were divided into two groups: the fundal pressure group included women where the fundal pressure maneuver was applied (n = 39); the control group included women who delivered spontaneously without fundal pressure (n = 47). 3D-TPU was performed within 48 h of delivery, and LAM biometry, LAM defect and loss of tenting were determined.

RESULTS

Anteroposterior hiatal dimensions on resting, maximal Valsalva and maximal PFMC were found to be higher in the fundal pressure group (p < 0.0001, p = 0.008, p = 0.007, respectively). The mean hiatal area at rest was larger in the fundal pressure group than in the control group (p = 0.04). The rate of LAM defect was significantly higher in the fundal pressure group (p = 0.001). The rate of loss of tenting was significantly higher in the fundal pressure group (p < 0.0001). According to multivariate regression models, the fundal pressure was the only independent factor associated with LAM defect (OR = 5.63; 95% CI = 12.01-15.74) and loss of tenting (OR = 8.74; 95% CI = 2.89-26.43).

CONCLUSIONS

Fundal pressure during the second stage of delivery is associated with a higher risk of LAM defect and loss of anterior vaginal wall support.

CLINICAL TRIAL REGISTRATION

NCT03752879.

Pelvic Organ Prolapse: ACOG Practice Bulletin, Number 214

Pelvic organ prolapse (POP) is a common, benign condition in women. For many women it can cause vaginal bulge and pressure, voiding dysfunction, defecatory dysfunction, and sexual dysfunction, which may adversely affect quality of life. Women in the United States have a 13% lifetime risk of undergoing surgery for POP (). Although POP can occur in younger women, the peak incidence of POP symptoms is in women aged 70-79 years (). Given the aging population in the United States, it is anticipated that by 2050 the number of women experiencing POP will increase by approximately 50% (). The purpose of this joint document of the American College of Obstetricians and Gynecologists and the American Urogynecologic Society is to review information on the current understanding of POP in women and to outline guidelines for diagnosis and management that are consistent with the best available scientific evidence.

The influence of pelvis reposition exercises on pelvic floor muscles asymmetry: A randomized prospective study

OBJECTIVE

The assessment of pelvis reposition exercise efficacy in the treatment of pelvic floor muscles (PFM) asymmetry. The hypothesis was that PFM asymmetry may have a functional reason related to lumbopelvic complex misalignment.

DESIGN

A parallel group trial with follow-up METHODS:: Thirty young women were divided into 2 groups: experimental (n = 15) and control (n = 15). In experimental group one, a 15-minute trial of pelvis reposition exercise was carried out. Ober test, the Thomas test, and transabdominal PFM ultrasound measurements were performed in both groups.

RESULTS

In the experimental group both the Ober and Thomas tests were positive at baseline in most subjects. After the exercise, improvement was noted in Ober test (P = .005; d = 0.75 on the right side, P = .005; d = 0.78 on the left side) and in the Thomas test (P = .005; d = 0.66 on the right side, P = .005; d = 0.67 on the left side). At baseline, the ultrasonographic evaluation of PFM performed during resting and during voluntary pelvic muscles contraction showed the right-left length asymmetry. The return of symmetrical PFM work after pelvis reposition exercise was observed in the experimental group. There were no statistically significant changes in the control group.s CONCLUSIONS:: We suggest that after reposition exercises, the pelvis was more symmetrically aligned in relation to body axis; therefore, the muscles of the pelvic floor have functional length and did not shorten or lengthen due to pelvis rotation. In this study, for the first time, it was presented that PFM asymmetry visible in ultrasonography may be corrected by this specific exercise. Further analysis of the causes of this asymmetry may lead to more accurate treatment of PFM dysfunctions.

Recommended standardized terminology of the anterior female pelvis based on a structured medical literature review

BACKGROUND

The use of imprecise and inaccurate terms leads to confusion amongst anatomists and medical professionals.

OBJECTIVE

We sought to create recommended standardized terminology to describe anatomic structures of the anterior female pelvis based on a structured review of published literature and selected text books.

STUDY DESIGN

We searched MEDLINE from its inception until May 2, 2016, using 11 medical subject heading terms to identify studies reporting on anterior female pelvic anatomy; any study type published in English was accepted. Nine textbooks were also included. We screened 12,264 abstracts, identifying 200 eligible studies along with 13 textbook chapters from which we extracted all pertinent anatomic terms.

RESULTS

In all, 67 unique structures in the anterior female pelvis were identified. A total of 59 of these have been previously recognized with accepted terms in Terminologia Anatomica, the international standard on anatomical terminology. We also identified and propose the adoption of 4 anatomic regional terms (lateral vaginal wall, pelvic sidewall, pelvic bones, and anterior compartment), and 2 structural terms not included in Terminologia Anatomica (vaginal sulcus and levator hiatus). In addition, we identified 2 controversial terms (pubourethral ligament and Grafenberg spot) that require additional research and consensus from the greater medical and scientific community prior to adoption or rejection of these terms.

CONCLUSION

We propose standardized terminology that should be used when discussing anatomic structures in the anterior female pelvis to help improve communication among researchers, clinicians, and surgeons.

Quality of reporting of diagnostic accuracy studies on pelvic floor three-dimensional transperineal ultrasound: a systematic review

OBJECTIVE

In recent years, a large number of studies have been published on the clinical relevance of pelvic floor three-dimensional (3D) transperineal ultrasound. Several studies compare sonography with other imaging modalities or clinical examination. The quality of reporting in these studies is not known. The objective of this systematic review was to determine the compliance of diagnostic accuracy studies investigating pelvic floor 3D ultrasound with the Standards for Reporting of Diagnostic Accuracy (STARD) guidelines.

METHODS

Published articles on pelvic floor 3D ultrasound were identified by a systematic literature search of MEDLINE, Web of Science and Scopus databases. Prospective and retrospective studies that compared pelvic floor 3D ultrasound with other clinical and imaging diagnostics were included in the analysis. STARD compliance was assessed and quantified by two independent investigators, using 22 of the original 25 STARD checklist items. Items with the qualifier 'if done' (Items 13, 23 and 24) were excluded because they were not applicable to all papers. Each item was scored as reported (score = 1) or not reported (score = 0). Observer variability, the total number of reported STARD items per article and summary scores for each item were calculated. The difference in total score between STARD-adopting and non-adopting journals was tested statistically, as was the effect of year of publication.

RESULTS

Forty studies published in 13 scientific journals were included in the analysis. Mean ± SD STARD checklist score of the included articles was 16.0 ± 2.5 out of a maximum of 22 points. The lowest scores (< 50%) were found for reporting of handling of indeterminate results or missing responses, adverse events and the time interval between tests. Interobserver agreement for rating the STARD items was excellent (intraclass correlation coefficient, 0.77). An independent t-test showed no significant mean difference ± SD in total STARD checklist score between STARD-adopting and non-adopting journals (16.4 ± 2.2 vs 15.9 ± 2.6, respectively). Mean ± SD STARD checklist score for articles published in 2003-2009 was lower, but not statistically different, compared with those published in 2010-2015 (15.2 ± 2.5 vs 16.6 ± 2.4, respectively).

CONCLUSION

The overall compliance with reporting guidelines of diagnostic accuracy studies on pelvic floor 3D transperineal ultrasound is relatively good compared with other fields of medicine. However, specific checklist items require more attention when reported. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Paravaginal defect: anatomy, clinical findings, and imaging

INTRODUCTION AND HYPOTHESIS

The paravaginal defect has been a topic of active discussion concerning what it is, how to diagnose it, its role in anterior vaginal wall prolapse, and if and how to repair it. The aim of this article was to review the existing literature on paravaginal defect and discuss its role in the anterior vaginal wall support system, with an emphasis on anatomy and imaging.

METHODS

Articles related to paravaginal defects were identified through a PubMed search ending 1 July 2015.

RESULTS

Support of the anterior vaginal wall is a complex system involving levator ani muscle, arcus tendineus fascia pelvis (ATFP), pubocervical fascia, and uterosacral/cardinal ligaments. Studies conclude that physical examination is inconsistent in detecting paravaginal defects. Ultrasound (US) and magnetic resonance imaging (MRI) have been used to describe patterns in the appearance of the vagina and bladder when a paravaginal defect is suspected. Different terms have been used (e.g., sagging of bladder base, loss of tenting), which all represent changes in pelvic floor support but that could be due to both paravaginal and levator ani defects.

CONCLUSION

Paravaginal support plays a role in supporting the anterior vaginal wall, but we still do not know the degree to which it contributes to the development of prolapse. Both MRI and US are useful in the diagnosis of paravaginal defects, but further studies are needed to evaluate their use.

3D analysis of cystoceles using magnetic resonance imaging assessing midline, paravaginal, and apical defects

INTRODUCTION AND HYPOTHESIS

This study assesses relative contributions of "midline defects" (widening of the vagina) and "paravaginal defects" (separation of the lateral vagina from the pelvic sidewall).

METHODS

Ten women with anterior predominant prolapse and ten with normal support underwent pelvic MR imaging. 3-D models of the anterior vaginal wall (AVW) were generated to determine locations of the lateral AVW margin, vaginal width, and apical position.

RESULTS

The lateral AVW margin was farther from its normal position in cases than controls throughout most of the vaginal length, most pronounced midvagina (effect sizes, 2.2-2.8). Vaginal widths differed in the midvagina with an effect size of 1.0. Strong correlations between apical and paravaginal support were evident in mid- and upper vagina (r = 0.77-0.93).

CONCLUSIONS

Changes in lateral AVW location were considerably greater than changes in vaginal width in cases vs controls, both in number of sites affected and effect sizes. These "paravaginal defects" are highly correlated with apical descent.

Ultrasound imaging of the pelvic floor: where are we going?

We produced a non systematic review of ultrasound imaging of the pelvic floor in women with urinary incontinence (UI) and/or pelvic organ prolapse (POP). We have searched the PubMed and Embase databases for the following PICO question: women; imaging; urinary incontinence, pelvic organ prolapse, pelvic floor, pelvic floor muscle, pelvic floor muscle training; physical examination, no imaging; diagnosis, prognosis, outcome. The production of a systematic review was deemed impossible based on the type and quality of the published evidence. Clinical research focused on the pathophysiology of the UI and POP looking relation between anatomic abnormalities, childbirth, the risk of UI or POP, the outcome of conservative treatment and reconstructive surgery. Published papers fall into the remits of diagnostic studies but often fail to comply with the recommendations of the STARD initiative. Most published evidence remains the product of a single institution effort and confirmatory studies are rarely found. Imaging studies in patients with UI did not provide evidence of any clinical benefit in the management of patients. In patients with POP, interesting correlations have been identified such as between childbirth, dimension of levator hiatus, avulsion of levator ani and risk of prolapse, but the non clinical benefit of pelvic floor imaging could still not be identified. Research on pelvic floor imaging requires a coordinated, international, multicentre effort to improve internal and external validity of imaging techniques, confirm observations published by single institutions and provide health technology assessment of imaging in the management of UI or POP patients.

Does levator ani injury affect cystocele type?

OBJECTIVE

To determine the prevalence of levator ani injury in patients with different types of cystocele, as defined by translabial ultrasound, in order to shed light on potential pathophysiological mechanisms.

METHODS

The datasets of 222 women who had undergone a physical examination, urodynamic testing and four-dimensional (4D) pelvic floor ultrasound were evaluated offline for prolapse, levator ani hiatal dimensions and levator ani trauma using tomographic ultrasound imaging (TUI), blinded against all clinical and urodynamic data. Cystoceles reaching below the symphysis pubis on ultrasound examination were classified based on bladder neck position, retrovesical angle (RVA) and urethral rotation as Green II (cystourethrocele) or Green III (cystocele with intact RVA).

RESULTS

Of 102 women who had a cystocele reaching below the symphysis pubis, 63 were classified as a Green type II cystocele and 39 as a Green type III cystocele. Women with Green type III cystoceles were older (59.4 vs. 48.7 years, P < 0.001), and had more severe prolapse (71 vs. 43%, P = 0.004) and objective voiding dysfunction (39 vs. 18%, P = 0.018). Women with Green III cystoceles also had larger hiatal dimensions and were more often diagnosed with an avulsion of the levator ani muscle (69 vs. 35%, P = 0.001).

CONCLUSION

A cystocele with an intact RVA is more likely to be associated with avulsion injury of the levator ani muscle and thus more likely to be caused by birth-related trauma. This contradicts the commonly held belief that such cystoceles are caused by central rather than by lateral fascial defects.

Three-dimensional ultrasound imaging

This review is about the development of three-dimensional (3D) ultrasonic medical imaging, how it works, and where its future lies. It assumes knowledge of two-dimensional (2D) ultrasound, which is covered elsewhere in this issue. The three main ways in which 3D ultrasound may be acquired are described: the mechanically swept 3D probe, the 2D transducer array that can acquire intrinsically 3D data, and the freehand 3D ultrasound. This provides an appreciation of the constraints implicit in each of these approaches together with their strengths and weaknesses. Then some of the techniques that are used for processing the 3D data and the way this can lead to information of clinical value are discussed. A table is provided to show the range of clinical applications reported in the literature. Finally, the discussion relating to the technology and its clinical applications to explain why 3D ultrasound has been relatively slow to be adopted in routine clinics is drawn together and the issues that will govern its development in the future explored.

Three-dimensional transperineal ultrasonography of the pelvic floor: improving visualization for new clinical applications and better functional assessment

OBJECTIVE

With increasing awareness of the scope of pelvic floor disorders has come development and introduction into clinical practice of new imaging techniques, with increasing importance of ultrasonography. Complex pelvic floor anatomy, the conceptual difficulty in the basics of some pelvic floor disorders, and the uneven standardization of ultrasonographic techniques were the impetuses of this review. The purpose of this study was to review the basic anatomy of the pelvic floor and the transperineal ultrasonographic evaluation technique and to provide an overview of the current clinical use of 3-dimensional transperineal ultrasonography in the evaluation of the anterior and posterior pelvic floor compartments.

METHODS

A literature review illustrated with index cases from our center was conducted.

RESULTS

Ultrasonography has been widely applied to evaluation of the anterior and posterior compartments of the pelvic floor. Three-dimensional ultrasonography has a role in improving pelvic floor assessment.

CONCLUSIONS

Three-dimensional transperineal ultrasonography has been applied to evaluation of normal and pathologic pelvic floor anatomy. Practical application, through well-designed and sufficiently powered clinical studies, will establish the association between the clinical presentations of dysfunction with ultrasonographic findings.

Direct imaging of the pelvic floor muscles using two-dimensional ultrasound: a comparison of women with urogenital prolapse versus controls

OBJECTIVE

To evaluate the anatomy of the levator ani muscle in women with urogenital prolapse versus matched controls without prolapse using real-time two-dimensional (2-D) ultrasound.

DESIGN

Prospective observational study.

SETTING

Tertiary referral urogynaecology unit.

POPULATION

Forty-three women with pelvic organ prolapse (POP) and 24 women (controls) attending a gynaecology clinic without prolapse.

METHODS

All participants completed a standardised symptom questionnaire.

MAIN OUTCOME MEASURES

The morphology of the vagina and paravaginal tissue was recorded at different levels. The thickness of the levator ani and the hiatal area were measured at rest. Reproducibility of the method was assessed by repeated measurements to assess intra-observer variability and inter-observer variability.

RESULTS

This method showed good intra-observer and inter-observer reproducibility and reliability. In controls, the pubococcygeus muscle showed more regular echogenicity with no evidence of trauma, whereas in women with prolapse the muscle had mixed echogenicity. (P = 0.002). The mean thickness of the pubococcygeus did not differ between groups. The levator hiatal area was significantly larger in women with pelvic floor prolapse versus controls (17.8 cm2 versus 13.5 cm2, P < 0.001). This increase in hiatal area positively and significantly correlated with prolapse severity (P < 0.001).

CONCLUSIONS

Morphology and hiatal area can be reliably imaged using 2-D ultrasound. Prolapse was related to changes in pelvic floor morphology and increased levator hiatal area. The use of 2-D ultrasound provides an important insight into the pathophysiology of prolapse.

MR imaging of the female urethra and supporting ligaments in assessment of urinary incontinence: spectrum of abnormalities

The traditional methods for evaluation of urinary incontinence in women include urodynamics, cystourethroscopy, cystourethrography, and ultrasonography. Magnetic resonance (MR) imaging has not played a major role in the assessment of women with urinary incontinence. However, high-resolution MR imaging allows detailed visualization of the urethral sphincter and supporting ligaments in women and may contribute to the diagnosis and staging of sphincteric incompetence related to intrinsic sphincter deficiency or urethral hypermobility. Both the anatomy and the function of the female urethra can be depicted on MR images. The spectrum of abnormalities detected at MR imaging in women with stress urinary incontinence are classified as (a) findings related to the urethral sphincter deficiency and (b) defects of the urethral support ligaments and urethral hypermobility. These abnormalities include a small urethral sphincter, funneling at the bladder neck, distortion of the urethral support ligaments, cystocele, an asymmetric pubococcygeus muscle, abnormal shape of the vagina, enlargement of the retropubic space, and an increased vesicourethral angle.