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Qu E, Wu S, Zhang M, Huang Z, Zheng Z, Zhang X. Validation of a built-in software in automatically reconstructing the tomographic images of the levator ani muscle. Int Urogynecol J 2024; 35:175-181. [PMID: 38019307 DOI: 10.1007/s00192-023-05686-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 10/31/2023] [Indexed: 11/30/2023]
Abstract
INTRODUCTION AND HYPOTHESIS Transperineal ultrasound (TPUS) is an effective tool for evaluating the integrity of the levator ani muscle (LAM). Several operating steps are required to obtain the standard multi-slice image of the LAM, which is experience dependent and time consuming. This study was aimed at evaluating the feasibility and reproducibility of the built-in software, Smart-pelvic™, in reconstructing standard tomographic images of LAM from 3D/4D TPUS volumes. METHODS This study was conducted at a tertiary teaching hospital, enrolling women who underwent TPUS. Tomographic images of the LAM were automatically reconstructed by Smart-pelvicTM and rated by two experienced observers as standard or nonstandard. The anteroposterior diameter (APD) of the levator hiatus was also measured on the mid-sagittal plane of the automatically and manually reconstructed images. The APD measurements of each approach were compared using Bland-Altman plots, and interclass correlation coefficient (ICC) was used to evaluate intra- and inter-observer reproducibility. Meanwhile, the time taken for the reconstruction process of both methods was also recorded. RESULTS The ultrasound volume of a total of 104 patients were included in this study. Using Smart-pelvicTM, the overall success rate of the tomographic image reconstruction was 98%. Regarding measurements of APD, the ICC between the automatic and manual reconstruction methods was 0.99 (0.98, 0.99). The average time taken for reconstruction per case was 2.65 ± 0.52 s and 22.08 ± 3.45 s, respectively. CONCLUSIONS Using Smart-pelvicTM to reconstruct tomographic images of LAM is feasible, and it can promote TPUS by reducing operator dependence and improving examination efficiency in a clinical setting.
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Affiliation(s)
- Enze Qu
- Department of Ultrasound, Third Affiliated Hospital of Sun Yat-Sen University, 600 Tianhe Road, Guangzhou, Guangdong Province, China
| | - Shuangyu Wu
- Department of Ultrasound, Third Affiliated Hospital of Sun Yat-Sen University, 600 Tianhe Road, Guangzhou, Guangdong Province, China
| | - Man Zhang
- Department of Ultrasound, Third Affiliated Hospital of Sun Yat-Sen University, 600 Tianhe Road, Guangzhou, Guangdong Province, China
| | - Zeping Huang
- Department of Ultrasound, Third Affiliated Hospital of Sun Yat-Sen University, 600 Tianhe Road, Guangzhou, Guangdong Province, China
| | - Zhijuan Zheng
- Department of Ultrasound, Third Affiliated Hospital of Sun Yat-Sen University, 600 Tianhe Road, Guangzhou, Guangdong Province, China
| | - Xinling Zhang
- Department of Ultrasound, Third Affiliated Hospital of Sun Yat-Sen University, 600 Tianhe Road, Guangzhou, Guangdong Province, China.
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Okada Y, Nakagawa C, Shigeta M, Nomura Y, Inoue E, Ichizuka K, Yoshimura Y. Evaluation of levator ani muscle elasticity after vaginal delivery and cesarean section using shear wave elastography. J Med Ultrason (2001) 2024; 51:95-101. [PMID: 37740863 PMCID: PMC10904486 DOI: 10.1007/s10396-023-01369-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 08/30/2023] [Indexed: 09/25/2023]
Abstract
PURPOSE The risk of pelvic floor muscle injury is commonly considered to be higher in vaginal than in cesarean delivery. This study aimed to compare levator ani muscle (LAM) elasticity after vaginal and cesarean delivery using shear wave elastography (SWE). METHODS Postpartum women who underwent a single SWE evaluation 1 month after their first delivery were divided into vaginal and cesarean delivery groups. The elastic moduli of both sides of the LAM were measured in a horizontal section and compared between the groups. In addition, a subgroup analysis was performed to compare LAM elasticity according to the delivery method within the vaginal delivery group-normal vaginal delivery, episiotomy, and operative vaginal delivery. RESULTS Sixty-two women were included (vaginal delivery, n = 47; elective cesarean section, n = 15). Multiple regression analysis revealed that the LAM elastic modulus was significantly lower in the vaginal delivery group than in the cesarean delivery group (right LAM: 44.2 vs. 72.7 kPa, p = 0.0036; left LAM 40.4 vs. 82.7 kPa, p < 0.0001). In the subgroup analysis, the right LAM elastic modulus was significantly lower in the operative vaginal delivery subgroup than in the normal vaginal delivery subgroup (p = 0.0131). However, there was no significant difference in the left LAM elastic modulus between the three subgroups. CONCLUSION LAM elasticity was significantly lower after vaginal delivery than after cesarean delivery. Furthermore, the elasticity of the right LAM was lower after operative vaginal delivery than after normal vaginal delivery. SWE has the potential to provide an objective quantitative assessment of postpartum pelvic floor muscle recovery.
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Affiliation(s)
- Yoshiyuki Okada
- Department of Female Pelvic Health Center, Showa University Northern Yokohama Hospital, 35-1 Chigasaki-Chuo, Tsuzuki-Ku, Yokohama City, Kanagawa, 224-8503, Japan.
- Department of Obstetrics and Gynecology, Showa University Northern Yokohama Hospital, Kanagawa, Japan.
| | - Chie Nakagawa
- Department of Female Pelvic Health Center, Showa University Northern Yokohama Hospital, 35-1 Chigasaki-Chuo, Tsuzuki-Ku, Yokohama City, Kanagawa, 224-8503, Japan
- Department of Obstetrics and Gynecology, Showa University Northern Yokohama Hospital, Kanagawa, Japan
| | - Miwa Shigeta
- Department of Female Pelvic Health Center, Showa University Northern Yokohama Hospital, 35-1 Chigasaki-Chuo, Tsuzuki-Ku, Yokohama City, Kanagawa, 224-8503, Japan
| | - Yukiko Nomura
- Department of Female Pelvic Health Center, Showa University Northern Yokohama Hospital, 35-1 Chigasaki-Chuo, Tsuzuki-Ku, Yokohama City, Kanagawa, 224-8503, Japan
- Department of Obstetrics and Gynecology, Showa University Northern Yokohama Hospital, Kanagawa, Japan
| | - Eisuke Inoue
- Showa University Research Administration Center, Tokyo, Japan
| | - Kiyotake Ichizuka
- Department of Obstetrics and Gynecology, Showa University Northern Yokohama Hospital, Kanagawa, Japan
| | - Yasukuni Yoshimura
- Department of Female Pelvic Health Center, Showa University Northern Yokohama Hospital, 35-1 Chigasaki-Chuo, Tsuzuki-Ku, Yokohama City, Kanagawa, 224-8503, Japan
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Macchi V, Porzionato A, De Caro R. The "Hand" teaching model in the pelvic floor. Asian J Surg 2023; 46:5561-5562. [PMID: 37591752 DOI: 10.1016/j.asjsur.2023.08.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 08/06/2023] [Indexed: 08/19/2023] Open
Affiliation(s)
- Veronica Macchi
- Institute of Human Anatomy, Department of Neurosciences, University of Padova, Italy; Unit of Clinical Anatomy, Department of General Surgery, University-Hospital of Padua, Italy; National Reference Center for the Conservation and Use of the Bodies of the Deceased, University of Padua, Italy
| | - Andrea Porzionato
- Institute of Human Anatomy, Department of Neurosciences, University of Padova, Italy; Unit of Clinical Anatomy, Department of General Surgery, University-Hospital of Padua, Italy; National Reference Center for the Conservation and Use of the Bodies of the Deceased, University of Padua, Italy
| | - Raffaele De Caro
- Institute of Human Anatomy, Department of Neurosciences, University of Padova, Italy; Unit of Clinical Anatomy, Department of General Surgery, University-Hospital of Padua, Italy; National Reference Center for the Conservation and Use of the Bodies of the Deceased, University of Padua, Italy.
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Li Y, Gong T, Lin X, Wei X, Cai X, Chen X, Lin L, Wang G. Evaluating changes in the strength of the levator ani muscle after vaginal delivery using T2-parameter mapping. Eur J Radiol 2023; 168:111137. [PMID: 37856940 DOI: 10.1016/j.ejrad.2023.111137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 10/02/2023] [Accepted: 10/05/2023] [Indexed: 10/21/2023]
Abstract
OBJECTIVE To evaluate pelvic floor muscle injury in patients with levator ani muscle (LAM) weakness after vaginal delivery using T2-parameter mapping. MATERIALS AND METHODS 40 parturients (patient group) and 25 nonparturients (healthy control group) were enrolled in the study. The LAM weakness group had a Modified Oxford Grading System (MOGS) grade of less than 3 after vaginal delivery. All participants underwent pelvic magnetic resonance imaging (MRI) scans, including T2 and T2* mapping, on which the main branches of the LAM, the puborectalis and iliococcygeus, were evaluated. The differences in T2 and T2* values in the puborectalis and iliococcygeus between patients with LAM weakness and controls were analyzed using an independent samples t test or a Mann-Whitney U test. RESULTS For both the right and left iliococcygeus, the T2* values of the patient group were lower than those of the control group (P = 0.002 and 0.008, respectively), while no significant difference was observed in the T2 values between the groups (P = 0.45 and 0.69, respectively). For both the right and left puborectalis, no significant differences in the T2* (P = 0.25 and P = 0.25, respectively) or T2 values (P = 0.38 and 0.43, respectively) were observed between the patient and control groups. CONCLUSION T2* mapping as a quantitative measurement is an effective imaging tool to assess LAM injury in women after vaginal delivery. The iliococcygeus was more susceptible to vaginal delivery damage than the puborectalis, and pelvic floor dysfunction may be mainly driven by iliococcygeus injury.
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Affiliation(s)
- Yuchao Li
- Shandong Provincial Hospital, Shandong University, Jinan, Shandong, China; Department of Ultrasound, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Tao Gong
- Department of Radiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Xueyan Lin
- Department of Obstetrics and Gynecology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Xinhong Wei
- Department of Ultrasound, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Xianyun Cai
- Department of Radiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Xin Chen
- Department of Radiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | | | - Guangbin Wang
- Shandong Provincial Hospital, Shandong University, Jinan, Shandong, China; Department of Radiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China.
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Horcicka L, Krcmar M, Nemec M, Hympanova L, Feyereisl J, Krofta L. Appearance of levator ani muscle subdivision defects on level III vaginal support structures in women with and without pelvic organ prolapse: an MRI study. Int Urogynecol J 2023; 34:1971-1982. [PMID: 37119270 PMCID: PMC10415508 DOI: 10.1007/s00192-023-05533-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 03/09/2023] [Indexed: 05/01/2023]
Abstract
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.
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Affiliation(s)
- L Horcicka
- Third Faculty of Medicine, Charles University, Ruska 2411/87, 100 00, Prague, Czech Republic
| | - M Krcmar
- Third Faculty of Medicine, Charles University, Ruska 2411/87, 100 00, Prague, Czech Republic
- Institute for the Care of Mother and Child, Podolské nábřeží 157, 147 00, Prague, Czech Republic
| | - M Nemec
- Third Faculty of Medicine, Charles University, Ruska 2411/87, 100 00, Prague, Czech Republic
| | - L Hympanova
- Third Faculty of Medicine, Charles University, Ruska 2411/87, 100 00, Prague, Czech Republic.
- Institute for the Care of Mother and Child, Podolské nábřeží 157, 147 00, Prague, Czech Republic.
| | - J Feyereisl
- Third Faculty of Medicine, Charles University, Ruska 2411/87, 100 00, Prague, Czech Republic
- Institute for the Care of Mother and Child, Podolské nábřeží 157, 147 00, Prague, Czech Republic
| | - L Krofta
- Third Faculty of Medicine, Charles University, Ruska 2411/87, 100 00, Prague, Czech Republic
- Institute for the Care of Mother and Child, Podolské nábřeží 157, 147 00, Prague, Czech Republic
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Yang J, Zhang K, Han J, Wang Y, Yao Y, Zhou Y. Comparison of the anterior pelvis and levator ani muscle on MRI in women with and without anterior pelvic organ prolapse. Int Urogynecol J 2023; 34:1885-1890. [PMID: 36786852 DOI: 10.1007/s00192-023-05464-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 01/05/2023] [Indexed: 02/15/2023]
Abstract
INTRODUCTION AND HYPOTHESIS The objective was to compare the differences in pelvic and levator ani muscle diameters in women with and without anterior pelvic organ prolapse. METHODS Three groups were included, including 50 nulliparous women (nulliparous group), 50 women with stage III-IV anterior vaginal prolapse (prolapse group), and 50 women of the same age as the prolapse group but without prolapse (nonprolapse control group). The ischial interspinous diameter (ISD), anterior pelvic area (APA), levator defect score (LDS), levator ani hiatus width (LH-W), H-line, M-line, levator ani plate length, levator ani plate angle, and cervix length (CL) were measured. RESULTS There were no significant differences in ISD (10.6±0.8 vs 10.6±0.9 cm), LH-W (3.0±0.4 vs 3.3±0.4 cm), or CL (2.9±0.6 vs 3.0±0.5 cm) between the nulliparous group and the nonprolapse control group (p>0.05). However, there were significant differences between them and the prolapsed group (11.2±0.6 cm, 3.6±0.4 cm, 4.2±1.5 cm; p<0.05). There were no significant differences in LDS (0.70±0.61 vs 0.70±0.65) or APA (58.4±8.4 vs 60.1±7.4 cm2) between the nonprolapse control group and the prolapse group (p>0.05), but they were significantly different from those of the nulliparous group (0.08±0.34, 55.1±6.0 cm2) (p<0.05). The area under the receiver-operating characteristic curve for the ISD of nonprolapse control and prolapse groups was 0.713, and the cutoff value was 10.95 cm. CONCLUSIONS The levator ani hiatus width and cervix length were larger in patients with anterior vaginal prolapse than in those without prolapse. An ischial ISD greater than 10.95 cm was associated with prolapse.
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Affiliation(s)
- Junfang Yang
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Haidian District, Garden North Road No. 49, Beijing, 100191, China
| | - Kun Zhang
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Haidian District, Garden North Road No. 49, Beijing, 100191, China
| | - Jinsong Han
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Haidian District, Garden North Road No. 49, Beijing, 100191, China.
| | - Yiting Wang
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Haidian District, Garden North Road No. 49, Beijing, 100191, China
| | - Ying Yao
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Haidian District, Garden North Road No. 49, Beijing, 100191, China
| | - Yan Zhou
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Haidian District, Garden North Road No. 49, Beijing, 100191, China
- , Beijing, China
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Martínez Franco E, Molinet Coll C, Altimira Queral L, Balsells S, Carreras M, Parés D. Factors involved in changes in the levator ani during pregnancy. Int Urogynecol J 2023; 34:1933-1938. [PMID: 36805781 DOI: 10.1007/s00192-023-05487-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 01/24/2023] [Indexed: 02/23/2023]
Abstract
INTRODUCTION AND HYPOTHESIS Levator ani muscle (LAM) dimensions increase during pregnancy to allow the delivery of the fetus. The objective was to investigate which factors are involved in LAM modifications during pregnancy. METHODS A prospective longitudinal observational study was conducted between July 2015 and March 2018. Ninety-nine nulliparous pregnant women were included. Data on the physical examination, 4D transperineal ultrasound and hormonal concentrations (progesterone, oestradiol and relaxin) were collected during the first and third trimesters. RESULTS We found higher hiatal dimensions at the beginning of pregnancy than in other studies with nonpregnant women. Increases in the levator ani hiatal (LH) dimensions were observed at contraction (1.01 ±1.96 cm2), rest (0.82 ± 2.51 cm2) and on Valsalva (2.36 ± 3.64 cm2) throughout pregnancy. The distensibility in the third trimester was higher than in the first trimester (5.79 vs 4.24 cm2; p=0); however, the contractility was lower (-3.32 vs -3.5 cm2; p=0.04). Women with lower scores on the Modified Oxford Grading Scale in the third trimester presented with lower contractility in the LAM. A larger LH at the end of pregnancy was associated with age and body mass index. Eleven women developed ballooning during pregnancy; in these women, relaxin was higher in both trimesters than in women without ballooning, but these results were not statistically significant. The linear models to predict third-trimester Valsalva LH, distensibility and contractility were not conclusive and did not show any factors to predict LAM modifications during pregnancy. CONCLUSIONS Hormones could play a role in modifying the muscle properties of LAM from the beginning of pregnancy, but we did not find an association between LAM measurements and hormone concentration in this study.
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Affiliation(s)
- Eva Martínez Franco
- Gynecology and Obstetrics Department, Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Universitat de Barcelona (UB), C/Antoni Pujadas num 42, 08830 Sant Boi de Llobregat, Barcelona, Spain.
| | - Cristina Molinet Coll
- Gynecology and Obstetrics Department, Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Universitat de Barcelona (UB), C/Antoni Pujadas num 42, 08830 Sant Boi de Llobregat, Barcelona, Spain
| | - Laura Altimira Queral
- Chemistry Laboratory, Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Universitat de Barcelona (UB), Barcelona, Spain
| | - Sol Balsells
- Statistical Advising Service, Fundació Sant Joan de Déu, Sant Boi de Llobregat, Barcelona, Spain
| | - Manel Carreras
- Gynecology and Obstetrics Department, Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Universitat de Barcelona (UB), C/Antoni Pujadas num 42, 08830 Sant Boi de Llobregat, Barcelona, Spain
| | - David Parés
- Colorectal Surgery Unit, Department of Surgery, Hospital Germans Trias i Pujol, Badalona, Universitat Autònoma de Barcelona, Barcelona, Spain
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Chill HH, Martin LC, Abramowitch SD, Rostaminia G. Multimodal measurements of levator bowl volume in nulligravid asymptomatic women: endovaginal ultrasound versus MRI. Int Urogynecol J 2023; 34:1627-1633. [PMID: 36656345 DOI: 10.1007/s00192-022-05441-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 12/02/2022] [Indexed: 01/20/2023]
Abstract
INTRODUCTION AND HYPOTHESIS Measurements of levator bowl volume using advanced imaging, may be predictive of pelvic floor muscle function. The aim of this study was to compare the volume of the levator bowl using both magnetic resonance imaging (MRI) and endovaginal ultrasound (EVU) of healthy asymptomatic women. METHODS All participants underwent a comprehensive interview including completion of the Pelvic Floor Distress Inventory Questionnaire-20 questionnaire, pelvic examination with a pelvic organ prolapse quantification evaluation, MRI, and EVU. The pelvic floor was segmented using Slicer and the MRI segmentations were trimmed using two methods: soft-tissue landmarks and the field of view (FOV) of the ultrasound volume. The levator bowl volume of the 3D segmented shapes was measured using Blender's 3D printing toolkit. Normality was tested using the Shapiro-Wilks test and comparisons were made using self-paired t tests. RESULTS The final analysis included 19 patients. Levator bowl volume measured via MRI was larger than that measured in EVU (46.1 ± 7.9 cm3 vs 27.4 ± 5.9 cm3, p<0.001). Reducing the FOV of the MRI to that of EVU caused the MRI volume to be much closer to the EVU volume (35.5 ± 3.3 cm3 vs 27.4 ± 5.9 cm3, p<0.001); however, it remained significantly larger. CONCLUSION Levator bowl volume measured using MRI was larger than that measured using EVU no matter the method of delineation of the levator muscles. Although EVU is safe, cheap, and easy to perform, it captures a smaller volume of levator bowel than MRI.
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Affiliation(s)
- Henry H Chill
- Female Pelvic Medicine and Reconstructive Surgery (FPMRS), Division of Urogynecology, University of Chicago, Northshore University HealthSystem, 9650 Gross Point Road, Suite 3900, Skokie, IL, 60076, USA.
| | - Liam C Martin
- Translational Biomechanics Laboratory, Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Steven D Abramowitch
- Translational Biomechanics Laboratory, Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ghazaleh Rostaminia
- Female Pelvic Medicine and Reconstructive Surgery (FPMRS), Division of Urogynecology, University of Chicago, Northshore University HealthSystem, 9650 Gross Point Road, Suite 3900, Skokie, IL, 60076, USA
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Alshiek J, Murad-Regadas SM, Mellgren A, Glanc P, Khatri G, Quiroz LH, Weinstein MM, Rostaminia G, Oliveira L, Arif-Tiwari H, Ferrari L, Bordeianou L, Shobeiri SA. Consensus definitions and interpretation templates for dynamic ultrasound imaging of defecatory pelvic floor disorders : Proceedings of the consensus meeting of the pelvic floor disorders consortium of the american society of colon and rectal surgeons, the society of abdominal radiology, the international continence society, the American urogynecologic society, the international urogynecological association, and the society of gynecologic surgeons. Int Urogynecol J 2023; 34:603-619. [PMID: 36617601 DOI: 10.1007/s00192-022-05414-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2022] [Indexed: 01/09/2023]
Affiliation(s)
- Jonia Alshiek
- Department of Obstetrics and Gynecology, Inova Health System, Fairfax, VA, USA
- Urogynecology Unit, Technion Medical School, Hillel Yaffe Medical Center, Hadera, Israel
| | - Sthela M Murad-Regadas
- Department of Surgery, School of Medicine of the Federal University of Ceará, Fortaleza, Brazil
| | - Anders Mellgren
- Department of Surgery, University of Illinois, Chicago, IL, USA
| | - Phyllis Glanc
- Department of Medical Imaging, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada
| | - Gaurav Khatri
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Lieschen H Quiroz
- Department of Obstetrics and Gynecology, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Milena M Weinstein
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Pelvic Floor Disorders Center, Harvard Medical School, Boston, MA, USA
| | - Ghazaleh Rostaminia
- Department of Obstetrics and Gynecology, Northshore Hospital, Chicago, IL, USA
| | - Lucia Oliveira
- Department of Colorectal Surgery Hospital Casa de Saúde São José, Rio de Janeiro, Brazil
| | - Hina Arif-Tiwari
- Department of Medical Imaging, College of Medicine, University of Arizona, Tucson, AZ, USA
| | | | - Liliana Bordeianou
- Department of Surgery, Massachusetts General Hospital, Pelvic Floor Disorders Center, Harvard Medical School, 55 Fruit St, GRB 425, Boston, MA, 02114, USA.
| | - S Abbas Shobeiri
- Department of Obstetrics and Gynecology, Inova Health System, Fairfax, VA, USA
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Xu Z, Chen N, Wang B, Yang J, Liu H, Zhang X, Li Y, Liu L, Wu Y. Creation of the biomechanical finite element model of female pelvic floor supporting structure based on thin-sectional high-resolution anatomical images. J Biomech 2023; 146:111399. [PMID: 36509024 DOI: 10.1016/j.jbiomech.2022.111399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 10/28/2022] [Accepted: 11/21/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE The main purpose of this study is to obtain a finite element biomechanical model that accurately mimics pelvic organ prolapse in women, to study pelvic floor supporting structures' biomechanical properties and function. We used thin-sectional high-resolution anatomical images (Chinese Visible Human, CVH) to reconstruct a detailed three-dimensional (3D) biomechanical finite element model of the female pelvic floor supporting structure including cardinal ligament, uterosacral ligament, levator ani muscle (LAM) and perianal body. The Valsalva maneuver was simulated by loading the uterus and bladder with a pressure increasing from 0 to 10 kPa. The stress, strain and displacement of supporting structures were calculated. The cardinal ligament, the uterosacral ligament and the LAM were stressed greatly when the uterus moved downward, and the maximum stress could reach 0.267 MPa, 1.51 MPa and 0.065 MPa respectively, and the maximum strain could reach 0.154, 0.16, 0.265, and the maximum displacement could reach 1.786 cm, 1.946 cm and 0.567 cm. Displacement of the perineal body also occurred, and its stress, strain and displacement were 0.092 MPa, 0.381, 0.73 cm. The stress, strain and displacement of the supporting structure around the urethra were 0.339 MPa, 0.169, 1.491 cm. Our model based on CVH has more detailed anatomical structures, which is superior to that based on MRI. Our simulation results were consistent with previous findings, which verified the unbalance of abdominal pressure and pelvic floor supporting structures will lead to POP, which provide a theoretical basis for pelvic floor anatomy and function as well as obstetrical surgery.
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Affiliation(s)
- Zhou Xu
- Department of Digital Medicine, College of Biomedical Engineering and Medical Imaging, Army Medical University (Third Military Medical University), Chongqing 400038, China
| | - Na Chen
- Department of Digital Medicine, College of Biomedical Engineering and Medical Imaging, Army Medical University (Third Military Medical University), Chongqing 400038, China
| | - Bingyu Wang
- School of Mechanical and Automotive Engineering, Xiamen University of Technology, Xiamen 36204, China
| | - Jingyi Yang
- Department of Digital Medicine, College of Biomedical Engineering and Medical Imaging, Army Medical University (Third Military Medical University), Chongqing 400038, China
| | - Hongjun Liu
- Department of Digital Medicine, College of Biomedical Engineering and Medical Imaging, Army Medical University (Third Military Medical University), Chongqing 400038, China
| | - Xiaoqin Zhang
- Department of Digital Medicine, College of Biomedical Engineering and Medical Imaging, Army Medical University (Third Military Medical University), Chongqing 400038, China
| | - Ying Li
- Department of Digital Medicine, College of Biomedical Engineering and Medical Imaging, Army Medical University (Third Military Medical University), Chongqing 400038, China
| | - Li Liu
- Department of Digital Medicine, College of Biomedical Engineering and Medical Imaging, Army Medical University (Third Military Medical University), Chongqing 400038, China
| | - Yi Wu
- Department of Digital Medicine, College of Biomedical Engineering and Medical Imaging, Army Medical University (Third Military Medical University), Chongqing 400038, China.
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Doxford-Hook E, Downey C, Gibson J, Marsh F. A review of levator ani avulsion after childbirth: Incidence, imaging and management. Midwifery 2022; 115:103494. [PMID: 36191381 DOI: 10.1016/j.midw.2022.103494] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 09/06/2022] [Accepted: 09/25/2022] [Indexed: 11/24/2022]
Abstract
Key Content • Levator ani muscle (LAM) avulsion injury occurs occultly during childbirth, most commonly during operative vaginal deliveries. • Injuries of levator ani have long term sequelae for pelvic floor health. As life expectancy increases the burden of disease upon urogynaecology services will need to be considered. • Diagnosis of this condition can be difficult as there is no agreed 'gold standard' imaging modality. • There is no consensus regarding surgical management of LAM avulsion. Learning objectives • Review anatomy and function of levator ani muscle • Identify the risk factors for levator ani avulsion injury • Role of imaging to appropriately identify LAM injury and current management options including appropriate follow up • Management of subsequent pregnancy following LAM avulsion Ethical issues • Is there value to the patient in diagnosing levator ani avulsion when there is no recommended treatment for these injuries?
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12
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Li XM, Zhang LM, Li Y, Zhu QY, Zhao C, Fang SB, Yang ZL. Usefulness of transperineal shear wave elastography of levator ani muscle in women with stress urinary incontinence. Abdom Radiol (NY) 2022; 47:1873-1880. [PMID: 35290481 DOI: 10.1007/s00261-022-03478-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 02/26/2022] [Accepted: 02/26/2022] [Indexed: 11/29/2022]
Abstract
This study aimed to quantitatively assess the quality of levator ani muscle (LAM) using shear wave elastography (SWE) and to evaluate the association between the elasticity of LAM and stress urinary incontinence (SUI). The study population included 32 women with SUI and 34 women with normal pelvic support. The thickness of LAM, bladder neck descent (BND), and urethral funneling (UF) were assessed by transperineal ultrasound. LAM elasticity was measured by SWE at rest and during the maximal Valsalva maneuver. Age, menopause, BND, and UF showed a positive correlation with SUI. There was no significant between-group difference in the elastic modulus values of LAM at rest. The thickness of LAM in women with SUI was greater than that in control group at rest and during the maximal Valsalva maneuver (P < 0.001). The elastic modulus values of Emax and Emean were significantly increased from rest to the maximal Valsalva maneuver in all participants (56.24 vs 82.43 kPa and 47.92 vs 72.37 kPa, P < 0.001). The change of these variables from rest to the maximal Valsalva maneuver in the control group was more obvious than that in the SUI group (34.09 vs 17.87 kPa and 31.55 vs 16.82 kPa, P < 0.05). The elasticity of LAM, as quantified by SWE, may potentially be used as an index for predicting SUI.
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Affiliation(s)
- X M Li
- Department of Ultrasound, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, 266003, Shandong, China
| | - L M Zhang
- Department of Ultrasound, Maternity and Child Health Care of Zaozhuang, Jining, 261031, China
| | - Y Li
- Department of Gynecology, The Affiliated Hospital of Qingdao University, Qingdao, 266003, China
| | - Q Y Zhu
- Department of Ultrasound, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, 266003, Shandong, China
| | - C Zhao
- Department of Ultrasound, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, 266003, Shandong, China
| | - S B Fang
- Department of Ultrasound, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, 266003, Shandong, China
| | - Z L Yang
- Department of Ultrasound, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, 266003, Shandong, China.
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Song XQ, Wang N. The "Hand as Foot" teaching method in the levator ani muscle. Asian J Surg 2022; 45:1895-1896. [PMID: 35440385 DOI: 10.1016/j.asjsur.2022.03.129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 03/31/2022] [Indexed: 11/19/2022] Open
Affiliation(s)
- Xian-Qing Song
- General Surgery Department, Ningbo Fourth Hospital, No. 291 Donggu Road, Dandong Street, Xiangshan County, Ningbo, Zhejiang, 315000, PR China.
| | - Ning Wang
- Pelvic Floor Rehabilitation Centre, Xiangshan Bay Maternity Hospital, No. 508 Xiangshan Bay Road, Dandong Street, Xiangshan County, Ningbo, Zhejiang, 315000, PR China.
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Jin X, Wu S, Huang J, Tong X, Li H, Chu L. Effect of prolonged second stage of labor on pelvic floor function: A prospective cohort study. Int Urogynecol J 2022. [PMID: 35267059 DOI: 10.1007/s00192-022-05136-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 02/09/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION AND HYPOTHESIS To evaluate the effect of the second stage of labor (SSL) lasting > 2 h on pelvic floor function. METHODS This single-center prospective cohort study included primiparous women with SSL > 2 h treated at Tongji Hospital between January 2018 and December 2019 (case group). A matched group of women with similar newborn weight and SSL < 2 h were recruited simultaneously (control group). Stress urinary incontinence (SUI) and pelvic floor muscle (PFM) characteristics were measured at 6 weeks, 6 months, and finally 1 year postpartum. RESULTS A total of 63 pairs of primiparous women completed 1-year follow-up. The incidence of SUI in the case group was significantly higher than that in the control group at 6 weeks postpartum (P = 0.020); however, the differences were not significant at 1 year postpartum (P=1.00). PFM endurance was significantly lower in the case group at 6 weeks (P = 0.000), 6 months (P = 0.000), and 1 year (P = 0.011) after childbirth. There was no difference in PFM strength between the two groups. The maximal voluntary contraction (MVC) of PFM was significantly lower in the case group at 6 weeks postpartum (P = 0.007), but the differences were not significant at 1 year postpartum (P = 0.197). PFM endurance and MVC were higher at 1 year than at 6 weeks postpartum in both groups. CONCLUSIONS The SSL > 2 h increased the incidence of SUI at 6 weeks postpartum and decreased PFM endurance for 1 year.
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Ashtari MS, Veshkini A, Masoudifard M, Gilanpour H, Bahonar A. Measuring morphological parameters of the pelvic diaphragm muscles using computed tomography in healthy dogs. Vet Res Forum 2021; 12:493-496. [PMID: 35529821 PMCID: PMC9010835 DOI: 10.30466/vrf.2019.114322.2719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 12/11/2019] [Indexed: 12/02/2022]
Abstract
Evaluation of pelvic diaphragm muscles in dogs merits clinical attention because of the anatomical importance and their involvement in perineal hernia. This study aimed to evaluate the normal pelvic diaphragm muscles (levator ani and coccygeus muscles) using the computed tomography (CT) scan. For this purpose, 10 male and 10 female clinically normal, adult intact mixed-breed dogs weighing 15.00 to 20.00 kg were selected randomly. All animals underwent CT examination under general anesthesia and positioned in sternal recumbency. All the CT images were taken and reconstructed with a same protocol. The measurements of the pelvic diaphragm muscles were performed based on the presented guideline to the observer. The results were presented descriptively. The mean lengths of the coccygeus muscle in CT images were evaluated 4.60 cm for males and 4.30 cm for females. The mean lengths of levator ani muscle in CT images were measured 4.90 cm in males and 4.50 cm in females. In conclusion, the results of the present study can be beneficial to clinicians and researchers for further evaluation of the supporting muscles in pelvic cavity and underlying anatomical changes in perineal hernia in dogs.
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Affiliation(s)
- Mohammad Sadegh Ashtari
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Science and Research Branch, Islamic Azad University, Tehran, Iran
| | - Abbas Veshkini
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Science and Research Branch, Islamic Azad University, Tehran, Iran; ,Correspondence Abbas Veshkini. DVM, DVSc, Department of Clinical Sciences, Faculty of Veterinary Medicine, Science and Research Branch, Islamic Azad University, Tehran, Iran. E-mail:
| | - Majid Masoudifard
- Department of Surgery and Radiology, Faculty of Veterinary Medicine, University of Tehran, Tehran, Iran
| | - Hassan Gilanpour
- Department of Basic Sciences, Faculty of Veterinary Medicine, Science and Research Branch, Islamic Azad University, Tehran, Iran
| | - Alireza Bahonar
- Department of Food Hygiene and Quality Control, Faculty of Veterinary Medicine, University of Tehran, Tehran, Iran
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Abstract
BACKGROUND The levator plate descent angle (LPDA) quantifies the levator plate position with reference to the pubic bone and perineal body at rest. Unfortunately, research on this notable new parameter is lacking, but it is clear that levator ani deficiency (LAD) will undermine the fundamental role of the levator ani muscle (LAM) in organ support. The aim of this study was to establish the relationship between the LPDA and LAD in patients with pelvic floor disorders. METHODS This retrospective study was conducted at Seoul Songdo Hospital, Korea between August 2019 and August 2020 on women with symptoms of pelvic floor disorder such as urinary incontinence, constipation, and fecal incontinence. In all cases, three-dimensional pelvic floor ultrasound was performed for LAD scoring, minimal levator hiatus, and LPDA evaluation. We evaluated LAD using a scoring system that graded levator injury according to the insertion point of each subdivision scored unilaterally. For the entire LAM group, a cumulative LAD score that ranged between 0 and 18 was possible. Scores were categorized as mild (0-6 points), moderate (7-12 points), and severe (13-18 points) deficiency RESULTS: A total of 93 patients were included in the study (mean age 65.89 ± 11.12 [range, 34-86] years). Thirteen participants had mild LAD scores (14.0%), 42 had moderate LAD scores (45.2%), and 38 had severe LAD scores (40.9%). There was a significant difference in mean age (59.23 ± 12.55 years vs. 64.43 ± 10.03 vs. 69.79 ± 10.55 years, p = 0.005) and mean parity (1.85 ± 0.90 vs 2.48 ± 1.15 vs 2.76 ± 1.10, p = 0.038) of patients between groups. There was also a significant difference in the mean Wexner incontinence score (7.14 ± 3.63 vs 7.24 ± 5.76 vs 11.41 ± 5.54, p = 0.028) and in the mean fecal incontinence quality of life (FIQOL) score (12.91 ± 3.11 vs 14.10 ± 3.87 vs 10.41 ± 3.65, p = 0.014). The mean value of the LPDA in the group with mild LAD scores was 14.65° (SD ± 3.54) and in the group with moderate LAD scores was 9.66° (SD ± 3.36). In the group with severe LAD scores, the mean LPDA was 1.83° (SD ± 4.71). The mean value for minimal levator hiatus (MLH) area in the mild LAD score group was 14.16cm2 (SD ± 2.72), that in the moderate LAD score group was 15.82cm2 (SD ± 2.30), and that in the severe LAD score group was 17.99cm2 (SD ± 2.81). There were significant differences between the three groups both in decreasing LPDA (p < 0.001) and increasing MLH (p < 0.001). There was a negative correlation between the LAD score and LPDA and the Pearson correlation coefficient was -0.528 (moderate correlation). There was a positive correlation between the LAD score and MLH, and the Pearson correlation coefficient was 0.303 (weak correlation). CONCLUSIONS The LAD score and LPDA have a moderate negative correlation. In patients with severe pelvic floor symptoms and extensive LAM injury, high LAD scores and low LPDA results were confirmed. In the treatment of patients with pelvic floor disorders, the LPDA seems to be a very useful parameter in determining the severity of structural defects.
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Affiliation(s)
- Hong Yoon Jeong
- Department of Surgery, Seoul Song Do Hospital, 72, Dasan-ro, Jung-gu, Seoul, 04597, Korea
| | - Duk Hoon Park
- Department of Surgery, Seoul Song Do Hospital, 72, Dasan-ro, Jung-gu, Seoul, 04597, Korea.
| | - Jong Kyun Lee
- Department of Surgery, Seoul Song Do Hospital, 72, Dasan-ro, Jung-gu, Seoul, 04597, Korea
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Manzini C, van den Noort F, Grob ATM, Withagen MIJ, Slump CH, van der Vaart CH. Appearance of the levator ani muscle subdivisions on 3D transperineal ultrasound. Insights Imaging 2021; 12:91. [PMID: 34213688 PMCID: PMC8253870 DOI: 10.1186/s13244-021-01037-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 06/13/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The levator ani muscle (LAM) consists of different subdivisions, which play a specific role in the pelvic floor mechanics. The aim of this study is to identify and describe the appearance of these subdivisions on 3-Dimensional (3D) transperineal ultrasound (TPUS). To do so, a study designed in three phases was performed in which twenty 3D TPUS scans of vaginally nulliparous women were assessed. The first phase was aimed at getting acquainted with the anatomy of the LAM subdivisions and its appearance on TPUS: relevant literature was consulted, and the TPUS scan of one patient was analyzed to identify the puborectal, iliococcygeal, puboperineal, pubovaginal, and puboanal muscle. In the second phase, the five LAM subdivisions and the pubic bone and external sphincter, used as reference structures, were manually segmented in volume data obtained from five nulliparous women at rest. In the third phase, intra- and inter-observer reproducibility were assessed on twenty TPUS scans by measuring the Dice Similarity Index (DSI). RESULTS The mean inter-observer and median intra-observer DSI values (with interquartile range) were: puborectal 0.83 (0.13)/0.83 (0.10), puboanal 0.70 (0.16)/0.79 (0.09), iliococcygeal 0.73 (0.14)/0.79 (0.10), puboperineal 0.63 (0.25)/0.75 (0.22), pubovaginal muscle 0.62 (0.22)/0.71 (0.16), and the external sphincter 0.81 (0.12)/0.89 (0.03). CONCLUSION Our results show that the LAM subdivisions of nulliparous women can be reproducibly identified on 3D TPUS data.
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Affiliation(s)
- Claudia Manzini
- Department of Obstetrics and Gynecology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Frieda van den Noort
- Robotics and Mechatronics, University of Twente, Enschede, Carre 3.526, Drienerlolaan 5, 7522NB, Enschede, The Netherlands.
| | - Anique T M Grob
- Multi-Modality Medical Imaging, Faculty of Science and Technology, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - Mariëlla I J Withagen
- Department of Obstetrics and Gynecology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Cornelis H Slump
- Robotics and Mechatronics, University of Twente, Enschede, Carre 3.526, Drienerlolaan 5, 7522NB, Enschede, The Netherlands
| | - C Huub van der Vaart
- Department of Obstetrics and Gynecology, University Medical Centre Utrecht, Utrecht, The Netherlands
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Yu H, Zheng H, Zhang X, Zhou Y, Xie M. Association between elastography findings of the levator ani and stress urinary incontinence. J Gynecol Obstet Hum Reprod 2020; 50:101906. [PMID: 32927106 DOI: 10.1016/j.jogoh.2020.101906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 08/04/2020] [Accepted: 09/02/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE To investigate the elasticity of the levator ani musle (LAM) with the patients suffering from stress urinary incontinence (SUI) by transperineal elastography. METHODS Conventional transperineal ultrasound and elastography were performed in the patients with SUI on quiescent condition and maximal Valsalva. Transperineal ultrasound and elastography were repeated after Kegel exercises. The scoring system and strain ratio (SR) values were recorded and analyzed. RESULTS After Kegel exercises, the ratio of subjective improvement or cure was 81 % (102/126). Mean elasticity score (ES) and SR of LAM were significantly higher than the value before on maximal Valsalva, respectively. Mean ES and SR of LAM after Kegel exercises were similar with the value before on quiescent condition, respectively. CONCLUSION The improvement of SUI was associated with the stiffer LAM assessed by elastography. Women with SUI who have softer LAM were more likely to have symptoms of SUI and Kegel exercise could strengthen the stiffness of LAM. BRIEF SUMMARY The improvement of SUI was associated with the stiffer LAM assessed by elastography.
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Affiliation(s)
- Huan Yu
- Department of Ultrasound, 128 Shen yang Road, Shanghai, 200090, China
| | - Huamin Zheng
- Department of Ultrasound, 128 Shen yang Road, Shanghai, 200090, China
| | - Xuyin Zhang
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, 128 Shen yang Road, Shanghai, 200090, China
| | - Yuqing Zhou
- Department of Ultrasound, Changning Maternity& Infant Health Hospital, 786 Yuyuan Road, Shanghai 200040, China.
| | - Meng Xie
- Department of Ultrasound, 128 Shen yang Road, Shanghai, 200090, China.
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Takmaz T, Aydın S, Gorchiyeva İ, Karasu AFG. The usual suspect: cross-sectional study of fundal pressure at second stage of delivery and the association with pelvic floor damage. Int Urogynecol J 2021; 32:1917-24. [PMID: 32902763 DOI: 10.1007/s00192-020-04523-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 08/26/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Uterine fundal pressure is applied to accelerate birth by increasing the expulsive force of the uterus in the second stage of delivery. The aim of the study was to evaluate the effect of using uterine fundal pressure during the second stage of delivery on the rate of pelvic floor damage among primiparous women using three-dimensional transperineal ultrasonography. METHODS The women were divided into two groups: the fundal pressure group included women where the fundal pressure maneuver was applied (n = 39); the control group included women who delivered spontaneously without fundal pressure (n = 47). 3D-TPU was performed within 48 h of delivery, and LAM biometry, LAM defect and loss of tenting were determined. RESULTS Anteroposterior hiatal dimensions on resting, maximal Valsalva and maximal PFMC were found to be higher in the fundal pressure group (p < 0.0001, p = 0.008, p = 0.007, respectively). The mean hiatal area at rest was larger in the fundal pressure group than in the control group (p = 0.04). The rate of LAM defect was significantly higher in the fundal pressure group (p = 0.001). The rate of loss of tenting was significantly higher in the fundal pressure group (p < 0.0001). According to multivariate regression models, the fundal pressure was the only independent factor associated with LAM defect (OR = 5.63; 95% CI = 12.01-15.74) and loss of tenting (OR = 8.74; 95% CI = 2.89-26.43). CONCLUSIONS Fundal pressure during the second stage of delivery is associated with a higher risk of LAM defect and loss of anterior vaginal wall support. CLINICAL TRIAL REGISTRATION NCT03752879.
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20
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Davidson MJ, Nielsen PMF, Taberner AJ, Kruger JA. Change in levator ani muscle stiffness and active force during pregnancy and post-partum. Int Urogynecol J 2020; 31:2345-2351. [PMID: 32785748 DOI: 10.1007/s00192-020-04493-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 08/03/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION AND HYPOTHESIS It is assumed changes occur to the biomechanics and viscoelastic response of the levator ani muscle during pregnancy; however, there is limited evidence of this. This study used instrumentation and clinical measures to determine the stiffness and active force capacity of levator ani muscle during pregnancy and post-partum, investigated any associations with delivery outcomes, and explored the biomechanical properties associated with symptoms of pelvic floor dysfunction. METHODS This was a prospective observational study, with nulliparous women with a singleton low-risk pregnancy. Data were collected at two stages during pregnancy and post-partum. Measurements included the Australian Pelvic Floor Questionnaire, palpation of active force, and elastometry measurements. Post-partum, 3D/4D ultrasound measurements were included. Repeated measures ANOVAs, pairwise comparisons, Pearson correlation coefficients, and Student's t-tests were used as appropriate. RESULTS Fifty-nine women took part in the study. Active force was significantly different over the pregnancy and post-partum, measured with instrumentation (p = 0.002) and palpation (p = 0.006 right, p = 0.029 left). There was no significant change in muscle stiffness during pregnancy. Post-partum muscle stiffness was significantly different between women who gave birth vaginally vs. caesarean section (p = 0.002). Post-partum there were differences in levator hiatal area, symptoms of bladder dysfunction, prolapse symptoms, and sexual dysfunction symptoms. CONCLUSIONS Active force of the levator ani muscle was significantly reduced during pregnancy and in the post-partum period, while muscle stiffness reduced only in those who had vaginal deliveries.
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Affiliation(s)
- Melissa J Davidson
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand.
| | - Poul M F Nielsen
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand.,Department of Engineering Science, University of Auckland, Auckland, New Zealand
| | - Andrew J Taberner
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand.,Department of Engineering Science, University of Auckland, Auckland, New Zealand
| | - Jennifer A Kruger
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand.,Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
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Gachon B, Fritel X, Pierre F, Nordez A. In vivo assessment of the elastic properties of women's pelvic floor during pregnancy using shear wave elastography: design and protocol of the ELASTOPELV study. BMC Musculoskelet Disord 2020; 21:305. [PMID: 32414362 PMCID: PMC7229576 DOI: 10.1186/s12891-020-03333-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 05/07/2020] [Indexed: 12/23/2022] Open
Abstract
Background Animal studies have reported an increase in pelvic floor muscle stiffness during pregnancy, which might be a protective process against perineal trauma at delivery. Our main objective is to describe the changes in the elastic properties of the pelvic floor muscles (levator ani, external anal sphincter) during human pregnancy using shear wave elastography (SWE) technology. Secondary objectives are as follows: i) to look for specific changes of the pelvic floor muscles compared to peripheral muscles; ii) to determine whether an association between the elastic properties of the levator ani and perineal clinical and B-mode ultrasound measures exists; and iii) to provide explorative data about an association between pelvic floor muscle characteristics and the risk of perineal tears. Methods Our prospective monocentric study will involve three visits (14–18, 24–28, and 34–38 weeks of pregnancy) and include nulliparous women older than 18 years, with a normal pregnancy and a body mass index (BMI) lower than 35 kg.m− 2. Each visit will consist of a clinical pelvic floor assessment (using the Pelvic Organ Prolapse Quantification system), an ultrasound perineal measure of the anteroposterior hiatal diameter and SWE assessment of the levator ani and the external anal sphincter muscles (at rest, during the Valsalva maneuver and during pelvic floor contraction), and SWE assessment of both the biceps brachii and the gastrocnemius medialis (at rest, extension and contraction). We will collect data about the mode of delivery and the occurrence of perineal tears. We will investigate changes in continuous variables collected using the Friedman test. We will look for an association between the elastic properties of the levator ani muscle and clinical / ultrasound measures using a Spearman test at each trimester. We will investigate the association between the elastic properties of the pelvic floor muscles and perineal tear occurrence using a multivariate analysis with logistic regression. Discussion This study will provide original in vivo human data about the biomechanical changes of pregnant women’s pelvic floor. The results may lead to an individualized risk assessment of perineal trauma at childbirth. Trial registration This study was registered on https://clinicaltrials.gov on July 26, 2018 (NCT03602196).
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Affiliation(s)
- Bertrand Gachon
- Department of obstetrics and gynecology, Poitiers university hospital, 2 rue de la Miletrie CS90577, 86021, Poitiers Cedex, France. .,Nantes Université, Movement - Interactions - Performance, MIP, EA 4334, F-44000, Nantes, France. .,Poitiers University, INSERM, Poitiers university hospital, CIC 1402, Poitiers, France.
| | - Xavier Fritel
- Department of obstetrics and gynecology, Poitiers university hospital, 2 rue de la Miletrie CS90577, 86021, Poitiers Cedex, France.,Poitiers University, INSERM, Poitiers university hospital, CIC 1402, Poitiers, France.,INSERM, Center for Research in Epidemiology and Population Health (CESP), U1018, Gender, Sexuality and Health Team, University Paris-Sud, UMRS 1018, Orsay, France
| | - Fabrice Pierre
- Department of obstetrics and gynecology, Poitiers university hospital, 2 rue de la Miletrie CS90577, 86021, Poitiers Cedex, France
| | - Antoine Nordez
- Nantes Université, Movement - Interactions - Performance, MIP, EA 4334, F-44000, Nantes, France.,Health and Rehabilitation Research Institute, Faculty of Health and Environmental Sciences, Auckland University of Technology, Auckland, New Zealand
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Abstract
Introduction and hypothesis Pelvic floor muscle function plays an important role in female sexual functioning. Smaller genital hiatal dimensions have been associated with sexual dysfunction, mainly dyspareunia. On the other hand, trauma of the levator ani muscle sustained during childbirth is associated with increased genital hiatus, which potentially can affect sexual functioning by causing vaginal laxity. This study aims to determine the association between levator hiatal dimensions and female sexual dysfunction after first vaginal delivery. Methods This is a secondary analysis of a prospective observational study. Two hundred four women who had a first, spontaneous vaginal delivery at term between 2012 and 2015 were recruited at a minimum of 6 months postpartum. Thirteen pregnant women were excluded. We analyzed the association of total PISQ-12 score, as well as individual sexual complaints (desire, arousal, orgasm and dyspareunia), with levator hiatal dimensions at rest, with maximum Valsalva and during pelvic floor muscle contraction as measured by 4D transperineal ultrasound. Statistical analysis was performed using linear regression analysis and Mann-Whitney U test. Results One hundred ninety-one women were evaluated at a median of 11 months postpartum. There was no significant association between total PISQ-12 score and levator hiatal dimensions. Looking at individual sexual complaints, women with dyspareunia had significantly smaller levator hiatal area and anterior-posterior diameter on maximum Valsalva. By using multivariate logistic regression analysis however we found dyspareunia was not independently associated with levator hiatal dimensions. Conclusions After first vaginal delivery sexual dysfunction is not associated with levator hiatal dimensions as measured by 4D transperineal ultrasound.
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Affiliation(s)
- Anne-Marie Roos
- Department of Obstetrics and Gynecology, Division of Urogynaecology, Erasmus Medical Centre, Doctor Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands.
| | - Leonie Speksnijder
- Department of Obstetrics and Gynecology, division of Urogynaecology, Amphia Hospital, Breda, The Netherlands
| | - Anneke B Steensma
- Department of Obstetrics and Gynecology, Division of Urogynaecology, Erasmus Medical Centre, Doctor Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands
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Suriyut J, Muro S, Baramee P, Harada M, Akita K. Various significant connections of the male pelvic floor muscles with special reference to the anal and urethral sphincter muscles. Anat Sci Int 2020; 95:305-12. [PMID: 31872375 DOI: 10.1007/s12565-019-00521-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 12/16/2019] [Indexed: 10/29/2022]
Abstract
The male pelvic floor is a complex structure formed by several muscles. The levator ani muscle and the perineal muscles are important components of the pelvic floor. The perineal muscles comprise the external anal sphincter, bulbospongiosus, superficial transverse perineal muscles, and ischiocavernosus. Although the connections of the muscles of the pelvic floor have been reported recently, the anatomical details of each muscle remain unclear. In this study, we examined the male pelvic floor to clarify the connection between the muscles related to function. Fifteen male pelvises were used for microscopic dissection, and three male pelvises were used for histological examination. On the lateral aspect, the perineal muscles were connected to each other. Bundles of the levator ani muscle extended to connect to the perineal muscles. In addition, the extended muscle bundle from the levator ani muscle and the perineal muscles surround the external urethral sphincter. On the medial aspect, the levator ani muscle and the external anal sphincter form the anterior and posterior muscular slings of the anal canal. The connection between the perineal muscles and levator ani muscle indicates a possible close relationship between the functions of the urethra and anus.
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Li N, Cui C, Cheng Y, Wu Y, Yin J, Shen W. Association between Magnetic Resonance Imaging Findings of the Pelvic Floor and de novo Stress Urinary Incontinence after Vaginal Delivery. Korean J Radiol 2018; 19:715-723. [PMID: 29962877 PMCID: PMC6005944 DOI: 10.3348/kjr.2018.19.4.715] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 12/02/2017] [Indexed: 11/15/2022] Open
Abstract
Objective The study aimed to evaluate the contributions of levator ani muscle (LAM) injury, vesical neck movement, urethral length and mobility, and urethral sphincter dysfunction observed on magnetic resonance imaging (MRI) towards stress urinary incontinence (SUI) after vaginal delivery. Materials and Methods Fifty primiparous women after 6 months of delivery (15 with SUI and 35 without) and 35 nulliparous as continent controls underwent MRI at rest and Valsalva maneuver. A published levator ani scoring system was used to characterize morphological changes of LAM. The severity of the injury was divided into three categories as none, minor, and major. A series of common parameters including levator plate angle, iliococcygeal angle, and levator hiatus were used to describe the functional conditions of LAM. Urethral mobility was defined based on the rotation of the urethra between Valsalva and rest status. Vesical neck movement was evaluated by its distance to the pubococcygeal line. Urethral sphincter dysfunction was defined as the widening of the proximal urethra and/or funneling at the urethrovesical junction during Valsalva. Results Primiparous incontinent (PI) women had additional major levator ani defects (33.3% vs. 17.1%) while less minor defects (0.7% vs. 31.4%) than primiparous continent (PC) women. Vesical neck downward movement in PI women was more obvious than PC women (28.5 mm vs. 24.2 mm, p = 0.006). Urethral mobility was more active in primiparous women than in nulliparous continent controls (57.4 vs. 52.4), whereas no difference was observed on urethral mobility in the primiparous group (p = 0.25). Urethral sphincter dysfunction and funneling were present in 80% of PI women versus 22.9% in PC women (p < 0.001). Conclusion The MRI findings revealed that de novo SUI was associated with major LAM injury, vesical neck downward movement as well as urethral sphincter dysfunction. Vesical neck funneling on sagittal images can be treated as a valuable predictor for SUI. The intervention for the PI should focus on the elevation of vesical neck, rehabilitation of LAM as well as recovery of the urethral sphincter muscle.
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Affiliation(s)
- Na Li
- Department of Radiology, Tianjin Third Center Hospital, Tianjin 300070, China
| | - Can Cui
- Department of Radiology, Tianjin First Center Hospital, Tianjin 300192, China
| | - Yue Cheng
- Department of Radiology, Tianjin First Center Hospital, Tianjin 300192, China
| | - Yanhong Wu
- Department of Obstetrics and Gynecology, Tianjin First Center Hospital, Tianjin 300192, China
| | - Jianzhong Yin
- Department of Radiology, Tianjin First Center Hospital, Tianjin 300192, China
| | - Wen Shen
- Department of Radiology, Tianjin First Center Hospital, Tianjin 300192, China
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Pang L, Yin L, Tajiri K, Huo M, Maruyama H. Measurement the thickness of the transverse abdominal muscle in different tasks. J Phys Ther Sci 2017; 29:209-211. [PMID: 28265140 PMCID: PMC5332971 DOI: 10.1589/jpts.29.209] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2016] [Accepted: 10/27/2016] [Indexed: 11/26/2022] Open
Abstract
[Purpose] This study examined the measurement of the thickness of the transverse
abdominal muscle in different tasks. [Subjects and Methods] The subjects were eleven
healthy adult females. Thicknesses of transverse abdominal muscle were measured in seven
tasks in the supine position. The tasks were: 1) Resting state, 2) Maximal contraction of
transverse abdominal muscle, 3) Maximal contraction of levator ani muscle, 4) Maximal
simultaneous contraction of both transverse abdominal muscle and levator ani muscle, 5)
Maximal simultaneous contraction of both transverse abdominal muscle and levator ani
muscle with front side resistance added to both knee, 6) Maximal simultaneous contraction
of both transverse abdominal muscle and levator ani muscle with diagonal resistance added
to both knees, and 7) Maximal simultaneous contraction of both transverse abdominal muscle
and levator ani muscle with lateral resistance added to both knees. [Results] The
thicknesses of transverse abdominal muscle during maximal simultaneous contraction and
maximal simultaneous contraction with resistance were greater than during the resting
state. [Conclusion] The muscle output during simultaneous contraction and resistance
movement were larger than that of each individual muscle.
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Affiliation(s)
- Ling Pang
- China-Japan Friendship Hospital Affiliated Jilin University, China
| | - Liquan Yin
- China-Japan Friendship Hospital Affiliated Jilin University, China
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Huebner M, Brucker SY, Tunn R, Naumann G, Reisenauer C, Abele H. Intrapartal pelvic floor protection: a pragmatic and interdisciplinary approach between obstetrics and urogynecology. Arch Gynecol Obstet 2017; 295:795-798. [PMID: 28224270 DOI: 10.1007/s00404-017-4316-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 02/01/2017] [Indexed: 11/28/2022]
Abstract
Pelvic floor protection is an issue of increasing relevance. This article sought to summarize the session at last year's annual meeting of the German Society of Gynecology and Obstetrics (DGGG) in Stuttgart (10/2016) called "Urogynecology 2020-what is the optimal rate of cesarean section-does urogynecology have to deal with Obstetrics?". The main focus was set on the two important anatomical structures, the levator ani muscle and the anal sphincters. Operative vaginal delivery, epidural anesthesia, and episiotomy are subject to discussion.
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Affiliation(s)
- Markus Huebner
- Department of Obstetrics and Gynecology, University Hospital of Tuebingen, Tuebingen, Germany.
| | - Sara Y Brucker
- Department of Obstetrics and Gynecology, University Hospital of Tuebingen, Tuebingen, Germany
| | - Ralf Tunn
- Department of Urogynecology, German Pelvic Floor Center, St. Hedwig Hospital, Berlin, Germany
| | - Gert Naumann
- Department of Obstetrics and Gynecology, Helios-Klinikum Erfurt, Erfurt, Germany
| | - Christl Reisenauer
- Department of Obstetrics and Gynecology, University Hospital of Tuebingen, Tuebingen, Germany
| | - Harald Abele
- Department of Obstetrics and Gynecology, University Hospital of Tuebingen, Tuebingen, Germany
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García Mejido JA, Valdivieso Mejias P, Fernández Palacín A, Bonomi Barby MJ, De la Fuente Vaquero P, Sainz Bueno JA. Evaluation of isolated urinary stress incontinence according to the type of levator ani muscle lesion using 3/4D transperineal ultrasound 36 months post-partum. Int Urogynecol J 2016; 28:1019-1026. [PMID: 27872979 DOI: 10.1007/s00192-016-3208-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 11/06/2016] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Vaginal delivery can lead to pelvic floor disorders. Many authors have described pelvic floor injuries that can predict future defects such as urinary incontinence and pelvic organ prolapse. We propose the assessment of urinary stress incontinence and its association with levator ani muscle (LAM) microtrauma (>20% in the levator hiatus area during Valsalva) and macrotraumas (avulsion) identified by 3/4D transperineal ultrasound (3D-TpUS) 36 months post-partum. MATERIALS AND METHODS This was a prospective observational study including 168 nulliparous women. All patients included were nulliparous with singleton gestation in cephalic presentation, at ≥37 weeks and were recruited on the first day after delivery. Thirty-six months after delivery, 3D-TpUS was carried out to identify LAM lesions (macro or micro). Clinical assessment of urinary stress incontinence (USI) was based on the ICIQ-UI-SF test; a simple stress test and urodynamic test were carried out in the same visit. RESULTS A total of 105 nulliparous women were studied (51 spontaneous deliveries [SpD] and 54 vacuum-assisted deliveries [VD]). Microtraumas were identified in 35.3% of SpD and 20.4% of VD. Macrotraumas (avulsion) were identified in 9.8% of SpD and 35.2% of VD (p = 0.006). No differences were found in USI between study groups or in relation to the identification of LAM defects (19.2% in the no lesion group, 25% in the macrotrauma and 13.8% in the microtrauma groups; p = not significant). Nor were significant differences found in the results from the different study groups in the International Consultation on Incontinence Modular Questionnaire Urinary Incontinence Short Form (ICIQ-UI SF) test (12.7±2.2 in the no lesion group, 12.5±4.2 in the macrotrauma and 13.25±4.8 in the microtrauma groups; p = NS). CONCLUSION No difference was observed in USI between patients with and without LAM lesions (microtrauma or macrotrauma) 36 months post-delivery.
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Affiliation(s)
| | | | | | | | | | - José Antonio Sainz Bueno
- Obstetrica y Ginecología, Hospital Universitario de Valme, Sevilla, CP: 41014, Spain. .,Universidad de Sevilla, Sevilla, Andalucía, Spain.
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Krofta L, Havelková L, Urbánková I, Krčmář M, Hynčík L, Feyereisl J. Finite element model focused on stress distribution in the levator ani muscle during vaginal delivery. Int Urogynecol J 2017; 28:275-84. [PMID: 27562467 DOI: 10.1007/s00192-016-3126-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 08/02/2016] [Indexed: 11/17/2022]
Abstract
Introduction and hypothesis During vaginal delivery, the levator ani muscle (LAM) undergoes severe deformation. This stress can lead to stretch-related LAM injuries. The objective of this study was to develop a sophisticated MRI-based model to simulate changes in the LAM during vaginal delivery. Methods A 3D finite element model of the female pelvic floor and fetal head was developed. The model geometry was based on MRI data from a nulliparous woman and 1-day-old neonate. Material parameters were estimated using uniaxial test data from the literature and by least-square minimization method. The boundary conditions reflected all anatomical constraints and supports. A simulation of vaginal delivery with regard to the cardinal movements of labor was then performed. Results The mean stress values in the iliococcygeus portion of the LAM during fetal head extension were 4.91–7.93 MPa. The highest stress values were induced in the pubovisceral and puborectal LAM portions (mean 27.46 MPa) at the outset of fetal head extension. The last LAM subdivision engaged in the changes in stress was the posteromedial section of the puborectal muscle. The mean stress values were 16.89 MPa at the end of fetal head extension. The LAM was elongated by nearly 2.5 times from its initial resting position. Conclusions The cardinal movements of labor significantly affect the subsequent heterogeneous stress distribution in the LAM. The absolute stress values were highest in portions of the muscle that arise from the pubic bone. These areas are at the highest risk for muscle injuries with long-term complications.
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Rostaminia G, Machiorlatti M, Shobeiri SA, Quiroz LH. Variability of the pubic arch architecture and its influence on the minimal levator hiatus area. Int J Gynaecol Obstet 2016; 134:217-20. [PMID: 27177513 DOI: 10.1016/j.ijgo.2015.11.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Revised: 11/20/2015] [Accepted: 04/15/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To investigate the association between the minimal levator hiatus (MLH) area at rest with its surrounding soft-tissue and bony structures in nulliparous asymptomatic women with a normal levator ani muscle. METHODS A subanalysis was undertaken of a prospective study of the appearance of the levator ani in asymptomatic nulliparous women conducted between September 2010 and September 2011. The subanalysis included women with a normal levator ani muscle. Three-dimensional ultrasonography volumes were used to obtain pelvic floor measurements. RESULTS The analysis included 56 women with mean age of 43.0±13.4years. The mean MLH area was 13.1±1.8cm(2) (range 9.0-17.3). The pubic arch angle had no influence on the MLH area (Pearson correlation coefficient r=0.13). Height and pubic arch length were positively correlated with the MLH area (r=0.26 [P=0.52] and r=0.50 [P<0.001], respectively). CONCLUSION The MLH size of nulliparous women varied widely and was positively correlated with the height and pubic arch length of the women. Therefore, caution is warranted when interpreting the MLH area as an indicator of a levator ani defect or a predictor of pelvic organ prolapse without taking a woman's pelvic bone characteristics into account.
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Affiliation(s)
- Ghazaleh Rostaminia
- Department of Obstetrics and Gynecology, Inova FairFax Hospital, Falls Church, VA, USA
| | - Michael Machiorlatti
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - S Abbas Shobeiri
- Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Lieschen H Quiroz
- Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.
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Nyangoh Timoh K, Bessede T, Zaitouna M, Peschaud F, Chevallier JM, Fauconnier A, Benoit G, Moszkowicz D. [Anatomy of the levator ani muscle and implications for obstetrics and gynaecology]. ACTA ACUST UNITED AC 2015; 43:84-90. [PMID: 25544728 DOI: 10.1016/j.gyobfe.2014.11.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 11/26/2014] [Indexed: 11/23/2022]
Abstract
Pelvic floor disorders include urogenital and anorectal prolapse, urinary and faecal incontinence. These diseases affect 25% of patients. Most of time, treatment is primarily surgical with a high post-operative risk of recurrence, especially for pelvic organ prolapse. Vaginal delivery is the major risk factor for pelvic floor disorders through levator ani muscle injury or nerve damage. After vaginal delivery, 20% of patients experiment elevator ani trauma. These injuries are more common in case of instrumental delivery by forceps, prolonged second phase labor, increased neonatal head circumference and associated anal sphincter injuries. Moreover, 25% of patients have temporary perineal neuropathy. Recently, pelvic three-dimensional reconstructions from RMI data allowed a better understanding of detailed levator ani muscle morphology and gave birth to a clear new nomenclature describing this muscle complex to be developed. Radiologic and anatomic studies have allowed exploring levator ani innervation leading to speculate on the muscle and nerve damage mechanisms during delivery. We then reviewed the levator ani muscle anatomy and innervation to better understand pelvic floor dysfunction observed after vaginal delivery.
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