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van der Steen A, Morsinkhof LM, Chen L, de Vries M, Simonis FFJ, Grob ATM. Assessment of daily variation in pelvic anatomy in women with and without pelvic organ prolapse. Int Urogynecol J 2023; 34:2407-2414. [PMID: 37145125 PMCID: PMC10590292 DOI: 10.1007/s00192-023-05550-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 04/08/2023] [Indexed: 05/06/2023]
Abstract
INTRODUCTION AND HYPOTHESIS Symptoms of pelvic organ prolapse (POP) can affect quality of life and are reported to progress during the day, although this was never objectified. The aim of this study is to determine whether the pelvic anatomy changes during the day using upright magnetic resonance imaging (MRI), in POP patients and asymptomatic women. METHODS In this prospective study 15 POP patients and 45 asymptomatic women were included. Upright MRI scans were obtained three times per day. The distances from the lowest points of the bladder and cervix to a standardized reference (pelvic inclination correction system) line were determined. A principal component analysis was performed on the levator plate (LP) shape. Statistical differences between time points and the groups were determined for the bladder, cervix, and LP shape. RESULTS For all women a significant decrease in bladder and cervix height of -0.2 cm (p<0.001) was seen between morning/midday and afternoon scans. A significant difference in bladder descent during the day between POP patients and asymptomatic women was found (p=0.004). Individual differences in bladder position in the POP group of up to 2.2 cm between the morning and afternoon scan were reported. There was a significant difference in LP shape (p<0.001) between the groups but there were no significant changes during the day. CONCLUSIONS This study found no clinically relevant pelvic anatomy changes during the day. Still, on an individual level differences can be large, so repeating clinical examination at the end of the day can be recommended in patients when anamnesis and physical examination do not match.
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Affiliation(s)
- Annemarie van der Steen
- Multi Modality Medical Imaging (M3I), TechMed Centre, University of Twente, Drienerlolaan 5, Enschede, The Netherlands.
- Department of Gynecology, Ziekenhuisgroep Twente, Hengelo/Almelo, The Netherlands.
| | - Lisan M Morsinkhof
- Magnetic Detection and Imaging (MD&I), TechMed Centre, University of Twente, Enschede, The Netherlands
| | - Luyun Chen
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - Mirjam de Vries
- Multi Modality Medical Imaging (M3I), TechMed Centre, University of Twente, Drienerlolaan 5, Enschede, The Netherlands
| | - Frank F J Simonis
- Magnetic Detection and Imaging (MD&I), TechMed Centre, University of Twente, Enschede, The Netherlands
| | - Anique T M Grob
- Multi Modality Medical Imaging (M3I), TechMed Centre, University of Twente, Drienerlolaan 5, Enschede, The Netherlands
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Cheng W, English E, Horner W, Swenson CW, Chen L, Pipitone F, Ashton-Miller JA, DeLancey JOL. Hiatal failure: effects of pregnancy, delivery, and pelvic floor disorders on level III factors. Int Urogynecol J 2023; 34:327-343. [PMID: 36129480 PMCID: PMC10171831 DOI: 10.1007/s00192-022-05354-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 08/28/2022] [Indexed: 01/26/2023]
Abstract
INTRODUCTION AND HYPOTHESIS The failure of the levator hiatus (LH) and urogenital hiatus (UGH) to remain closed is not only associated with pelvic floor disorders, but also contributes to recurrence after surgical repair. Pregnancy and vaginal birth are key events affecting this closure. An understanding of normal and failed hiatal closure is necessary to understand, manage, and prevent pelvic floor disorders. METHODS This narrative review was conducted by applying the keywords "levator hiatus" OR "genital hiatus" OR "urogenital hiatus" in PubMed. Articles that reported hiatal size related to pelvic floor disorders and pregnancy were chosen. Weighted averages for hiatal size were calculated for each clinical situation. RESULTS Women with prolapse have a 22% and 30% larger LH area measured by ultrasound at rest and during Valsalva than parous women with normal support. Women with persistently enlarged UGH have 2-3 times higher postoperative failure rates after surgery for prolapse. During pregnancy, the LH area at Valsalva increases by 29% from the first to the third trimester in preparation for childbirth. The enlarged postpartum hiatus recovers over time, but does not return to nulliparous size after vaginal birth. Levator muscle injury during vaginal birth, especially forceps-assisted, is associated with increases in hiatal size; however, it only explains a portion of hiatus variation-the rest can be explained by pelvic muscle function and possibly injury to other level III structures. CONCLUSIONS Failed hiatal closure is strongly related to pelvic floor disorders. Vaginal birth and levator injury are primary factors affecting this important mechanism.
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Affiliation(s)
- Wenjin Cheng
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA.
- Beaumont Hospital Dearborn, Department of Obstetrics and Gynecology, 18101 Oakwood Blvd, Dearborn, MI, 48124, USA.
| | - Emily English
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
- Michigan Medicine, University of Michigan Health-West, Grand Rapids, MI, USA
| | - Whitney Horner
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - Carolyn W Swenson
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
- Division of Urogynecology and Pelvic Reconstructive, University of Utah, Salt Lake City, UT, USA
| | - Luyun Chen
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Fernanda Pipitone
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
- Hospital das Clínicas, University of São Paulo, São Paulo, Brazil
| | - James A Ashton-Miller
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - John O L DeLancey
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
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Mothes AR, Raguse I, Kather A, Runnebaum IB. Native-tissue pelvic organ prolapse (POP) repair with perineorrhaphy for level III support results in reduced genital hiatus size and improved quality of life in sexually active and inactive patients. Eur J Obstet Gynecol Reprod Biol 2023; 280:144-149. [PMID: 36493583 DOI: 10.1016/j.ejogrb.2022.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 10/06/2022] [Accepted: 11/21/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Recent findings address the importance of Level III defects with increased genital hiatus being associated with pelvic organ prolapse (POP), correlated with Level I defects and strongly related to POP recurrence. We hypothesised that concomitant perineorrhaphy in POP repair reduces genital hiatus (gh) and increases perineal body (pb), that gh would be larger with number of vaginal deliveries and that patients' QOL was not different comparing sexually active vs inactive patients with overall judgement of cure comparable to the literature at evaluation. METHODS Retrospective observational study including consecutive patients with indications for posterior repair and Level III support between 2016 and 2018. Concomitant perineorrhaphy was indicated due to complaints of wide introitus or genital hiatus of ≥ 3.5 cm. Primary objective was to compare pre- and postoperative gh and pb according to POP-Q. Secondary objectives were preoperative gh and pb values by parity, POMs obtained with P-QOL/D comparing sexually active vs inactive patients, and subjective judgement of cure according to EGGS system. RESULTS In n = 121 patients, mean gh value was reduced postoperatively by 29.5 % (31 ± 6 vs 44 ± 10 mm, p < 0.001), mean pb value increased by 25.5 % (47 ± 8 vs 35 ± 8 mm, p < 0.001). Influence of parity on preoperative gh (p = 0.020), but not pb values (p = 0.119) was observed. All P-QOL/D domain scores improved significantly postoperatively without differences seen in sexually active vs inactive patients. EGGS responses indicated partial/full goal achievement in 90 % and cure in 87 %. CONCLUSIONS In the study cohort, perineorrhaphy as concomitant in POP repair led to Level III support reflected by decreased genital hiatus size. Functional QOL was improved regardless of sexual activity status and the majority of patients reported partial or full cure.
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Affiliation(s)
- Anke R Mothes
- Department of Gynaecology and Reproductive Medicine, Jena University Hospital, Friedrich-Schiller-University Jena, Am Klinikum 1, 07747 Jena, Germany; Department of Gynaecology, St. Georg Hospital Eisenach, Academic Teaching Hospital of Friedrich-Schiller-University Jena, Eisenach, Germany
| | - Isabel Raguse
- Department of Gynaecology and Reproductive Medicine, Jena University Hospital, Friedrich-Schiller-University Jena, Am Klinikum 1, 07747 Jena, Germany; Department of Traumatology, Hand and Reconstructive Surgery, Jena University Hospital, Friedrich-Schiller-University Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Angela Kather
- Department of Gynaecology and Reproductive Medicine, Jena University Hospital, Friedrich-Schiller-University Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Ingo B Runnebaum
- Department of Gynaecology and Reproductive Medicine, Jena University Hospital, Friedrich-Schiller-University Jena, Am Klinikum 1, 07747 Jena, Germany.
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Morsinkhof LM, Schulten MK, DeLancey JOL, Simonis FFJ, Grob ATM. Pelvic inclination correction system for magnetic resonance imaging analysis of pelvic organ prolapse in upright position. Int Urogynecol J 2022; 33:2801-2807. [PMID: 35907021 PMCID: PMC9477951 DOI: 10.1007/s00192-022-05289-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 06/21/2022] [Indexed: 02/05/2023]
Abstract
INTRODUCTION AND HYPOTHESIS Pelvic organ prolapse quantification by means of upright magnetic resonance imaging (MRI) is a promising research field. This study determines the angle for the pelvic inclination correction system (PICS) for upright patient position, which is hypothesized to deviate from the supine PICS angle. The necessity of different PICS angles for various patient positions will also be discussed. METHODS Magnetic resonance scans of 113 women, acquired in an upright patient position, were used to determine the upright PICS angle, defined as the angle between the sacrococcygeal-inferior pubic point (SCIPP) line and the horizontal line. The difference and correlation between the upright and supine PICS angles were calculated using the paired Student's t-test and the Pearson's correlation coefficient (r) respectively. The effect of the difference between the upright and supine PICS angle on the measured pelvic organ extent was calculated using goniometry. RESULTS The mean (interquartile range) PICS angles were 29° (26-35°) for the upright and 33° (30-37°) for the supine patient position. They were significantly different (p<0.001) and very strongly correlated (r = 0.914, p<0.001). The 4° difference between the average upright and supine PICS angle results in an average underestimation of the measured cervix height of approximately 0.5 cm for patients scanned in upright position. CONCLUSIONS The PICS angle for the upright patient position is 29°. The use of a dedicated PICS angle for different patient positions allows for more accurate pelvic organ extent analysis in patients with prolapse.
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Affiliation(s)
- Lisan M Morsinkhof
- Magnetic Detection and Imaging Group, Technical Medical Centre, University of Twente, Drienerlolaan 5, 7522 NB, Enschede, The Netherlands.
| | - Martine K Schulten
- Multi Modality Medical Imaging Group, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - John O L DeLancey
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - Frank F J Simonis
- Magnetic Detection and Imaging Group, Technical Medical Centre, University of Twente, Drienerlolaan 5, 7522 NB, Enschede, The Netherlands
| | - Anique T M Grob
- Multi Modality Medical Imaging Group, Technical Medical Centre, University of Twente, Enschede, The Netherlands
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