Levator co-activation is a significant confounder of pelvic organ descent on Valsalva maneuver

OBJECTIVE

A Valsalva maneuver is used clinically and on imaging in order to determine female pelvic organ prolapse. We have examined the potential confounding effect of levator co-activation at the time of a Valsalva maneuver and the impact of repetition with biofeedback instruction.

METHODS

Fifty nulliparous women at 36-38 weeks' gestation received 3D/4D translabial ultrasound investigation in the dorsal resting position after bladder emptying. Valsalva maneuvers were recorded initially and after repeated attempts with visual biofeedback both during the maneuver and after, with the operator demonstrating findings on the ultrasound monitor, in order to abolish levator co-activation. Offline analysis was subsequently undertaken.

RESULTS

Significant differences between first and optimal Valsalva maneuver were found for bladder neck position, bladder neck descent, hiatal sagittal diameter and hiatal area on Valsalva. In a minority of women (22/50) we observed a reduction in the sagittal hiatal diameter on first Valsalva maneuver, indicating levator co-activation. A reduction in sagittal diameter was seen in only 11/50 after instruction. Levator co-activation was associated with significantly lower bladder neck descent.

CONCLUSION

The Valsalva maneuver is frequently accompanied by a pelvic floor muscle contraction. Levator co-activation may be a substantial confounder, reducing pelvic organ descent. Without repetition and digital, auditory or visual biofeedback, women may not perform a correct Valsalva maneuver. Biofeedback markedly reduces the likelihood of levator co-activation but does not abolish it completely.

Sonographic characteristics of rectal sensations in healthy females

PURPOSE

This study was designed to characterize rectal sensations by visualizing the internal and external anal sphincter and intra-anal transport of bolus during elicited rectal sensations.

METHODS

The anal canal was visualized with real-time transperineal ultrasonography in 13 healthy female volunteers. Rectal sensations were elicited by injecting water into the rectum. The ultrasound images were recorded on a videotape and analyzed offline.

RESULTS

The median time between an injection of water and the events studied was calculated in 105 rectal sensations. A relaxation in the internal anal sphincter (4 seconds after the injection of water), an antegrade transport of bolus (4 seconds) into the anal canal, and a contraction in the external anal sphincter (5 seconds) were observed before a sensation (6 seconds) was reported. The antegrade flow continued until the distal internal anal sphincter contracted (18 seconds) and the bolus moved in a retrograde transport direction (17 seconds) thereafter the sensation disappeared (18 seconds) and the external anal sphincter relaxed (22 seconds). A significant correlation in time between the end of the sensation, contraction in the internal anal sphincter, reversed flow of anal contents, and relaxation of the external anal sphincter was found (Pearson, P<0.01).

CONCLUSIONS

The results verified that the internal anal sphincter contributes to the perception of rectal sensations by a relaxation allowing intra-anal bolus to increase the pressure on the anoderm during rectal contraction. A new observation is presented on the time relation between contraction in the distal internal anal sphincter, reversed flow in the anal canal, and the end of rectal sensations.

Bleeding disorders among young women: A population-based prevalence study

BACKGROUND

Bleeding problems are prevalent in the general population but may indicate a general bleeding disorder. Our aim was to describe the prevalence of perceived bleeding symptoms, including menorrhagia, in young healthy females.

METHODS

By aid of school nurses we distributed a questionnaire to all girls (n =1,410) in the first grade of the upper secondary schools in the town of Malmö, Sweden. We received 1,019 (72%) responses. The questionnaire consisted of 17 main questions addressing general bleeding problems, menses and menstrual bleeding problems, family history, and other health related questions.

RESULTS

The mean age of the girls was 16.7 years. Eight girls had a previously diagnosed bleeding disorder and had a higher frequency of most bleeding symptoms. Seventy-three percent of girls experienced at least one bleeding symptom, 43% had more than one symptom, 23% were troubled by more than two symptoms, and 10% more than three symptoms. Thirty-seven percent experienced heavy menstruation and of these 22% had different drugs as treatment for menorrhagia. Thirty-eight percent had a family history of heavy menstruation and half of them suffered from heavy menstruation themselves.

CONCLUSIONS

Bleeding symptoms were relatively prevalent in this population and similar to other population-based studies.