Impact of vaginal parity and aging on the architectural design of pelvic floor muscles

Analysis of minimal levator ani hiatus area based on MRI in female adults without pelvic floor dysfunction at different age groups

PURPOSE

To investigate the association of minimal levator ani hiatus area with age in female adults without pelvic floor dysfunction.

METHODS

532 female subjects aged 18 ~ 90 years without pelvic floor dysfunction, divided into four groups (Group A, 18 ~ 29 years old; Group B, 30 ~ 39 years old; Group C, 40 ~ 49 years old; Group D, ≥ 50 years old) based on age, underwent traditional pelvic two-dimensional (2D) T2-weighted imaging (T2WI) axial to the body (AxB) for measuring the minimal levator ani hiatus area. 39 female volunteers were re-recruited to undergo both traditional pelvic 2D T2WI AxB and three-dimensional (3D) T2WI. An axial plane parallel to the direction of the puborectalis muscle (AxPRM) was acquired based on 3D T2WI. The difference of levator ani hiatus area measured on AxB and AxPRM images in 39 female volunteers was compared by one-sample t test, to verify if minimal levator ani hiatus area can be acquired on the traditional pelvic 2D T2WI AxB images. Spearman analysis evaluated the association of minimal levator ani hiatus area with age and the rank-sum test analyzed the area differences among four age groups.

RESULTS

Female age was positively correlated with minimal levator ani hiatus area (r = 0.23; p < 0.001). The minimal levator ani hiatus areas of 532 subjects were: 15.17 ± 1.77 cm2 in Group A, 15.52 ± 2.21 cm2 in Group B, 16.03 ± 2.16 cm2 in Group C, and 16.40 ± 2.10 cm2 in Group D. ANOVA showed significant statistical differences among four age groups (F = 7.519, p < 0.0001). Significant differences in minimal levator ani hiatus areas were found between Group A and Group C (p = 0.0491), Group A and Group D (p = 0.0007), and Group B and Group D (p < 0.001). There was no statistical difference in minimal levator ani hiatus areas measured on AxB and AxPRM images in 39 female volunteers (p = 0.1000). There were no statistical difference in minimal levator ani hiatus areas between nulliparous and multiparous group for each age group (all p > 0.05).

CONCLUSIONS

Based on a large sample, this study summarized the minimum levator ani hiatus area of female adults without pelvic floor dysfunction in different age groups. We found significant differences among different age groups. In addition, a positive correlation was found between age and the minimum levator ani hiatus area. These findings can provide reference criteria for diagnosing pelvic organ prolapse in female adults of different age groups.

A unified pelvic floor conceptual model for studying morphological changes with prolapse, age, and parity

Several 2-dimensional and 3-dimensional measurements have been used to assess changes in pelvic floor structures and shape. These include assessment of urogenital and levator hiatus dimensions, levator injury grade, levator bowl volume, and levator plate shape. We argue that each assessment reflects underlying changes in an individual aspect of the overall changes in muscle and fascial structures. Vaginal delivery, aging, and interindividual variations in anatomy combine to affect pelvic floor structures and their connections in different ways. To date, there is no unifying conceptual model that permits the evaluation of how these many measures relate to one another or that reflects overall pelvic floor structure and function. Therefore, this study aimed to describe a unified pelvic floor conceptual model to better understand how the aforementioned changes to the pelvic floor structures and their biomechanical interactions affect pelvic organ support with vaginal birth, prolapse, and age. In this model, the pelvic floor is composed of 5 key anatomic structures: the (1) pubovisceral, (2) puborectal, and (3) iliococcygeal muscles with their superficial and inferior fascia; (4) the perineal membrane or body; and (5) the anal sphincter complex. Schematically, these structures are considered to originate from pelvic sidewall structures and meet medially at important connection points that include the anal sphincter complex, perineal body, and anococcygeal raphe. The pubovisceral muscle contributes primarily to urogenital hiatus closure, whereas the puborectal muscle is mainly related to levator hiatus closure, although each muscle contributes to the other. Dorsally and laterally, the iliococcygeal muscle forms a shelflike structure in women with normal support that spans the remaining area between these medial muscles and attachments to the pelvic sidewall. Other features include the levator plate, bowl volume, and anorectal angle. The pelvic floor conceptual model integrates existing observations and points out evident knowledge gaps in how parturition, injury, disease, and aging can contribute to changes associated with pelvic floor function caused by the detachment of one or more important connection points or pubovisceral muscle failure.

Is there correlation between perineometry and Modified Oxford Scale in women? Systematic review with meta-analysis and grade recommendations

BACKGROUND

The International Continence Society (ICS) recommends the use of perineometry and digital palpation to assess the pelvic floor muscles (PFM). Exploring the degree of correlation between both assessment strategies will serve to improve safety for clinical practice. Therefore, we performed a systematic review and meta-analysis on the correlation between assessment strategies.

METHODS

Observational studies were included. Bias risk assessment based on Downs and Black scale and the evidence's level were assessed using the GRADE. The random effect model measured the correlation values and were quantitatively analyzed through meta-analysis. Registration in PROSPERO database - CRD42021253775.

RESULTS

Six studies were selected. There was a high positive correlation between perineometry and MOS (r = 0.74; 95%-IC 0.61-0.83; I2: 81%, p < 0.01). Subgroup analysis was performed with 3 studies with continent women, and revealed a high positive correlation (r = 0.80; 95%-IC 0.62-0.90; I2: 90%, p < 0.01), while 2 studies with incontinent women revealed a moderate positive correlation (r = 0.64; 95%-IC 0.48-0.75; I2: 0%, p = 0.40). GRADE analysis revealed a low strength of evidence.

CONCLUSION

The high positive correlation between perineometry and MOS suggests that if the assessment strategies are applied in a standardized way, these tests can be used together or separately to assess the functionality of PFMs in clinical practice. However, the results should be interpreted with caution due to the low strength of GRADE evidence.

Appearance of levator ani muscle subdivision defects on level III vaginal support structures in women with and without pelvic organ prolapse: an MRI study

INTRODUCTION AND HYPOTHESIS

Injury of the levator ani muscle (LAM) is a significant risk factor for pelvic organ prolapse (POP). The puborectalis (PRM) and pubovisceral (PVM) subdivisions are level III vaginal support structures. The null hypothesis was that there is no significant difference in patterns of LAM subdivisions in healthy nulliparous women. Secondarily, we evaluated the presence of different LAM injury in a POP-symptomatic cohort.

METHODS

This retrospective magnetic resonance imaging study included: 64 nulligravidae without any pelvic floor dysfunction (PFD) and 526 women of various parity with symptomatic POP. Primary outcome was PVM and PRM morphology on the axial planes: the attachment site on the pubic bone, and the visible separation/border between the PVM and PRM. The attachment was scored as "normal" or "abnormal". The "abnormal" attachment was divided in two types: "type I"-loss of the muscle substance, but preservation of the overall muscle architecture-and "type II"-muscle detachment from the pubic bone.

RESULTS

The puboanal muscle (PAM) subdivision was evaluated as a representative part of the PVM. The PAM and PRM attachments and separation were distinguished in all asymptomatic nulliparae. PAM and PRM attachments did not significantly differ. POP group characteristics were parity 1.9 ± 0.8, instrumental delivery 5.6%, hysterectomy or POP surgery 60%, all Pelvic Organ Prolapse Quantification (POP-Q) stages, LAM defect 77.6% (PRM: 77.1%; PAM: 51.3%). Type I injuries were more frequent (PRM 54.7%; PAM 53.9%) compared with type II (PRM 29.4%; PAM 42.1%).

CONCLUSIONS

A LAM defect was present in 77.6% of women with symptomatic POP. In PRM and PAM subdivisions type I injury was more frequent than type II.

The hysterectomy: influence of the surgical method in benign disease on convalescence and quality of life

PURPOSE

The aim of this study was to evaluate the postoperative course after different methods of hysterectomy for benign diseases with special emphasis on time to recovery and patient-centred aspects such as postoperative quality of life and satisfaction.

METHODS

A collective of 242 women who had undergone vaginal hysterectomy (VH), laparoscopic supracervical hysterectomy (LASH) or total laparoscopic hysterectomy (TLH) for various benign conditions was studied in this retrospective investigation. Patients completed a standardised questionnaire addressing quality of life, recovery and sick leave as well as general questions on their postoperative course after hysterectomy.

RESULTS

A total of 242 cases were analysed (82 VH, 92 LASH and 68 TLH). The data demonstrate significant differences in regard to age between groups. The present study shows shorter hospitalisation with laparoscopy, with LASH patients returning to work at least one week earlier on average. There were no relevant differences in the overall postoperative course during the index hospital stay. In the long run, laparoscopic patients were not more satisfied with their choice than VH patients.

CONCLUSION

No significant long-term differences could be observed in terms of quality of life and overall postoperative satisfaction between VH and LH groups. In regard to socioeconomic aspects, laparoscopic approaches were associated with shorter hospitalisation and LASH patients returning to work at least one week earlier on average. Contrary to these data on objective recovery; however, a laparoscopic approach did not lead to patient-perceived, i.e. subjective improvement of time to full recovery.

Surgical outcomes in patients aged 70 years and older following uterosacral ligament suspension: a comparative study

PURPOSE

The number of elderly patients bothered by pelvic organ prolapse symptoms is growing rapidly. The aim of this study was to evaluate the relationship between age and surgical outcomes in women undergoing uterosacral ligament suspension for treatment of apical prolapse.

METHODS

We performed a retrospective cohort study including women who underwent uterosacral ligament suspension between 2010 and 2020. The cohort was divided into two groups: (1) Patients 70 years or older; (2) Patients under the age of 70. Outcome measures included clinical, anatomical, and composite outcomes as well as patient satisfaction.

RESULTS

A total of 271 patients were included in the final analysis. Of them 209 patients were under age 70 and 62 patients 70 years or older. Mean age was 59 ± 6 vs. 73 ± 3 for the young and elderly age groups, respectively. Clinical success was high for both groups, reaching 94% vs. 89% for elderly and young patients, respectively (p = 0.34). Anatomical and composite outcome success were higher in the young age group (76% vs. 56%, p < 0.01 and 70% vs. 54%, p = 0.02, respectively); however, following multivariate analysis these differences were no longer statistically significant. Following multivariate logistic regression analysis for the dependent parameter of anatomical success, increased pre-operative genital hiatus and vaginal surgical route were associated with anatomical failure while performing a concomitant posterior colporrhaphy increased likelihood for anatomical success.

CONCLUSION

Women over the age of 70 undergoing uterosacral ligament suspension for treatment of apical prolapse have comparable outcomes to younger patients.

Secondary urethral sphincter function of the rabbit pelvic and perineal muscles

Perineal and pelvic floor muscles play an important role in continence by providing mechanical support to pelvic organs. It is also known that the pubococcygeus muscle (PcM) contracts in the storage phase and is inactive during voiding, while the bulbospongiosus muscle (BsM) is active during the voiding phase. Recent evidence suggested an additional role of these muscles in supporting urethral closure in rabbits. However, the individual role of perineal and pelvic muscles as urethral sphincters is not well-defined. Here we evaluated the individual, sequential and synergistic roles of the PcM and BsM in assisting urethral closure and defined the optimal electrical stimulation parameters that can effectively contract these muscles and increase the urethral pressure (P _ura ) in young nulliparous animals (n = 11). Unilateral stimulation of either the BsM or PcM at 40 Hz induced modest increases in average P _ura (0.23 ± 0.10 and 0.07 ± 0.04 mmHg, respectively). Investigation on the changes in P _ura evoked by stimulation frequencies between 5 and 60 Hz show that sequential contralateral PcM-BsM activation at 40 Hz induced a 2-fold average P _ura increase (0.23 ± 0.07 mmHg) compared to that evoked by PcM stimulation. Simultaneous activation of PcM and BsM at 40 Hz also showed an increased average P _ura (0.26 ± 0.04 mmHg), with a 2-fold increase in average P _ura observed during the unilateral sequential PcM-BsM stimulation at 40 Hz (0.69 ± 0.2 mmHg). Finally, stimulation at 40 Hz of the bulbospongiosus nerve (BsN) induced an approximate 4-fold increase in average P _ura (0.87 ± 0.44 mmHg; p < 0.04) compared to that elicited by BsM stimulation, confirming that direct nerve stimulation is more effective. Together, this study shows that in the female rabbit, both perineal and pelvic muscles support of the urethral function during continence, and that unilateral stimulation of the BsN at 40-60 Hz is sufficient to achieve maximal secondary sphincter activity. The results also support the potential clinical value of neuromodulation of pelvic and perineal nerves as bioelectronic therapy for stress urinary incontinence.

Never Too Late to Train: The Effects of Pelvic Floor Muscle Training on the Shape of the Levator Hiatus in Incontinent Older Women

Pelvic floor muscle (PFM) training is the first-line treatment for women of all ages with urinary incontinence (UI), but evidence supporting its effects on the functional anatomy of the pelvic floor is scarce in older women. We aimed to evaluate the long-term (one-year) effects of PFM training on the shape of the levator hiatus (LH) in older women with UI and its association with PFM force, incontinence severity, and potential effect modifiers (age, UI severity, BMI, and UI type). This is a secondary analysis of the GROUP study, a non-inferiority RCT assessing the effects of a structured and progressive 12-week PFM training program to treat UI in older women. Data were available from 264/308 participants at the one-year follow-up. PFM training resulted in reduced LH size toward a more "circular" shape, which was consistently associated with greater PFM force and reduced UI severity. Further, no significant interactions were found between LH shape changes and any of the potential effect modifiers, suggesting that women will potentially benefit from PFM training, regardless of age, UI severity, BMI, and UI type (stress or mixed), with changes that can be observed in the functional anatomy of the pelvic floor and sustained in the long-term.

Pelvic floor muscle strength in women with diabetes

Introduction and Aim: Diabetes mellitus (DM) is a global health problem with increasing prevalence linked to the alterations in the lifestyle, growing obesity rates and ageing. Women with insulin resistance (IR)/high insulin levels have worse electromyographic activity in the PFMs than women without IR/high insulin levels which prove the effect of IR/high insulin levels on PFMs. This study aimed at assessing and strengthening the pelvic floor muscles in women with diabetes and urinary incontinence.   Materials and Methods: The subjects were diabetic women of age group 45-55 with urinary incontinence assigned to one of two groups namely the group A (experimental group) and the group B (control group) which consisted of 30 patients each. The strength of the pelvic floor muscle was measured by vaginal examination prior and after the treatment and a Kegels Perineometer was inserted to measure the Strength of contraction (MOS), Length of hold (s), Repetitions (n) and Fast contractions (n) for both the groups. Experimental group was advised to do pelvic floor strengthening exercises in various positions with differing durations and increasing repetitions while control group received the regular physiotherapy care.   Results: The results revealed that there was significant increase in the pelvic floor strengths in both the groups but while comparing the post test results of both the groups there was a significant higher strength of contraction, length of hold, repetitions and fast contractions scores in experimental group.   Conclusion: It is evident from the study that performing the pelvic floor strengthening exercises in various positions as in the experimental group exhibited more improved post test results which proved to show reduced symptoms of urinary incontinence and improved quality of life than that of the subjects in the control group.

Reversal of diabetic-induced myopathy by swimming exercise in pregnant rats: a translational intervention study

Gestational diabetes mellitus (GDM) plus rectus abdominis muscle (RAM) myopathy predicts long-term urinary incontinence (UI). Atrophic and stiff RAM are characteristics of diabetes-induced myopathy (DiM) in pregnant rats. This study aimed to determine whether swimming exercise (SE) has a therapeutic effect in mild hyperglycemic pregnant rats model. We hypothesized that SE training might help to reverse RAM DiM. Mild hyperglycemic pregnant rats model was obtained by a unique subcutaneous injection of 100 mg/kg streptozotocin (diabetic group) or citrate buffer (non-diabetic group) on the first day of life in Wistar female newborns. At 90 days of life, the rats are mated and randomly allocated to remain sedentary or subjected to a SE protocol. The SE protocol started at gestational day 0 and consisted of 60 min/day for 6 days/week in a period of 20 days in a swim tunnel. On day 21, rats were sacrificed, and RAM was collected and studied by picrosirius red, immunohistochemistry, and transmission electron microscopy. The SE protocol increased the fiber area and diameter, and the slow-twitch and fast-twitch fiber area and diameter in the diabetic exercised group, a finding was also seen in control sedentary animals. There was a decreased type I collagen but not type III collagen area and showed a similar type I/type III ratio compared with the control sedentary group. In conclusion, SE during pregnancy reversed the RAM DiM in pregnant rats. These findings may be a potential protocol to consider in patients with RAM damage caused by GDM.

Host-biomaterial interactions in mesh complications after pelvic floor reconstructive surgery

Polypropylene (PPL) mesh is widely used in pelvic floor reconstructive surgery for prolapse and stress urinary incontinence. However, some women, particularly those treated using transvaginal PPL mesh placement for prolapse, experience intractable pain and mesh exposure or extrusion. Explanted tissue from patients with complications following transvaginal implantation of mesh is typified by a dense fibrous capsule with an immune cell-rich infiltrate, suggesting that the host immune response has a role in transvaginal PPL mesh complications through the separate contributions of the host (patient), the biological niche within which the material is implanted and biomaterial properties of the mesh. This immune response might be strongly influenced by both the baseline inflammatory status of the patient, surgical technique and experience, and the unique hormonal, immune and microbial tissue niche of the vagina. Mesh porosity, surface area and stiffness also might have an effect on the immune and tissue response to transvaginal mesh placement. Thus, a regulatory pathway is needed for mesh development that recognizes the roles of host and biological factors in driving the immune response to mesh, as well as mandatory mesh registries and the longitudinal surveillance of patients.

Age and/or postmenopausal status as risk factors for pelvic organ prolapse development: systematic review with meta-analysis

INTRODUCTION AND HYPOTHESIS

Age is named as a risk factor for pelvic organ prolapse (POP), despite not being the primary outcome for many observational studies. Postmenopausal status is another associated factor but has many confounders. We aimed to systematically review the role of age and/or postmenopausal status in POP development.

METHODS

Systematic review addressing age and hormones, more specifically by postmenopausal status, from inception to March 2020 in four databases (PubMed, Embase, WOS, Cochrane Library). Quality of evidence was classified by the ROBINS-I classification for non-randomized studies. Experimental studies, animal studies, studies linking age with recurrent POP and case series were excluded. Effect estimates were collected from adjusted odds ratio plus 95% confidence intervals. Significance level was 5%. A discussion exploring mechanistic factors was also included.

RESULTS

Nineteen studies (11 cross sectional, 6 cohort and 2 case control) were included for quantitative analysis. Only two studies presented a low overall risk of bias for age; most of the domains were of moderate risk. Every additional year was responsible for a 10% increase in the risk to develop POP (OR = 1.102 [1.021-1.190]; i² = 80%, random analysis, p = 0.012). This trend was confirmed when age was dichotomized into a cutoff of 35 (p = 0.035) and 50 (p < 0.001) years. Although an increase in the risk for POP was noted in postmenopausal women, this did not reach statistical significance (OR = 2.080 [0.927-4.668], i² = 0%, p = 0.076).

CONCLUSION

Age is a risk factor for POP; postmenopausal status was not statistically associated with POP, prompting the need for further studies addressing this factor.

Is there agreement between the preference of examiner and women for unidigital and bidigital vaginal palpation? A qualitative study

INTRODUCTION AND HYPOTHESIS

The International Continence Society recommends vaginal palpation as a method for assessing pelvic floor muscle (PFM) function. Our aim was to analyze the agreement between preferences of examiner and participants according to unidigital and bidigital vaginal palpation during PFM assessment. The second aim was to investigate qualitatively women's perception of vaginal palpation.

METHODS

Maximal voluntary contractions (MVCs) were requested during both types of vaginal palpation and were classified by the Modified Oxford Scale (MOS). Examiner and participants answered if they had preferences regarding vaginal palpation. Women answered qualitatively what they felt during the assessment. Cohen's linear kappa (κ) evaluated the agreement after allocation of the women with a weaker and stronger MVC and qualitative analysis was performed by transcription considering age range (18-35; 36-59; ≥60 years).

RESULTS

Agreement was almost zero for women with weaker and stronger MVC at unidigital (κ = 0.06 and κ = -0.12) and bidigital vaginal palpation (κ = 0.008 and κ = 0.005). Participants associated bidigital palpation with more perception and an easier way of contracting the PFMs. Women between 36 and 59 years associated unidigital palpation with a harder but comfortable way of contracting the PFMs. Subjects aged ≥60 years associated bidigital palpation with an uncomfortable, harder way of contracting PFM, with less space into the vagina.

CONCLUSIONS

Agreement between preferences was almost zero neither between women with a weaker and stronger PFM contraction, nor between the types of vaginal palpation. Bidigital palpation increased women's perception, made the contraction easier, and was associated with less space in the vaginal canal and less comfort.

The Prevalence and Association of Stress Urinary Incontinence, Core Muscle Endurance, and Low Back Pain among Married Women in Saudi Arabia: A Case-Control Study

Purpose

There may be a strong association among stress urinary incontinence (SUI), low back pain (LBP), and core muscle endurance (CME) in married women. This study is aimed at evaluating the prevalence and clinical association between SUI, CME, and LBP among married women in Saudi Arabia.

Methods

The study was based on a case-control research design, conducted among 143 women with LBP (mean age, 32 ± 7.4 years) and 160 healthy women (mean age, 31.7 ± 6.7 years). SUI, CME, and functional disability were assessed using the international consultation on the Incontinence Questionnaire-Short Form (ICIQ-SF), prone plank test (PP), and Oswestry Disability Index for LBP-United Arab Emirates edition (ODI-UAE).

Results

The prevalence of SUI was found to be 60% in the LBP group while 20% in the control group. CME revealed a stronger negative correlation with SUI in the LBP group (r_s = −0.75) than in the control group (r_s = −0.63).

Conclusions

The prevalence of SUI was observed higher in women with LBP than healthy women. CME exhibited a stronger association with SUI than LBP among women with LBP compared to healthy women in Saudi Arabia. Therefore, the role of CME in SUI development or vice versa among married women with LBP may be subjected to further research.

Previous obstetrical history does not impact short-term mid-urethral sling outcomes

Abstract

Introduction and hypothesis

Pregnancy and delivery are known risk factors for stress and mixed urinary incontinence. The most common surgical treatment is mid-urethral sling (MUS) surgery. This study evaluated the potential impact of the obstetrical history on the short-term subjective and objective failure rates after MUS surgery.

Methods

A registry-based surgical cohort study using data from the Medical Birth Registry of Norway (MBRN) and the national Norwegian Female Incontinence Registry (NFIR). Data from 14,787 women that underwent MUS surgery from 1998 to 2016 with complete registrations in the MBRN were included. Outcomes were 6–12-month postoperative subjective and objective failure rates. The potential impact of obstetrical and constitutional factors on both outcomes was tested in a multivariate logistic regression model.

Results

Several obstetrical variables seemed to impact both outcomes in the univariate analyses. However, in the multivariate analyses, none of the obstetrical variables significantly impacted subjective failure, and only being nulliparous before MUS surgery remained a risk factor for objective failure [aOR 1.60, (95% CI 1.07–2.40), p = 0.022]. High body mass index at time of surgery, non-retropubic slings, high preoperative urgency symptom load, and surgical complications were all strong risk factors for poor outcomes in the multivariate analyses.

Conclusion

Although childbirth is considered a risk factor for developing stress urinary incontinence, childbirth does not appear to affect the result of MUS in parous women. Our results suggest that nulliparous women with SUI may have a different pathophysiology than SUI after childbirth.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00192-021-04836-5.

Characterization of Pelvic Floor Activity in Healthy Subjects and with Chronic Pelvic Pain: Diagnostic Potential of Surface Electromyography

Chronic pelvic pain (CPP) is a highly disabling disorder in women usually associated with hypertonic dysfunction of the pelvic floor musculature (PFM). The literature on the subject is not conclusive about the diagnostic potential of surface electromyography (sEMG), which could be due to poor signal characterization. In this study, we characterized the PFM activity of three groups of 24 subjects each: CPP patients with deep dyspareunia associated with a myofascial syndrome (CPP group), healthy women over 35 and/or parous (>35/P group, i.e., CPP counterparts) and under 35 and nulliparous (<35&NP). sEMG signals of the right and left PFM were recorded during contractions and relaxations. The signals were characterized by their root mean square (RMS), median frequency (MDF), Dimitrov index (DI), sample entropy (SampEn), and cross-correlation (CC). The PFM activity showed a higher power (>RMS), a predominance of low-frequency components (<MDF, >DI), greater complexity (>SampEn) and lower synchronization on the same side (<CC) in CPP patients, with more significant differences in the >35/P group. The same trend in differences was found between healthy women (<35&NP vs. >35/P) associated with aging and parity. These results show that sEMG can reveal alterations in PFM electrophysiology and provide clinicians with objective information for CPP diagnosis.

Quantifying the Effects of Aging on Morphological and Cellular Properties of Human Female Pelvic Floor Muscles

Age-related pelvic floor muscle (PFM) dysfunction is a critical defect in the progression to pelvic floor disorders (PFDs). Despite dramatic prevalence of PFDs in older women, the underlying pathophysiology of age-related PFM dysfunction remains poorly understood. Using cadaveric specimens, we quantified aging effects on functionally relevant PFM properties and compared PFMs with the appendicular muscles from the same donors. PFMs, obturator internus, and vastus lateralis were procured from younger (N = 4) and older (N = 11) donors with known obstetrical and medical history. Our findings demonstrate that PFMs undergo degenerative, rather than atrophic, alterations. Importantly, age-related fibrotic degeneration disproportionally impacts PFMs compared to the appendicular muscles. We identified intramuscular lipid accumulation as another contributing factor to the pathological alterations of PFMs with aging. We observed a fourfold decrease in muscle stem cell (MuSC) pool of aged relative to younger PFMs, but the MuSC pool of appendicular muscles from the same older donors was only twofold lower than in younger group, although these differences were not statistically significant. Age-related degeneration appears to disproportionally impact PFMs relative to the appendicular muscles from the same donors. Knowledge of tissue- and cell-level changes in aged PFMs is essential to promote our understanding of the mechanisms governing PFM dysfunction in older women.

Novel Application of Photogrammetry to Quantify Fascicle Orientations of Female Cadaveric Pelvic Floor Muscles

Although critical for understanding and simulating pelvic floor muscle function and pathophysiology, the fascicle arrangements of the coccygeus and levator ani remain mostly undetermined. We performed close-range photogrammetry on cadaveric pelvic floor muscles to robustly quantify surface fascicle orientations. The pelvic floor muscles of 5 female cadavers were exposed through anatomic dissections, removed en bloc, and photographed from every required angle. Overlapping images were mapped onto in silico geometries and muscle fascicles were traced manually. Tangent vectors were calculated along each trace; interpolated to define continuous, 3D vector fields; and projected onto axial and sagittal planes to calculate angles with respect to the pubococcygeal line. Contralateral and ipsilateral pelvic floor muscles were compared within each donor (Kuiper's tests) and using mean values from all donors (William-Watsons tests). Contralateral muscles and all but one ipsilateral muscle pair differed significantly within each donor (p < 0.001). When mean values were considered collectively, no contralateral or ipsilateral statistical differences were found but all muscles compared differed by more than 10° on average. Close-range photogrammetry and subsequent analyses robustly quantified surface fascicle orientations of the pelvic floor muscles. The continuous, 3D vector fields provide data necessary for improving simulations of the female pelvic floor muscles.

Inter- and intrarater reliability of unidigital and bidigital vaginal palpation to evaluation of maximal voluntary contraction of pelvic floor muscles considering risk factors and dysfunctions

AIMS

To evaluate inter- and intrarater reliability of unidigital and bidigital vaginal palpation of pelvic floor muscle (PFM) maximal voluntary contraction (MVC) according to PFM risk factors and dysfunctions.

METHODS

A total of 187 women were recruited and evaluated by two examiners. Both performed the evaluation of MVC with unidigital and bidigital palpation, graded by Modified Oxford Scale. After 7-10 days, one examiner repeated the assessment. To analyze reliability by Cohen's linear Kappa (κw), participants were allocated into different groups according to: body mass index (BMI), menopause, parity, type of delivery and PFM dysfunctions, as pelvic organ prolapse (POP), constipation, urgency, urgency urinary incontinence, pelvic pain, and stress urinary incontinence.

RESULTS

Inter-rater reliability of unidigital palpation was considered fair (κw = 0.21-0.40) to moderate (κw = 0.41-0.60) according to BMI, postmenopausal status, parity, type of delivery, and PFM dysfunctions. Inter-rater reliability of bidigital palpation varied from none (κw = 0.00-0.20) to moderate for all risk factors and PFM dysfunctions. Intra-rater reliability of unidigital palpation was considered fair only for women with POP (κw = 0.37) and moderate to substantial (κw = 0.61-0.80) to all other variables. Intra-rater reliability of bidigital palpation ranged from moderate to almost perfect (κw = 0.81-1.00).

CONCLUSIONS

When performing vaginal palpation, physiotherapists must consider the way that is performing the evaluation, as some PFM risk factors and dysfunctions could influence the inter- and intrarater reliability of unidigital and bidigital palpation.

Anatomy of the bulbus vestibuli: A cadaveric study

BACKGROUND

To describe the BV anatomy in detail, to compare previous BV descriptions and illustrations to the current study's findings and photograms, to show the BV topographic relation of the BV to the urethral meatus, to document the BV anatomy using photograms.

METHODS

Ten fresh human female adult cadavers were used. Stratum-by-stratum anatomical dissections in sagittal, transverse, and coronal planes were performed. The BV was dissected-off from the original location of the posterior-distal vaginal wall and the anterior anal wall.

RESULTS

The BV was located within the posterior-distal vagina and composed of two vertical legs, which fused to one another. The inferior pars intermedia fused both descending legs to the anterior-proximal perineal urethral wall, and BV embraced the anterior-proximal urethra. The superior pars intermedia connects the BV to the posterior-distal clitoral body. The BV legs traversed parallel to and aside from the vaginal introitus and the lateral urethra and not crossing the anterior-distal urethra. The tile-end was a tapered end which terminates in the vicinity of Bartholin glands. Laterally, the BV legs outspread to the medial labia minora and attach to the ischiopubic ramus. The anatomical site-specific defect (s) occurs within the BV.

CONCLUSIONS

The present study resolves the BV anatomical controversy and shows that the BV runs parallel to and aside from the anterior-distal urethra and the BV. The site-specific defect(s) can occur within the BV. This study provides important information for anatomy educators and surgeons.

CACNA1H downregulation induces skeletal muscle atrophy involving endoplasmic reticulum stress activation and autophagy flux blockade

Multiple vaginal delivery (MVD) is an important factor for pelvic floor muscle (PFM) function decline and pelvic floor dysfunction (PFD). PFD is common in middle-aged and elderly women, but its pathogenesis is not clear. In this study, we found that the expression of CACNA1H was lower in the PFM of old mice after MVD compared with old or adult mice. In in-vitro studies, we found that treatment with the T-type Ca²⁺ channel (T-channel) inhibitor NNC-55 or downregulation of the CACNA1H gene by siRNA intervention promoted myotube atrophy and apoptosis. Mechanistically, we revealed that NNC-55 increased the expression of GRP78 and DDIT3 in myotubes, indicating endoplasmic reticulum stress (ERS) activation, and that the IRE1 and PERK pathways might be involved in this effect. NNC-55 induced the formation of autophagosomes but inhibited autophagy flux. Moreover, rapamycin, an autophagy activator, did not rescue myotube atrophy or apoptosis induced by NNC-55, and the autophagy inhibitors 3-MA and HCQ accelerated this damage. Further studies showed that the ERS inhibitors 4-PBA and TUDAC relieved NNC-55-induced damage and autophagy flux blockade. Finally, we found multisite muscle atrophy and decreased muscle function in Cacna1h^−/− (TH-null) mice, as well as increased autophagy inhibition and apoptotic signals in the PFM of old WT mice after MVD and TH-null mice. Taken together, our results suggest that MVD-associated PFD is partially attributed to CACNA1H downregulation-induced PFM atrophy and that ERS is a potential therapeutic target for this disease.

The importance of developing relevant animal models to assess existing and new materials

PURPOSE OF REVIEW

We summarize the recent literature on the use of different animal models for testing existing and new materials for treatment of pelvic organ prolapse.

RECENT FINDINGS

A wide spectrum of animal models is being used in urogynecology, both for the study of physiologic and pathophysiologic processes, training in surgical procedures, yet mainly to study the host response to implant materials. The quality of studies is variable, and procedures, read-outs, and reporting are not standardized. This makes comparison very difficult. The research community is experimenting with different knitting patterns, novel polymers, bioactivation, as well as resorbable rather than durable implants. Outcomes of the experiments are dependent on the location of implantation. Lighter polypropylene constructs seem to induce a less vigorous host response than elder heavier products. Modification of the surface yields contradictory findings. Resorbable acellular collagen matrices may be reintroduced as prophylactically inserted support structures.

SUMMARY

Although animal experimentation with novel candidate implants is advocated, there is a lack of standardization in reporting. The concept of resorbable construct is being revived, as durable materials have caused clinical graft-related complications. Large animal experiments seem to provide interesting and more comprehensive information, yet their use may be contested.

Effects of mechanical trauma on the differentiation and ArfGAP3 expression of C2C12 myoblast and mouse levator ani muscle

INTRODUCTION AND HYPOTHESIS

Severe mechanical injury or inadequate repair of the levator ani muscle (LAM) is a key contributor to the development of pelvic floor dysfunction (PFD). We explored the effects of mechanical stress on myoblasts and LAM at the cellular and animal level and the possible mechanism of PFD induced by mechanical trauma.

METHODS

A C2C12 cell mechanical injury model was established with a four-point bending device, and a LAM injury mouse model was established via vaginal distention and distal traction, a common way of simulating the birth injury. The cells were divided into control, 1333 μ strain for 4-h cyclic mechanical strain (CMS), 1333 μ strain for 8-h CMS, and 5333 μ strain for 4-h CMS groups. Mice were divided into control and injury groups. After treatment, mitochondrial membrane potential (ΔΨm), reactive oxygen species (ROS) levels, indicators of oxidative damage, cell apoptosis, muscle and cell morphology, cell differentiation, and expression of adenosine diphosphate (ADP)-ribosylation factor GTPase activating protein 3 (ArfGAP3) were detected.

RESULTS

5333 μ strain for 4-h CMS loading could induce myoblast injury with a reduction of ΔΨm, increased ROS levels, aggravation of oxidative damage-associated proteins NADPH oxidase 2 (NOX2) and xanthine oxidase (XO), and an increased apoptosis rate of C2C12 cells. At the same time, the injury CMS loading can promote the differentiation of myoblasts and increase the expression of ArfGAP3, a factor regulating intracellular transport. Mechanical trauma could also lead to the oxidative damage of LAM, indicated by 8-hydroxy-2'-deoxyguanosine(8-OHdG), NOX2 and XO protein accumulation, and increase the expression of ArfGAP3 in LAM.

CONCLUSIONS

Oxidative stress caused by mechanical trauma induces dysfunction and damage repairing of LAM and C2C12 myoblast, and ArfGAP3 may promote the repairing process.

"Comparative intra- and inter-rater reliability of maximal voluntary contraction with unidigital and bidigital vaginal palpation and construct validity with Peritron manometer"

AIMS

Evaluate the intra- and inter-rater reliability of maximal voluntary contraction (MVC) of pelvic floor muscle (PFM) assessment by unidigital and bidigital vaginal palpation. As a secondary aim, evaluate the construct validity of vaginal palpation and a manometer.

METHODS

A total of 120 women were recruited and allocated into three groups according to age (group 1 [G1]: 18-35; G2: 36-59; G3: ≥60 years). Examiner A conducted an interview and examiners B and C performed evaluations of PFM function using both unidigital and bidigital vaginal palpation. Seven to 10 days later, examiner B repeated both types of vaginal palpation and measured the MVC pressure with a Peritron. Reliability was analyzed using Cohen's linear weighted Kappa (κ_w ). The construct validity was calculated using the Spearman's correlation (r_s ).

RESULTS

Intra-rater reliability of unidigital and bidigital palpation was κ_w  = 0.75 and κ_w  = 0.58 in G1, κ_w  = 0.59 and κ_w  = 0.73 in G2, and κ_w  = 0.79 and κ_w  = 0.86 in G3, respectively. Inter-rater reliability of unidigital and bidigital palpation was κ_w  = 0.52 and κ_w  = 0.48 in G1, κ_w  = 0.47 and κ_w  = 0.52 in G2, and κ_w  = 0.50 and κ_w  = 0.64 in G3, respectively. Spearman's correlation coefficients were significant at r_s  = 0.79 and r_s  = 0.80 for unidigital and bidigital vaginal palpation, respectively.

CONCLUSIONS

Unidigital or bidigital vaginal palpation were indicated to evaluate G1 and G2 but bidigital palpation was more reliable in G3 when two examiners performed the evaluation. For the assessment conducted by one examiner, unidigital palpation was more reliable in G1 while bidigital palpation was more reliable in G2 and G3. Both unidigital and bidigital palpation have high measures of validity.

MRI comparative study of levator ani muscle changes in nulliparous and multiparous females

Background

Pelvic floor dysfunction is known to be among the principal factors influencing public health, regarding frequency, cost and effect on women’s quality of life. Radiographic assessment of the pelvic floor function and anatomy plays a vital role in the recognition of pelvic floor defects. The aim of this study is to detect the postpartum-related levator ani muscle changes thus defining the relationship between the vaginal deliveries and the etiology of pelvic floor dysfunction in order to provide guidelines to decrease the incidence of pelvic floor injuries during parturition and guide the treatment plan.

Results

There was a significant difference in the puborectalis muscle thickness between the case and control groups in the right puborectalis (P value ≤ 0.001) and in the left puborectalis (P value (≤ 0.001) as well as significant midpoint thickness (P value = 0.03) with 46.2% puborectalis muscle injury in the case group compared with none in the control group.

Conclusion

Pelvic floor MRI is highly recommended as it is a contrast-free modality that allows for both anatomical and functional analysis. Its incorporation in the routine postpartum assessment will allow early detection of abnormalities even in asymptomatic cases thus ensuring proper management and preventing the development of pelvic floor dysfunction predisposed to by repeated vaginal deliveries.

Published Human Cadaveric Measurements Are Strongly Biased Toward the Elderly Population

Understanding of anatomy is based on the study of anatomical variations. Morphometric variations can have important implications in surgical practice. The sizes of some anatomical structures are affected by age; however, cadavers used in anatomical research are usually of advanced age. The main aim of this study is to quantify the mean age of samples in cadaveric studies reporting morphometric values. PubMed was searched for the last 3 years to locate cadaveric studies reporting size values, excluding histological, forensic, and osteological collections. Out of the 390 potentially relevant papers, 109 (28%) studies did not report the ages of their samples. In total, 177 studies were included for analysis comprising 4,807 subjects. The most studied structures were those of the musculoskeletal system. The mean age of the pooled sample was 71.1 ± 11.0 years. The lowest reported age was 16 while the highest was 104 years. Univariate and multivariate analyses showed no correlation with any of the following variables: country of study, anatomical region, anatomical structure, or journal type. The mean age of cadavers used to measure the sizes of human anatomical structures falls largely within the senior age category. The reported values in an aging population will not necessarily mirror other populations such as the pediatric. The outcomes of surgeries that depend to some extent on tight morphometric values such as flap surgeries, microsurgery, tendon transfer, or mini-invasive procedures could differ when they are performed on other age categories. More anatomical research is needed for better reporting of age-related morphometric changes. Clin. Anat., 33:804-808, 2020. © 2019 Wiley Periodicals, Inc.

Age-associated changes in the mechanical properties of human cadaveric pelvic floor muscles

Proper function of the female pelvic floor requires intact pelvic floor muscles (PFMs). The prevalence of pelvic floor disorders (PFDs) increases substantially with age, in part due to clinically identified deterioration of PFM function with age. However, the etiology of this decline remains largely unknown. We previously demonstrated that PFMs undergo age-related fibrotic changes. This study sought to determine whether aging also impacts PFMs' passive mechanical properties that are largely determined by the intramuscular extracellular matrix. Biopsies from younger (≤52y) and older (>52y) female cadaveric donors were procured from PFMs, specifically coccygeus (C) and two portions of the levator ani - iliococcygeus (IC) and pubovisceralis (PV), and the appendicular muscles - obturator internus (OI) and vastus lateralis (VL). Muscle bundles were subjected to a passive loading protocol, and stress-sarcomere length (L_s) relationships calculated. Muscle stiffness was compared between groups using 2-way ANOVA and Sidak pairwise comparisons, α < 0.05. The mean age was 43.4 ± 11.6y and 74.9 ± 11.9y in younger (N = 5) and older (N = 10) donors, respectively. In all PFMs, the quadratic coefficient of parabolic regression of the stress-L_s curve, a measure of stiffness, was lower in the younger versus older group: C: 33.7 ± 13.9 vs 87.2 ± 10.7, P = 0.02; IC: 38.3 ± 12.7 vs 84.5 ± 13.9, P = 0.04; PV: 24.7 ± 8.8 vs 74.6 ± 9.6, P = 0.04. In contrast, non-PFM stiffness was not affected by aging: OI: 14.5 ± 4.7 vs 32.9 ± 6.2, P = 0.8 and VL: 13.6 ± 5.7 vs 30.1 ± 5.3, P = 0.9. Age-associated increase in PFM stiffness is predicted to negatively impact PFM function by diminishing muscle load-bearing, excursional, contractile, and regenerative capacity, thus predisposing older women to PFDs.

Childbirth after mid-urethral sling surgery: effects on long-term success and complications

INTRODUCTION AND HYPOTHESIS

To evaluate long-term outcomes in women with one or more childbirths after mid-urethral sling (MUS) surgery and potential differences in outcomes based on mode of delivery.

METHODS

A population-based cohort study using data from two national registries. Women registered with childbirth after MUS (case group) or without childbirth after MUS (control group), with equal follow-up time, underwent a structured telephone interview using a validated short-form urinary disease-specific questionnaire. Primary outcomes were current stress urinary incontinence (SUI) rate and change in cure rate. Secondary outcomes were effect of delivery mode, rates of repeat operations for SUI, complications, treatment satisfaction and urgency urinary incontinence rate. Childbirth as an independent risk factor for SUI recurrence was also evaluated.

RESULTS

Seventy-two women with and 156 women without childbirth after MUS were included. Median follow-up time was 10 years for both groups. Subjective SUI cure rates were 82% (cases) and 75% (controls), respectively (p = 0.31). A significantly lower SUI cure rate was seen in the women with more than one childbirth after MUS (50% vs. 88% p = 0.006). No differences in primary or secondary outcomes were found between groups at follow-up, nor did mode of delivery affect outcomes. Childbirth after MUS was not an independent risk factor for subjective SUI recurrence (OR 0.8 CI 0.3-1.7).

CONCLUSIONS

No differences in outcomes were seen between groups at follow-up independently of delivery mode. However, having more than one delivery after MUS seems to impact the continence status.

Aging effects on pelvic floor support: a pilot study comparing young versus older nulliparous women

INTRODUCTION AND HYPOTHESIS

We sought to determine age-related changes to the pelvic floor in the absence of childbirth effects.

METHODS

A case-control study was conducted from June 2017 to August 2018 comparing two groups of nulliparous women: <40 years old and ≥ 70 years old. Clinical evaluation included POP-Q, instrumented speculum testing, and handgrip strength. Dynamic 3D-stress MRI was performed on all women to obtain genital and levator hiatus (LH) lengths, LH area, and levator bowl volume. LH shape was quantified using a novel measure called the "V-U index." Pubovisceral muscle (PVM) cross-sectional area (CSA) was also measured. Bivariate comparisons between the two groups were made for all variables. Effect sizes were calculated for MRI measurements.

RESULTS

Twelve young and 9 older nulliparous women were included. Levator bowl volume at rest was 83% larger in older women (108.0 ± 34.5 cm³ vs 59.2 ± 19.3 cm³, p = 0.001, d = 1.82). MRI genital hiatus at rest was larger among the older group (2.7 ± 0.6 cm vs 3.5 ± 0.6 cm, p = 0.007, d = 1.34). V-U index, a measure of LH shape where 0 = "V" and 1 = "U," differed between groups indicating a more "U"-like shape among older women (0.71 ± 0.23 vs 0.35 ± 0.18, p = 0.001, d = 1.72). Handgrip strength was lower in the older vs young group (23.2 ± 5.2 N vs 33.4 ± 5.2 N, p < 0.0001); however, the Kegel augmentation force and PVM CSA were similar (3.2 ± 1.1 N vs 3.3 ± 2.2 N, p = 0.89, and 0.8 ± 0.3 cm² vs 0.7 ± 0.2 cm², p = 0.23 respectively).

CONCLUSIONS

Levator bowl volume at rest was over 80% larger among older women, reflecting a generalized posterior distension with age.

Effects of an 8-week pelvic core stability and nutrition community programme on maternal health outcomes

INTRODUCTION

Women, during the antenatal and post-partum period, report pelvic, low back pain, stress and urge urinary incontinence, colorectal dysfunction, and other co-morbidities that negatively affect health-related quality of life. Exercise and nutrition are important considerations for improving maternal health in this period.

PURPOSE

The purpose of this study was to examine the effects of a community-driven nutrition and exercise programme focused on pelvic floor and core stability, healthy nutrition, and breastfeeding counselling over an 8-week period on pelvic floor and urinary distress (UDI), prolapse and colorectal distress for antenatal and post-partum women with limited access to health care, and low socio-economic resources from a Midwestern Region of the United States.

MATERIALS AND METHODS

Purposive sample of 35 females, ages 18-44, were recruited for this prospective, preintervention to postintervention study, following ethical approval from Institutional Review Board and voluntary written consent from participants. The Health History Questionnaire, SF-36, Food Frequency Questionnaire, report of pelvic organ prolapse dysfunction (POPDI), colorectal-anal dysfunction (CRADI), and UDI as measured by the Pelvic Floor Distress Inventory (PFDI) were completed before and after intervention.

RESULTS

Thirty-five women (n = 35) 18 to 44 years old (mean age of 22.72 ± 3.45 years) completed the study. A significant difference was found from preintervention to postintervention scores means for PFDI total scores, CRADI individual scores, and UDI individual scores (p < .05). POPDI scores decreased preintervention to postintervention but were not significant. A significant improvement in healthy nutrition and breastfeeding postintervention was also found (z = 3.21, p = .001). Further analysis showed significant, but weak, correlation between parity and POPDI (r = .366, p = .033); between parity and UDI (r = .384, p = .03); and between parity and PFDI (r = .419, p = .014).

DISCUSSION

Our study found a significant reduction in pelvic floor dysfunction, urinary, and colorectal-anal distress symptoms and improvement in breastfeeding and healthy nutrition following an 8-week community-driven nutrition and exercise programme focused on pelvic floor and core stability, healthy nutrition, and breastfeeding counselling.

Joint Hypermobility among Female Patients Presenting with Chronic Myofascial Pelvic Pain

BACKGROUND

Female chronic pelvic pain is estimated to affect up to 24% of adult women, many of whom have a component of myofascial pelvic pain. Although an association of joint hypermobility and pelvic pain has been hypothesized, limited data are available that estimate the prevalence of joint hypermobility in this population.

OBJECTIVE

To estimate the prevalence of generalized hypermobility spectrum disorder (G-HSD) among female patients with chronic myofascial pelvic pain and examine the association between G-HSD and other frequent pelvic pain-associated complaints.

STUDY DESIGN

Retrospective case control.

SETTING

Tertiary referral center within a university-affiliated public health system.

PATIENTS

Adult women who were diagnosed with myofascial pelvic pain during a 1-year period (n = 77 with G-HSD and n = 241 without G-HSD).

METHODS

Data were abstracted via chart review of patients meeting inclusion criteria.

OUTCOMES

The primary outcome of this study was the prevalence of G-HSD among patients with persistent myofascial pelvic pain. Secondary outcomes included the prevalence of dyspareunia, provoked vestibulodynia, stress urinary incontinence, irritable bowel syndrome, hip pain, low back pain, and fibromyalgia in patients with persistent myofascial pelvic pain with and without G-HSD.

RESULTS

Twenty-four percent (N = 77; 95% CI: 19.6, 29.4) of myofascial pelvic pain patients also met criteria for G-HSD. After adjusting for confounders, the odds in favor of having G-HSD was 3.55 higher (95% CI: 1.50, 8.40) (P = .004) in females with dyspareunia; 7.46 higher (95% CI: 2.41, 23.1) (P < .001) with low back pain; 3.76 higher (95% CI: 1.35, 10.5) (P = .02) with stress urinary incontinence; 4.72 higher (95% CI: 2.00, 11.2) (P < .001) with irritable bowel syndrome; and 3.12 higher (95% CI: 1.36, 7.13) (P = .007) with hip pain. There was no significant association identified between provoked vestibulodynia or fibromyalgia and G-HSD.

CONCLUSION

The estimated prevalence of G-HSD is higher in chronic myofascial pelvic pain patients than in the general population with statistically significant associations with several comorbid conditions. Characterizing these associations is the first step in developing effective, evidence-based screening recommendations.

LEVEL OF EVIDENCE

III.

A comparable rate of levator ani muscle injury in operative vaginal delivery (forceps and vacuum) according to the characteristics of the instrumentation

INTRODUCTION

Forceps delivery is associated with a high rate of levator ani muscle (LAM) trauma (avulsion) at 35%-65% whereas data on avulsion rates after vacuum delivery vary greatly. Nevertheless, a common characteristic of all previous studies carried out to evaluate the association between instrumental deliveries (forceps and vacuum) and LAM avulsion, is the fact that characteristics of the instrumentation have not been described or evaluated. The objective of this study is to compare the rate of LAM avulsion between forceps and vacuum deliveries according to the characteristics of the instrumentation.

MATERIAL AND METHODS

Prospective, observational study, including 263 nulliparous women, who underwent an instrumental delivery with either Malmström vacuum or Kielland forceps. The characteristics of the instrumentation, position (anterior position and other position) and height of the fetal head at the moment of instrumentation (low instrumentation [vertex at +2 station] and mid-instrumentation [head is involved but leading part above +2 station]) were assessed. Evaluation of LAM avulsion was performed at 6 months postpartum by three-/four-dimensional transperineal ultrasound. Using the multi-view mode, a complete avulsion was diagnosed when the abnormal muscle insertion was identified in all three central slices, that is, in the plane of minimal hiatal dimensions and the 2.5-mm and 5.0-mm slices cranial to this one. To detect a 30% or 15% difference in the LAM injury rate, with 80% power and 5% α-error, we needed, respectively 42 and 99 women per study group.

RESULTS

In all, 263 nulliparous individuals have been evaluated (162 vacuum deliveries, 101 forceps deliveries). Instrumentation in an occipito-anterior position was more frequent in vacuum deliveries (75.3% vs 56.4%, P = .002), whereas other positions were more frequent in the forceps deliveries group (24.7% vs 43.6%). No statistically significant differences were noted regarding the height of the fetal head at the moment of instrumentation. No statistically significant differences were found in the presence of LAM avulsion (41.4% vs 38.6%) between vacuum and forceps deliveries. The univariate analysis of the crude odds ratio was 1.17, 95% CI 0.67-1.98, P = .70 for the avulsion of the LAM and the multivariate of the adjusted OR 0.90, 95% CI; 0.53-1.55, P = .71.

CONCLUSIONS

We consider that, in our population, LAM avulsion rate should not be a factor taken into account when choosing the type of instrumentation (Malmström vacuum or Kielland forceps) in an operative delivery.

Pelvic floor disorders in postpartum adolescents in the Western Amazon: a cross-sectional study

PURPOSE

To analyze the postpartum pelvic floor disorders (PFD) and mode of delivery among adolescents, late adolescents, and young women from Western Amazon.

PATIENTS AND METHODS

Cross-sectional study was carried out in the urban area of Western Amazon in the city of Rio Branco, Acre, Brazil, from October 2016 to February 2017. This is a convenience sample of women up to 30 years who completed six months postpartum, separated in three groups according to maternal age: adolescents (age ≤19 years), late adolescents (20-24 years), and young women (25-30 years). Participants were home interviewed and answered Pelvic Floor Distress Inventory-20 (PFDI-20). Delivery clinical data were collected from patient's medical records.

RESULTS

In total, 285 participants were interviewed: 41 adolescents, 103 late adolescents, and 141 young women. After controlling for confounding factors, prevalences of PFD were higher in the adolescents' group compared with the young women's group (urinary incontinence [UI], prevalence ratio [PR] = 1.75, 95% CI 1.14-2.69; urge urinary incontinence [UUI], PR = 1.88, 95% CI 1.02-3.47; stress urinary incontinence, PR = 2.00, 95% CI 1.11-3.62; fecal incontinence [FI], PR = 4.40, 95% CI 1.36-14.27). PFDI-20 scores also presented higher values in the adolescent group (Pelvic Organ Prolapse Distress Inventory [POPDI], PR = 2.02, 95% CI 1.49-2.75; urinary distress inventory [UDI], PR = 2.09, 95% CI 1.47-2.98; PFDI, PR = 2.12, 95% CI 1.47-2.98). Analyzing the influence of cesarean section, adolescents have higher prevalence of UI (PR = 1.84, 95% CI 1.04-3.26, P=0.037), UUI (PR = 2.36, 95% CI 1.03-5.40, P=0.042), and FI (PR = 4.09, 95% CI 1.21-13.81, P=0.023). In addition, POPDI (PR = 2.15, 95% CI 1.60-2.89, P<0.001), UDI (PR = 2.25, 95% CI 1.61-3.16, P<0.001), and PFDI (PR = 2.27, 95% CI 1.68-3.08, P<0.001) scores are also higher among adolescents where the baby is born by cesarean section.

CONCLUSION

Adolescents present higher prevalence and symptoms of PFD; furthermore, cesarean delivery has a greater negative influence on the pelvic floor of adolescents when compared with young women. This reinforces the importance of PFD investigation among the adolescent population, mainly in developing countries which have high rates of adolescent pregnancy and cesarean section.

Normal values for assessment of anal sphincter morphology, anorectal motion, and pelvic organ prolapse with MRI in healthy women

BACKGROUND

Endoanal MRI and MR defecography are used to identify anal sphincter injury and disordered defecation. However, few studies have evaluated findings in asymptomatic healthy people. The effects of BMI and parity on rectoanal motion and evacuation are unknown.

METHODS

In 113 asymptomatic females (age 50 ± 17 years, Mean ± SD) without risk factors for anorectal trauma, anal sphincter appearance, anorectal motion, and pelvic organ prolapse were evaluated with MRI. The relationship between age, BMI, and parity and structural findings were evaluated with parametric and non-parametric tests.

RESULTS

The anal sphincters and puborectalis appeared normal in over 90% of women. During dynamic MRI, the anorectal angle was 100 ± 1º (Mean ± SEM) at rest, 70 ± 2° at squeeze, and 120 ± 2° during defecation. The change in anorectal angle during squeeze (r = -.25, P < .005), but not during evacuation (r = .13, P = .25) was associated with age. In the multivariable models, BMI (P < .01) and parity (P < .01) were, respectively, independently associated with the intersubject variation in the anorectal angle at rest and the angle change during squeeze. Ten percent or fewer women had had descent of the bladder base or uterus 4 cm or more below the pubococcygeal line or a rectocele measuring 4 cm or larger. Only 5% had a patulous anal canal.

CONCLUSIONS

In addition to age, BMI and parity also affect anorectal motion in asymptomatic women. These findings provide age-adjusted normal values for rectoanal anatomy and pelvic floor motion.

Evaluation of a Mobile Application for Pelvic Floor Exercises

BACKGROUND

Pelvic floor exercises are effective in improving muscle strength and urinary incontinence symptoms. Increasingly popular mobile applications can be effective in teaching patients these exercises.

INTRODUCTION

A mobile application, Bwom^©, aims to educate women about pelvic floor exercises with individually tailored plans relevant to the user's risk factors. The objective of this study is to assess the understandability and actionability of Bwom.

MATERIALS AND METHODS

This is a cross-sectional survey of patients and providers at an academic medical center. The survey utilized the Patient Education Material Assessment Tool (PEMAT) validated by the U.S. Department of Health Services, which provides scores on understandability and actionability. Participants completed an initial demographic survey, used Bwom for 2 weeks, and then completed the PEMAT tool.

RESULTS

Twenty five patients and 22 providers participated in the study, for a total of 47 participants. Providers included gynecology residents and faculty (91%), pelvic floor physical therapists (5%), and other healthcare professionals (5%). The majority of patients were age 31-40 (70%) and Caucasian (55%). Thirty nine percent had not yet tried pelvic floor exercises on their own before the study. The mean understandability score was 93.8% (±11.7) and the mean actionability score was 91.7% (±16.3).

DISCUSSION

This study paves the way for future investigations into the effectiveness of this app in decreasing symptoms of pelvic floor weakness and incontinence.

CONCLUSIONS

This study demonstrates that Bwom shows promise as a mobile application to educate women about pelvic floor exercises by providing user-friendly actions in an understandable way.

Structure-function relationship of the human external anal sphincter

INTRODUCTION AND HYPOTHESIS

Obstetrical external anal sphincter (EAS) injury and subsequent dysfunction are leading risk factors for female fecal incontinence (FI). Limited knowledge of the EAS structure-function relationship hinders treatment optimization. We directly measured functionally relevant intrinsic parameters of human EAS and tested whether vaginal delivery alters the EAS structure-function relationship.

METHODS

Major predictors of in vivo EAS function were compared between specimens procured from vaginally nulliparous (VN, n = 5) and vaginally parous (VP, n = 7) cadaveric donors: operational sarcomere length (Ls), which dictates force-length relationship; physiological cross-sectional area (PCSA), which determines isometric force-generating capacity; fiber length (Lfn), responsible for muscle excursion and contractile velocity; and muscle stiffness. Data were analyzed using unpaired and paired t tests, α < 0.05. Results are presented as mean ± SEM.

RESULTS

The VN and VP (median parity 3) groups were similar in age and BMI. No gross anatomical defects were identified. EAS Ls (2.36 ± 0.05 μm) was shorter than the optimal Lso (2.7 μm), at which contractile force is maximal, P = 0.0001. Stiffness was lower at Ls than Lso (5.4 ± 14 kPa/μm vs 35.3 ± 12 kPa/μm, P < 0.0001). This structural design allows active and passive tension to increase with EAS stretching. EAS relatively long Lfn (106 ± 24.8 mm) permits rapid contraction without decreased force, whereas intermediate PCSA (1.3 ± 0.3 cm2) is conducive to maintaining resting tone. All parameters were similar between groups.

CONCLUSIONS

This first direct examination of human EAS underscores how EAS intrinsic design matches its intended function. Knowledge of the EAS structure-function relationship is important for understanding the pathogenesis of FI and the optimization of treatments for EAS dysfunction.

Comparison of outcomes between postpartum and non-postpartum women with stress urinary incontinence treated with conservative therapy: A prospective cohort study

AIM

This study aimed to compare the outcomes of pelvic floor muscle training (PFMT) between postpartum and non-postpartum women with stress urinary incontinence (SUI) and to detect potential factors that may influence these outcomes.

METHODS

A total of 54 and 79 participants were recruited into postpartum (PP group) and non-postpartum (non-PP group) groups, respectively. A physiotherapist treated the participants twice a week for 6-8 weeks. At baseline and 6 and 12 months after treatment, the 1-h pad weight test (PWT), vaginal contraction pressure (VCP), and Incontinence Impact Questionnaire Short Form (IIQ-7) were assessed by an evaluator or physiotherapist. The primary outcome was PWT improvement. The participants whose PWT improvement reached a >50% reduction relative to baseline were considered responders. Secondary outcomes included VCP, IIQ-7 score, and patient satisfaction rate.

RESULTS

The PWT improvement was 87.04% (95%CI: 0.78, 0.96) in the PP group at 1-year follow-up, which was significantly better than the 72.15% improvement (95%CI: 0.62, 0.82) in the non-PP group (OR = 2.591, 95%CI: 1.018, 6.595, P = 0.041). Changes in VCP and BMI were significant predictors of responders in the regression analysis. As the change in VCP increased by 1 cmH₂ O, the efficiency increased by 4.2% (OR = 1.042, 95%CI: 1.010, 1.070). The change in BMI increased by 1 kg/m² , and the efficiency decreased 23.0% (OR = 0.770, 95%CI: 0.633, 0.937).

CONCLUSIONS

The outcome of PFMT in postpartum participants with SUI was better than that in non-postpartum participants. Women with more improvements in VCP and weight loss showed better amelioration of SUI symptoms after PFMT.

Influence of a protocol of Pilates exercises on the contractility of the pelvic floor muscles of non-institutionalized elderly persons

Abstract Objective: To investigate the influence of a protocol of Pilates exercises on the functionality and contractility of the pelvic floor muscles (PFM) of older women living in the city of Campo Grande, Mato Grosso, Brazil. Method: Ten women (median age of 63.4±4.5 years) with little or no pelvic floor dysfunction were subjected to 24 sessions of Pilates exercises lasting one hour each, for 12 weeks. The pressure of the pelvic floor muscles (PFM) was assessed using a perineometer (cmH20) and contractility was assessed with the PERFECT scheme. Data were described as median ± interquartile range and inferential analysis was performed using the Wilcoxon paired test, with a significance level of 5%. Results: In view of the proposed treatment, the degree of voluntary contraction of the PFM of the participants increased from 79.0±83.5 to 90.0±82.0 cmH20, with a statistically significant difference in paired comparison (p=0.012). According to the PERFECT scheme, there was an increase in contraction time (from 5.0±0.1 to 7.0±4.7 seconds) and in the number of fast repetitions (from 7.0±4.5 to 8.0±4.7), with a statistically significant difference for both variables (p=0.017 and p=0.008, respectively). Conclusion: The results indicate that the Pilates method increased the contractility and pressure of the PFM of elderly women with little or no PFM impairment. Further studies are required to determine whether the Pilates method is an effective method for the treatment of women with severe pelvic floor dysfunction.

On the Stiffness of the Mesh and Urethral Mobility: A Finite Element Analysis

Midurethral slings are used to correct urethral hypermobility in female stress urinary incontinence (SUI), defined as the complaint of involuntary urine leakage when the intra-abdominal pressure (IAP) is increased. Structural and thermal features influence their mechanical properties, which may explain postoperative complications, e.g., erosion and urethral obstruction. We studied the effect of the mesh stiffness on urethral mobility at Valsalva maneuver, under impairment of the supporting structures (levator ani and/or ligaments), by using a numerical model. For that purpose, we modeled a sling with “lower” versus “higher” stiffness and evaluated the mobility of the bladder and urethra, that of the urethrovesical junction (the α-angle), and the force exerted at the fixation of the sling. The effect of impaired levator ani or pubourethral ligaments (PUL) alone on the organs displacement and α-angle opening was similar, showing their important role together on urethral stabilization. When the levator ani and all the ligaments were simulated as impaired, the descent of the bladder and urethra went up to 25.02 mm, that of the bladder neck was 14.57 mm, and the α-angle was 129.7 deg, in the range of what was found in women with SUI. Both meshes allowed returning to normal positioning, although at the cost of higher force exerted by the mesh with higher stiffness (3.4 N against 2.3 N), which can relate to tissue erosion. This finite element analysis allowed mimicking the biomechanical response of the pelvic structures in response to changing a material property of the midurethral synthetic mesh.

Architectural assessment of rhesus macaque pelvic floor muscles: comparison for use as a human model

INTRODUCTION AND HYPOTHESIS

Animal models are essential to further our understanding of the independent and combined function of human pelvic floor muscles (PFMs), as direct studies in women are limited. To assure suitability of the rhesus macaque (RM), we compared RM and human PFM architecture, the strongest predictor of muscle function. We hypothesized that relative to other models, RM best resembles human PFM.

METHODS

Major architectural parameters of cadaveric human coccygeus, iliococcygeus, and pubovisceralis (pubococcygeus + puborectalis) and corresponding RM coccygeus, iliocaudalis, and pubovisceralis (pubovaginalis + pubocaudalis) were compared using 1- and 2-way analysis of variance (ANOVA) with post hoc testing. Architectural difference index (ADI), a combined measure of functionally relevant structural parameters predictive of length-tension, force-generation, and excursional muscle properties was used to compare PFMs across RM, rabbit, rat, and mouse.

RESULTS

RM and human PFMs were similar with respect to architecture. However, the magnitude of similarity varied between individual muscles, with the architecture of the most distinct RM PFM, iliocaudalis, being well suited for quadrupedal locomotion. Except for the pubovaginalis, RM PFMs inserted onto caudal vertebrae, analogous to all tailed animals. Comparison of the PFM complex architecture across species revealed the lowest, thus closest to human, ADI for RM (1.9), followed by rat (2.0), mouse (2.6), and rabbit (4.7).

CONCLUSIONS

Overall, RM provides the closest architectural representation of human PFM complex among species examined; however, differences between individual PFMs should be taken into consideration. As RM is closely followed by rat with respect to PFM similarity with humans, this less-sentient and substantially cheaper model is a good alternative for PFM studies.

Age-related alterations in female obturator internus muscle

INTRODUCTION AND HYPOTHESIS

Pelvic floor muscle rehabilitation is a widely utilized, but often challenging therapy for pelvic floor disorders, which are prevalent in older women. Regimens involving the use of appendicular muscles, such as the obturator internus (OI), have been developed for strengthening of the levator ani muscle (LAM). However, changes that lead to potential dysfunction of these alternative targets in older women are not well known. We hypothesized that aging negatively impacts OI architecture, the main determinant of muscle function, and intramuscular extracellular matrix (ECM), paralleling age-related alterations in LAM.

METHODS

OI and LAM were procured from three groups of female cadaveric donors (five per group): younger (20 - 40 years), middle-aged (41 - 60 years), and older (≥60 years). Architectural predictors of the excursional (fiber length, L _f), force-generating (physiological cross-sectional area, PCSA) and sarcomere length (L _s) capacity of the muscles, and ECM collagen content (measure of fibrosis) were determined using validated methods. The data were analyzed using one-way ANOVA and Tukey's post-hoc test with a significance level of 0.05, and linear regression.

RESULTS

The mean ages of the donors in the three groups were 31.2 ± 2.3 years, 47.6 ± 1.2 years, and 74.6 ± 4.2 years (P < 0.005). The groups did not differ with respect to parity or body mass index (P > 0.5). OI L _f and L _s were not affected by aging. Age >60 years was associated with a substantial decrease in OI PCSA and increased collagen content (P < 0.05). Reductions in OI and LAM force-generating capacities with age were highly correlated (r ² = 0.9).

CONCLUSIONS

Our findings of age-related decreases in predicted OI force production and fibrosis suggest that these alterations should be taken into consideration, when designing pelvic floor fitness programs for older women.