Levator Plate Upward Lift on Dynamic Sonography and Levator Muscle Strength

Correlation between pelvic floor ultrasound parameters and vaginal pressures in nulliparous women: a subanalysis of the SUM-AN study

INTRODUCTION AND HYPOTHESIS

Pelvic floor ultrasound is used as a validated technique for measuring levator ani dimensions. Vaginal manometry has been used in the past as a method to assess levator ani muscle (LAM) strength. Whether the combination of both methods can contribute to our understanding of pelvic floor pathophysiology has not yet been described. We hypothesized that as female pelvic floor muscular hiatus increases, the vaginal pressure and strength decrease.

METHODS

We recruited 20 asymptomatic nulliparous women ages 18-85 years. Minimal levator hiatus (MLH) area, anteroposterior/left-right (AP/LR) diameter ratio, the distance between levator plate and the pubic symphysis (LP-PS) while at rest and squeeze were measured using endovaginal ultrasound (US). Vaginal pressure at rest, squeeze (Kegel) and Valsalva were measured using 3D manometry. Logistic and linear regression analysis was performed to assess correlations.

RESULTS

MLH area was negatively correlated with the sum of all the squeeze pressures produced on the four walls of the vagina (p = 0.049, R² = 0.197). There was also a borderline negative correlation between MLH and the sum of rest pressures (p = 0.09, R² = 0.15). AP/LR ratio was negatively correlated with the sum of squeeze pressures (p = 0.056, R² = 0.197). LP-PS distances, both while at rest and during squeeze, were negatively correlated with the vaginal squeeze pressure (p = 0.046, R² = 0.21; p = 0.011, R² = 0.31, respectively). LP-V distance, both at rest and during squeeze, was negatively correlated with the sum of squeeze pressures on four vaginal walls (p = 0.02, R² = 0.25; p = 0.005, R² = 0.36, respectively).

CONCLUSIONS

Stronger levator ani muscles, smaller MLH area and a more oval shape of pelvic floor hiatus as assessed by pelvic floor ultrasound are associated with higher squeeze vaginal pressures as assessed by 3D manometry.

An International Continence Society (ICS) report on the terminology for pelvic floor muscle assessment

INTRODUCTION

The terminology for female and male pelvic floor muscle (PFM) assessment has expanded considerably since the first PFM function and dysfunction standardization of terminology document in 2005. New terms have entered assessment reports, and new investigations to measure PFM function and dysfunction have been developed. An update of this terminology was required to comprehensively document the terms and their definitions, and to describe the assessment method and interpretation of the finding, to standardize assessment procedures and aid diagnostic decision making.

METHODS

This report combines the input of members of the Standardisation Committee of the International Continence Society (ICS) Working Group 16, with contributions from recognized experts in the field and external referees. A logical, sequential, clinically directed assessment framework was created against which the assessment process was mapped. Within categories and subclassifications, each term was assigned a numeric coding. A transparent process of 12 rounds of full working group and external review was undertaken to exhaustively examine each definition, plus additional extensive internal development, with decision making by collective opinion (consensus).

RESULTS

A Terminology Report for the symptoms, signs, investigations, and diagnoses associated with PFM function and dysfunction, encompassing 185 separate definitions/descriptors, has been developed. It is clinically based with the most common assessment processes defined. Clarity and user-friendliness have been key aims to make it interpretable by clinicians and researchers of different disciplines.

CONCLUSION

A consensus-based Terminology Report for assessment of PFM function and dysfunction has been produced to aid clinical practice and be a stimulus for research.

Reliability of ultrasound imaging of pelvic floor morphology and function among females who have undergone pelvic radiotherapy

AIMS

To investigate the intra- and inter-rater reliability of two-dimensional (2D) transperineal ultrasound imaging (USI) measures of bladder wall thickness (BWT), urethral length (UL), and parameters related to levator plate length (LP) and transient changes in LP during pelvic floor muscle (PFM) contraction, and on Valsalva in women who received radiation therapy (RT) for treatment of pelvic cancer.

METHODS

Twenty women with a history of RT for the treatment of pelvic cancer were assessed independently by two raters on the same day. Five outcomes were assessed for reliability: BWT, UL, and LP at rest (LP-R), during a maximal voluntary contraction of the PFMs (LP-MVC), and during a maximal-effort Valsalva maneuver (LP-MVM). Reliability was determined using intra-class correlation coefficients (ICC) and Bland-Altman analyses. Measurement error was determined using standard error of the measurement (SEM) and minimal detectable difference.

RESULTS

Intra-rater reliability was very good for LP-R, LP-MVC, LP-MVM, and UL (ICC: 0.97 [0.93-0.99], 0.95 [0.88-0.98], 0.84 [0.59-0.94], and 0.96 [0.89-0.98], respectively). Inter-rater reliability was very good for LP-R (ICC: 0.82 [0.55-0.93]), and good for LP-MVC, LP-MVM, and UL (ICC: 0.79 [0.46-0.92], 0.79 [0.49-0.92], and 0.75 [0.36-0.90], respectively). BWT had poor intra- and inter-rater reliability. The variability between measurements was the smallest for LP-R, LP-MVC, and UL for intra-rater assessments, and for LP-R and UL for inter-rater assessments. SEM values for intra-rater assessments were LP-R: 1.5 mm, LP-MVC: 1.84 mm, LP-MVM: 4.33 mm, and UL: 1.16 mm.

CONCLUSIONS

Although these results support the reliability of 2D-transperineal USI for the evaluation of UL and PFM parameters, they do not support its use for the assessment of BWT.

Ultrasound Indicators of Rectal Support Defect in Women With Obstructive Defecatory Symptoms

OBJECTIVE

The anatomic and physiologic pathophysiology of obstructive defecatory symptoms is complex and poorly understood. As a consequence, there is no one surgical method that can achieve overall superiority. We aimed to investigate rectal architectural change in women with obstructive defecatory symptoms using three-dimensional pelvic floor ultrasound.

METHODS

This retrospective cohort study included 65 women who were referred to our urogynecology clinic because of varied pelvic floor disorders between January 2013 and January 2014. Patients completed a standardized interview including PFDI-20 questionnaire and received a standard examination and assessment of pelvic floor by three-dimensional endovaginal ultrasound. Women were categorized to case and control based on their answers to questions 7, 8, and 14 on PFDI-20 (Colorectal and Anal Distress Index) questionnaire. In ultrasound images, levator plate descent angle, levator plate-probe distance, and rectal area have been measured and values have been compared among symptomatic and asymptomatic patients.

RESULTS

Forty-five women with obstructive defecatory symptoms and 20 asymptomatic women entered the study. There was no significant difference in mean (SD) age (56.55 [SD] 13.29 vs 51.8 [15], P = 0.2), mean (SD) body mass index (27.39 [6.7] vs 24.2 [4.08], P = 0.11), and median (range) parity (3 [1-7] vs 2 [1-6], P = 0.15) among categories. There was significant difference in ultrasound measurements, levator plate descent angle, levator plate-probe distance, and rectal area, between women with obstructive defecatory symptoms and asymptomatic women.

CONCLUSIONS

Women with obstructive defecatory symptoms have wider rectum and descendent levator plate regardless of the stage of prolapse as measured by POPQ or the severity of rectocele.