Do some levator avulsions improve over time?

OBJECTIVE

To determine whether the sonographic appearance of levator avulsion after vaginal childbirth can improve significantly over the first few years postpartum.

METHODS

Retrospective study of women seen in the context of two prospective perinatal imaging studies. All subjects had undergone an interview, clinical examination and 4D translabial ultrasound (TLUS) on average 4.3 months and 3.1 years post-partum. Volume data sets were analysed at a later date blinded against all other data. The number of abnormal slices at both time points was compared using Mann- Whitney U Test. Patients in whom findings had changed over time were reviewed separately in parallel in order to reduce the impact of differences in slice location and imaging settings. The symmetry test was used to analyse changes between the two postnatal visits.

RESULTS

Of 1148 women originally recruited, 315 had had at least two postnatal visits. 42 were excluded, leaving 273 women for analysis. They were first seen on average 4.3 (2.6-9.8) months after childbirth and the last time 3.1 (1.4-8) years postpartum. Cohen's kappa for the two assessments was 0.89, with agreement in 97% (264/273) of cases. At the first visit, complete avulsion was diagnosed in 20, partial avulsion in 32, and no avulsion in 221. While seven partial avulsions appeared sonographically normal at the second visit, there were no statistically significant changes in avulsion category between visits (P=0.4).

CONCLUSION

Tomographic pelvic floor imaging obtained 2.5-10 months after childbirth may be used as a proxy for long- term outcomes. Findings at a mean of 3.1 years showed 97% agreement with imaging obtained at an average of 4.3 months. There was a non-significant reduction in abnormal slices affecting at most 3/12 slices. This may be explained by compensatory hypertrophy of remaining intact muscle. Sonographic normalisation of complete avulsion was not observed. This article is protected by copyright. All rights reserved.

Does Cystocele Type Vary Between Vaginally Parous and Nulliparous Women?

OBJECTIVES

To evaluate whether cystocele type varies with vaginal parity.

METHODS

Retrospective analysis of 464 vaginally nulliparous women seen at 2 urogynecology units between November 2006 and November 2019. A control group consisted of 871 vaginally parous women seen between July 2017 and November 2019. Patients underwent a standardized interview, POPQ, urodynamic testing, and translabial ultrasound. On imaging, significant cystocele was defined as bladder descent to ≥10 mm below symphysis pubis. Volume datasets were analyzed offline and blinded against clinical data.

RESULTS

Of 5266 women seen during the inclusion period, 464 were vaginally nulliparous. Three were excluded due to missing data, leaving 461. A control group of 871 parous women was generated from patients seen during the last 2.5 years of the inclusion period. Vaginally nulliparous women were presented at a younger age compared to vaginally parous women (P < .001). Symptoms of prolapse were reported in 104 (22%) nulliparae and 489 (56%) parous women (P < .0001). Vaginally parous women demonstrated more bladder descent (P < .0001) and more cystocele (418/871 versus 43/461, P < .0001), with a higher proportion of type III cystocele (cystocele with intact retrovesical angle) (20/43 versus 273/ 418, P < .0001). Cystourethrocele (Green type II) was more common in nulliparae and cystocele type III in parous women (P = .015). On multivariate analysis, these differences in proportions remained significant (P = .049).

CONCLUSIONS

Nulliparity was associated with a higher proportion of Green type II cystoceles. Green type III cystocele was more common in vaginally parous women, suggesting that the latter may be more likely to be due to childbirth-related pelvic floor trauma.

Assessment of Perineal Scars on Translabial Pelvic Floor Ultrasound: A Pilot Study

OBJECTIVE

We aimed to describe a method for identifying and evaluating perineal scars using translabial pelvic floor ultrasound. We hypothesized that translabial ultrasound can identify a perineal scar and can differentiate episiotomies from spontaneous tears.

METHODS

This pilot study is a secondary analysis of data obtained in the Epi-No® trial. Perineal integrity was assessed using volumes acquired on pelvic floor muscle contraction according to the method previously described for anal sphincter imaging. A scar was diagnosed if a hypoechoic distortion in the perineum was noted. We postulated that an episiotomy would result in a linear scar visible on four dimensional translabial ultrasound whereas nonlinear scars were considered the result of spontaneous perineal tear of grade 2 or higher. The results of this assessment were compared with data retrieved from electronic medical records.

RESULTS

A scar was identified in 79/120 women (66%): 42 (35%) linear and 37 (31%) nonlinear. Sonographic and clinical diagnosis agreed on the presence or absence of perineal trauma in 66%. Agreement for the type of laceration was 50%.

CONCLUSION

In this retrospective pilot study, a blinded assessment of translabial ultrasound volume data showed agreement between clinical data and sonographic assessment of perineal integrity in 66% and of type of laceration in 50%. More work is needed to optimize the method in assessment of perineal scars to improve its performance before it can be used in clinical audit and research.

Translabial ultrasound evaluation after tension-free transobturator tape technique: Outcomes based on the tape's position

OBJECTIVE

The purpose of this study was to evaluate the feasibility and accuracy of postoperative translabial ultrasound to assess the position of the tape implanted with the tension-free transobturator tape technique.

METHODS

We enrolled women with clinically and urodynamically proven type I or II stress urinary incontinence who were referred for transobturator tape treatment.

RESULTS

A total of 50 women underwent a transobturator tape procedure and were included in the analysis. We divided the patients into two study groups (group A and group B), characterized by normal and obstructed flow at least 30 days after the surgical procedure visit, respectively. We performed a translabial ultrasound evaluation to assess the suburethral localization of the sling. On the longitudinal scan, the distance between the bladder neck and the suburethral sling was >10 mm in all patients in group A (16.7 ± 1.6). On the contrary, the values in group B were ≤10 mm (5.3 ± 4.8).

CONCLUSION

Our findings highlight the role of a skilled sonographic operator performing translabial ultrasound as a first-line method for evaluating postoperative transobturator tape procedure and sling positioning. Moreover, translabial ultrasound could be helpful to determine a "cutoff" of the bladder neck to sling distance, as this is related to the onset of the obstruction.

All or nothing? A second look at partial levator avulsion

OBJECTIVE

To define associations between partial levator trauma and symptoms and signs of pelvic organ prolapse (POP).

METHODS

This was a retrospective study of 3484 women attending a tertiary urogynecology unit for symptoms of pelvic floor dysfunction between January 2012 and February 2020. All women underwent a standardized interview, clinical pelvic organ prolapse quantification (POP-Q) examination and tomographic ultrasound imaging of the pelvic floor. Women with full levator avulsion were excluded from analysis. Partial levator avulsion was quantified using the tomographic trauma score (TTS), in which slices 3-8 are scored bilaterally for abnormal insertions. Binomial multiple logistic regression was analyzed independently for the outcome variables prolapse symptoms, symptom bother and objective prolapse on clinical examination and imaging, with age and body mass index as covariates. Two continuous outcome variables, prolapse bother score and hiatal area on Valsalva, were analyzed using multiple linear regression.

RESULTS

Of the 3484 women, ultrasound data were missing or incomplete in 164 due to lack of equipment, clerical error and/or inadequate image quality. Full levator avulsion was diagnosed in 807 women, leaving 2513 for analysis. TTS ranged from 0-10, with a median of 0. Partial trauma (TTS > 0) was observed in 667/2513 (26.5%) women. All subjective and objective measures of POP were associated significantly with TTS, most strongly for cystocele. Associations were broadly linear and similar for all slice locations but disappeared after accounting for hiatal area on Valsalva.

CONCLUSION

Partial avulsion is associated with POP and prolapse symptoms. This association was strongest for cystocele, both on POP-Q and ultrasound imaging. The effect of partial avulsion on POP and prolapse symptoms is explained fully by its effect on hiatal area. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Case report: Hydrometrocolpos conditioning recurrent urinary tract infections

We present a case of a 12.5-year-old girl who has suffered from recurrent urinary tract infections for many years but has never undergone a detailed diagnostic process. Only as a teenager did she complain of acute pain in her lower abdomen and it turned out that her genital organs had not properly developed. She had an obstructive defect in the reproductive tract. When there was a significant amount of discharge collected in the lumen of the genital tract and the organs had distended, acute pain appeared, which allowed us to make the diagnosis. In the diagnostic process, transperineal ultrasonography turned out to be extremely helpful, allowing us to establish the type and thickness of the obstruction. The patient underwent excision of transverse vaginal septum, and postoperative silicon dilators were used to prevent the recurrence of the obstruction. There was no recurrence of urinary infection or complications during the 11 months of follow-up.

Is age at menarche a predictor of maternal birth trauma?

OBJECTIVE

Age at menarche and the interval between menarche and age at first vaginal birth have been shown to be associated with reproductive performance; however, their association with maternal birth trauma has not been studied. We aimed to determine whether age at menarche, age at first vaginal birth and their interval are associated independently with levator ani muscle (LAM) avulsion and external anal sphincter (EAS) defect.

METHODS

This was a retrospective analysis of the ultrasound volume datasets of 466 vaginally parous patients attending one of two tertiary urogynecological units in Australia. All patients had undergone a standardized interview and clinical examination using the pelvic organ prolapse quantification staging system, followed by four-dimensional translabial ultrasound. Tomographic ultrasound imaging was used to evaluate the LAM for avulsion and the EAS for significant defect.

RESULTS

Of the 466 women analyzed, LAM avulsion was diagnosed in 121 (26.0%) and significant EAS defect in 55 (11.8%). Logistic regression analysis showed no association between age at menarche and LAM avulsion (P = 0.67). Weak but significant associations were noted between LAM avulsion and age at first vaginal birth (odds ratio (OR), 1.070 (95% CI, 1.03-1.11); P = 0.0007) and between LAM avulsion and menarche-to-first-vaginal-birth interval (OR, 1.064 (95% CI, 1.02-1.11); P = 0.0018). No significant associations were noted between significant EAS defect and any of the evaluated variables (all P ≥ 0.49).

CONCLUSIONS

Age at menarche is not predictive of maternal birth trauma i.e. LAM avulsion and EAS residual defect. There was a statistically significant association between LAM avulsion and menarche-to-first-vaginal-birth interval; however, this was not stronger than the previously established association between LAM avulsion and age at first vaginal birth, arguing against any distinct effect of prolonged prepregnancy hormonal stimulation on the biomechanical properties of the pelvic floor. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Location of obstetric anal sphincter injury scars on translabial tomographic ultrasound

OBJECTIVE

Obstetric anal sphincter injury (OASI) is a common preventable cause of anal incontinence. Both diagnosis and primary repair of OASI are often suboptimal, partly owing to the absence of effective clinical audit. The aim of this study was to evaluate the location of scars or defects of the external anal sphincter (EAS), diagnosed by translabial ultrasound (TLUS), following primary OASI repair.

METHODS

This was a retrospective analysis of 309 women who were seen at a tertiary obstetric unit after primary repair of OASI between June 2012 and May 2019. All women underwent a standardized interview, including St Mark's incontinence score, followed by clinical examination and TLUS assessment within 2-9 months after OASI repair. Postprocessing of TLUS volume datasets was performed by an investigator who was blinded to all other information. Tomographic ultrasound imaging was used to evaluate the presence of a scar or defect in the proximal and distal parts of the EAS. Women were classified into four groups according to the imaging findings: (1) no visible defect or distortion (likely false positive); (2) only proximal OASI; (3) only distal OASI; and (4) both proximal and distal OASI.

RESULTS

Of the 309 women seen during the study period, 34 were excluded because they were referred for reasons other than recent (< 1 year) OASI, 16 owing to missing data and four owing to poor image quality, leaving 255 patients for analysis. Women were seen on average 0.25 ± 0.1 years after the index birth, and their mean age at delivery was 29.1 ± 4.6 years. Anal incontinence was reported by 97 (38.0%) women. A scar or defect was seen only in the proximal part of the EAS in 64 (25.1%) women and only in the distal part in 19 (7.5%) (P < 0.001). In 165 (64.7%) women, the damage affected both the proximal and distal EAS.

CONCLUSIONS

EAS scars after primary OASI repair commonly affect the entire length of the EAS; however, partial tears seem to be more likely to occur proximally. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Breech progression angle: new feasible and reliable transperineal ultrasound parameter for assessment of fetal breech descent in birth canal

OBJECTIVE

To assess the feasibility and reliability of transperineal ultrasound in the assessment of fetal breech descent in the birth canal, by measuring the breech progression angle (BPA).

METHODS

Women with a singleton pregnancy with the fetus in breech presentation between 34 and 41 weeks' gestation were recruited. Transperineal ultrasound images were acquired in the midsagittal view for each woman, twice by one operator and once by another. Each operator measured the BPA after anonymization of the transperineal ultrasound images. BPA was defined as the angle between a line running along the long axis of the pubic symphysis and another line extending from the most inferior portion of the pubic symphysis tangentially to the lowest recognizable fetal part in the maternal pelvis. Each operator was blinded to all other measurements performed for each woman. Intra- and interobserver reproducibility of BPA measurement was evaluated using the intraclass correlation coefficient (ICC). To investigate the presence of any bias, intra- and interobserver agreement was also analyzed using Bland-Altman analysis. Student's t-test and Levene's W₀ test were used to investigate whether a number of different clinical factors had an effect on systematic differences and homogeneity, respectively, between BPA measurements.

RESULTS

Overall, 44 women were included in the analysis. BPA was measured successfully by both operators on all images. Both intra- and interobserver agreement analyses showed excellent reproducibility in BPA measurement, with ICCs of 0.88 (95% CI, 0.80-0.93) and 0.83 (95% CI, 0.71-0.90), respectively. The mean difference between measurements was 0.4° (95% CI, -1.4 to 2.2°) for intraobserver repeatability and -0.4° (95% CI, -2.6 to 1.8°) for interobserver repeatability. The upper limits of agreement were 12.0° (95% CI, 8.9-15.1°) and 13.6° (95% CI, 9.9-17.3°) for intra- and interobserver repeatability, respectively. The lower limits of agreement were -11.2° (95% CI, -14.3 to -8.1°) and -14.4° (95% CI, -18.2 to -10.7°) for intra- and interobserver repeatability, respectively. No systematic difference between BPA measurements was found on either intra- or interobserver agreement analysis. None of the clinical factors examined (maternal body mass index, maternal age, gestational age at the ultrasound scan and parity) showed a statistically significant effect on intra- or interobserver reliability.

CONCLUSIONS

BPA represents a new feasible and highly reproducible measurement for the evaluation of fetal breech descent in the birth canal. Future studies assessing its usefulness in the prediction of successful external cephalic version and breech vaginal delivery are needed. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Importance of Translabial Ultrasound for the Diagnosis of Pelvic Organ Prolapse and Its Correlation with the POP-Q Examination: Analysis of 363 Cases

The incidence of pelvic organ prolapse (POP) is increasing in our aging society. We aimed to evaluate the clinical usefulness of translabial ultrasound (TLUS) by comparing the findings of POP-Q examination and TLUS in advanced POP patients and we also aimed to evaluate the prevalence of rectocele and enterocele on the TLUS. We analyzed the TLUS and POP-Q exam findings of 363 symptomatic POP patients who visited our clinic from March 2019 to April 2021. We excluded three patients who had conditions mimicking POP, as revealed by the TLUS. The most common POP type was anterior compartment POP (68.61%), followed by apical compartment (38.61%) and posterior compartment (16.11%) POP. Agreement between the POP-Q exam and TLUS was tested using Cohen’s kappa (κ). p values < 0.05 were considered statistically significant. The incidence of rectocele or enterocele was only 1.67% (6/360) and there was no rectocele or enterocele in most patients (246/252, 96.63%) when the POP-Q exam revealed posterior compartment POP, suggesting that they only had posterior vaginal wall relaxation. The positive predictive value of the POP-Q exam for detecting rectocele or enterocele (as revealed by TLUS) was only 2.38%, whereas the negative predictive value was 100%. In conclusion, the application of TLUS is useful in the diagnosis of POP, especially for differentiation of true POP from conditions mimicking POP. The correlation between the POP-Q exam and TLUS is low, especially in posterior compartment POP, and therefore, patients with POP-Q exam findings suggesting posterior compartment POP should undergo TLUS to check for rectocele or enterocele. The use of TLUS in the diagnosis of POP patients can improve the accuracy of the diagnosis of POP patients in conjunction with a POP-Q exam.

Fetal head progression and regression on maternal pushing at term and labor outcome

OBJECTIVES

The aim of our study was two-fold. First, to evaluate the association between the change in the angle of progression (AoP) on maternal pushing and labor outcome. Second, to assess the incidence and clinical significance of the reduction of AoP on maternal pushing.

METHODS

This was a prospective cohort study of nulliparous women with singleton pregnancy at term. AoP was measured at rest and on maximum Valsalva maneuver before the onset of labor, and the difference between AoP on maximum Valsalva and that at rest (ΔAoP) was calculated for each woman. Following delivery and data collection, we assessed the association between ΔAoP and various labor outcomes, including Cesarean section (CS), duration of the first, second and active second stages of labor, Apgar score and admission to the neonatal intensive care unit (NICU). The prevalence of women with reduction of AoP on maximum Valsalva maneuver (AoP-regression group) was calculated and its association with the mode of delivery and duration of different stages of labor was assessed.

RESULTS

Overall, 469 women were included in the analysis. Among these, 273 (58.2%) had spontaneous vaginal birth, 65 (13.9%) had instrumental delivery and 131 (27.9%) underwent CS. Women in the CS group were older, had narrower AoP at rest and on maximum Valsalva, higher rate of epidural administration and lower 1-min and 5-min Apgar scores in comparison with the vaginal-delivery group. ΔAoP was comparable between the two groups. On Pearson's correlation analysis, AoP at rest and on maximum Valsalva maneuver had a significant negative correlation with the duration of the first stage of labor. ΔAoP showed a significant negative correlation with the duration of the active second stage of labor (Pearson's r, -0.125; P = 0.02). Cox regression model analysis showed that ΔAoP was associated independently with the duration of the active second stage (hazard ratio, 1.014 (95% CI, 1.003-1.025); P = 0.012) after adjusting for maternal age and body mass index. AoP reduction on maximum Valsalva was found in 73 (15.6%) women. In comparison with women who showed no change or an increase in AoP on maximum Valsalva, the AoP-regression group did not demonstrate significant difference in maternal characteristics, mode of delivery, rate of epidural analgesia, duration of the different stages of labor or rate of NICU admission.

CONCLUSIONS

In nulliparous women at term before the onset of labor, narrower AoP at rest and on maximum Valsalva, reflecting fetal head engagement, is associated with a higher risk of Cesarean delivery. The increase in AoP from rest to Valsalva, reflecting more efficient maternal pushing, is associated with a shorter active second stage of labor. Fetal head regression on maternal pushing is present in about 16% of women and does not appear to have clinical significance. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Is pelvic floor muscle contractility an important factor in anal incontinence?

OBJECTIVE

Pelvic floor muscle contractility (PFMC) may contribute to anal continence. The aim of this study was to assess the association between clinical and sonographic measures of PFMC and anal incontinence (AI) symptoms, after controlling for anal sphincter and levator ani muscle (LAM) trauma.

METHODS

This was a retrospective study of 1383 women assessed at a tertiary center between 2013 and 2016. All patients underwent an interview, including the St Mark's incontinence score (SMIS) in those who reported AI symptoms, a clinical examination, including assessment of PFMC using the modified Oxford scale (MOS), and four-dimensional translabial ultrasound (TLUS). Sonographic measures of PFMC, i.e. cranioventral shift of the bladder neck (BN) and reduction of anteroposterior (AP) diameter of the levator hiatus, were measured offline using ultrasound volumes obtained at rest and on maximum pelvic floor contraction. The reviewer was blinded to all clinical data.

RESULTS

Of the 1383 patients assessed during the study period, seven were excluded due to missing imaging data, leaving 1376 for analysis. Mean age of the participating women was 55 years and mean body mass index was 29 kg/m² . AI was reported by 221 (16.1%) women, with a mean SMIS of 11.8. Mean MOS grade was 2.3. On TLUS, mean BN cranioventral shift was 5.9 mm and mean AP diameter reduction was 8.1 mm. LAM avulsion and significant external anal sphincter (EAS) defect were diagnosed in 24.8% and 8.7% patients, respectively. On univariate analysis, sonographic measures of PFMC were not associated with AI. Lower MOS grade was associated with symptoms of AI; however, statistical significance was lost on multivariate analysis.

CONCLUSION

Clinical and sonographic measures of PFMC were not significantly associated with AI symptoms after controlling for EAS and LAM trauma. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Levator ani muscle avulsion: Digital palpation versus tomographic ultrasound imaging

OBJECTIVE

To determine the diagnostic performance of digital palpation of levator ani muscle (LAM) avulsion compared with translabial tomographic ultrasound imaging (TUI).

METHODS

A cross-sectional study, incorporating 195 women involved in a longitudinal cohort study. Palpation for levator integrity was performed, followed by a four-dimensional translabial ultrasound. LAM avulsion defects were diagnosed in the presence of puborectalis muscle detachment from its insertion. Post-processing analysis of ultrasound volumes for LAM integrity on TUI was performed blinded against palpation findings. Agreement between methods was assessed using Cohen's κ.

RESULTS

In all, 388 paired assessments of LAM bilaterally, were available. Sixteen (8.2%) unilateral avulsion defects were detected on palpation. Sonographically, 31 (16%) were diagnosed with avulsions: 4.6% bilateral and 11.3% unilateral. An overall agreement of 91% was observed between digital palpation and TUI, yielding a Cohen's κ of 0.32 (95% confidence interval 0.15-0.48) demonstrating "fair agreement": and implying 25% sensitivity, 98% specificity, 63% positive predictive value, and 92% negative predictive value. Analysis of the first and last 20 palpations showed no change in performance during the 13-day study period.

CONCLUSION

Assessment of LAM avulsion defects by digital palpation is feasible but may require substantial training. Confirmation by imaging is crucial, especially if the diagnosis of avulsion may influence clinical management.

How comparable is clinical grading of obstetric anal sphincter injury with that determined by four-dimensional translabial ultrasound?

OBJECTIVES

To evaluate the agreement between grading of obstetric anal sphincter injuries (OASI) on translabial ultrasound (TLUS), using a newly developed algorithm, and grading on postpartum examination. A secondary aim was to assess the correlation between tear severity, as defined on ultrasound, and symptoms of anal incontinence and/or fecal urgency.

METHODS

This was a retrospective study of patients seen at a perineal clinic between 2012 and 2018, after recent primary repair of OASI. All patients underwent a standardized interview including the St Mark's anal incontinence test and four-dimensional TLUS. Post-processing of ultrasound volume data was performed blinded to all other data. Using tomographic ultrasound imaging, a set of eight slices was obtained, and the central six slices were evaluated for sphincter abnormalities. Slices with distortion, thinning or defects were rated as abnormal. The following algorithm was used to grade OASI: a Grade-3a tear was diagnosed if the external anal sphincter (EAS) was abnormal in < 4/6 slices; a Grade-3b tear was diagnosed if the EAS was abnormal in ≥ 4/6 slices; and a Grade-3c/4 tear was diagnosed if both the EAS and internal anal sphincter were abnormal in ≥ 4/6 slices. Clinical grading of OASI was determined according to the Royal College of Obstetricians and Gynaecologists guidelines. Agreement between clinical and TLUS diagnosis of OASI was evaluated using weighted κ.

RESULTS

Of the 260 women seen during the study period, 45 (17%) were excluded owing to missing data or a repeat OASI, leaving 215 complete datasets for analysis. The average follow-up interval was 2.4 months (range, 1-11 months) after OASI and the mean age of the women was 29 years (range, 17-42 years). One hundred and seventy-five (81%) women were vaginally primiparous. OASI was graded clinically as Grade 3a in 87 women, Grade 3b in 80, Grade 3c in 29 and Grade 4 in 19. On imaging, full agreement between clinical and TLUS grading was noted in 107 (50%) women, with a weighted κ of 0.398. In 96 (45%) women, there was disagreement by one category, with a weighted κ of 0.74 and in 12 (6%) there was disagreement by two categories. Twenty-four (11%) women were found to have a normal anal sphincter on imaging. Overall, potential clinical over-diagnosis was noted in 72 (33%) women and potential under-diagnosis in 36 (17%). The seniority of the diagnosing obstetrician did not significantly alter agreement between clinical and sonographic OASI grading (κ 0.44, 0.43, and 0.34, for specialists and senior and junior residents, respectively). The association between symptoms of anal incontinence and/or fecal urgency and TLUS grading did not reach significance (P = 0.052).

CONCLUSIONS

Clinical and TLUS-based grading of OASI showed fair agreement. Clinical over-diagnosis may be increasingly common in our population, although under-diagnosis may still occur in a significant minority. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

Vaginal laxity: which measure of levator ani distensibility is most predictive?

OBJECTIVE

To assess the predictive value of measures of levator hiatal distension at rest and on maximum Valsalva maneuver for symptoms of vaginal laxity.

METHODS

This was a retrospective study of women seen at a tertiary urogynecological unit. All women underwent a standardized interview, clinical examination and four-dimensional translabial ultrasound examination. Area, anteroposterior diameter (APD) and coronal diameter (CD) of the levator hiatus were measured at rest and on maximum Valsalva maneuver in the plane of minimal hiatal dimensions using the rendered volume technique, by an operator blinded to all clinical data. The association between levator hiatal measurements and vaginal laxity was assessed, and receiver-operating-characteristics (ROC)-curve analysis was used to determine their predictive value.

RESULTS

Data from 490 patients were analyzed. Mean age was 58 (range, 18-88) years, and vaginal laxity was reported by 111 (23%) women. Measurements obtained on maximum Valsalva were significantly larger in women who reported vaginal laxity than in those who did not, with mean levator hiatal area, APD and CD of 30.45 ± 8.74 cm² , 7.24 ± 1.16 cm and 5.60 ± 0.89 cm, respectively, in the vaginal-laxity group, compared with 24.84 ± 8.63 cm² , 6.64 ± 1.22 cm and 5.01 ± 0.97 cm in the no-laxity group (P < 0.001 for all). Measurements obtained at rest were not significantly different between the groups. Multiple logistic regression analysis controlling for age, body mass index, vaginal parity and levator avulsion confirmed these results. The best regression model for the prediction of vaginal laxity included age, vaginal parity and levator hiatal area on maximum Valsalva. ROC-curve analysis of levator hiatal measurements on maximum Valsalva in the prediction of vaginal laxity demonstrated areas under the curve of 0.68 (95% CI, 0.63-0.73) for area, 0.63 (95% CI, 0.57-0.68) for APD and 0.68 (95% CI, 0.62-0.73) for CD.

CONCLUSIONS

Levator hiatal area on maximum Valsalva seems to be the measure of levator ani distensibility that is most predictive of symptoms of vaginal laxity. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Predictors of successful ring pessary use in women with pelvic organ prolapse

BACKGROUND

Pelvic organ prolapse (POP) is a common chronic health issue. Pessary rings are used for conservative management. To date, there is little evidence on objective anatomical findings as predictors of successful ring pessary management.

AIM

To determine any association between history, clinical and four-dimensional translabial ultrasound (TLUS)/pelvic floor ultrasound examination and pessary success.

MATERIALS AND METHODS

From November 2013 to November 1015, all new patients presenting with symptomatic prolapse to a tertiary urogynaecological unit underwent an assessment including interview, clinical examination, that is, International Continence Society POPQ (pelvic organ prolapse quantification) and TLUS. Women with symptomatic prolapse were offered conservative management with a ring pessary. Those who agreed had a ring inserted that day. Successful trial of pessary use was defined as continued use for at least three months. Retrospective analysis of imaging data was performed blinded to other data. Statistical analysis was performed to assess the relationship between history, examination and imaging and pessary success.

RESULTS

Of 525 patients seen during the inclusion period, 177 had symptomatic prolapse. One hundred and twenty-eight were offered a pessary, 89 accepted. Five had incomplete data, leaving 84. Forty- Two (50%) were still using the pessary at a three-month follow-up. Predictors associated with failure included being pre-menopausal (P = 0.031), a previous hysterectomy (P = 0.051), increasing genital hiatus and perineal body (Gh + Pb) (P = 0.013), posterior compartment prolapse (P = 0.027) and a larger hiatal area on Valsalva on TLUS (P = 0.049). Pre-menopausal status (P = 0.003), increasing Gh + Pb (P = 0.011) and previous hysterectomy (P = 0.001) remained significant on multivariate analysis.

CONCLUSIONS

A history of previous hysterectomy is a predictor of pessary failure as are Gh+Pb on Valsalva and premenopausal status.

Translabial ultrasound imaging of urethral diverticula

OBJECTIVE

Urethral diverticulum is an uncommon cause of urinary dysfunction in women, with often a significant delay in diagnosis. Urethroscopy and/or magnetic resonance imaging are/is widely used for its identification. Translabial ultrasound is an alternative, particularly since the introduction of three-/four-dimensional imaging. The aim of our study was to review 10 years' experience of urethral diverticula evaluated by translabial ultrasound.

METHODS

We reviewed 4121 patients seen in a tertiary urogynecologic unit between 2008 and 2018. All women were examined using multiplanar translabial ultrasound as well as office urethroscopy. Data regarding demographics, presenting symptoms and findings on clinical examination were collected. Archived ultrasound volumes were analyzed for diverticular location, diameters, complexity and echogenicity as well as tract visualization.

RESULTS

Of our study population, 23 (0.6%) were found to have a major urethral abnormality on translabial ultrasound, 15 of whom were confirmed to have a urethral diverticulum on urethroscopy. Of these, 12 had a cystic component and three were non-cystic on imaging. Mean maximum diameter was 15.3 mm (range, 4-32 mm). In 9/15 there was a simple diverticulum, while in 6/15 it was classified as complex. A communicating tract was seen in 10/15 (67%), and this was located at the 5-7 o'clock position in 7/10 (70%). Mean urethral circumference covered by the diverticulum was 39%.

CONCLUSIONS

Translabial ultrasound is a valid, non-invasive method for the diagnosis of urethral diverticulum. A cystic structure crossing the urethral rhabdosphincter has high predictive value for urethroscopic diagnosis of urethral diverticulum. Multiple hyperechogenic foci may indicate the presence of a small urethral diverticulum. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

How Valid Is Tomographic Ultrasound Imaging in Diagnosing Levator and Anal Sphincter Trauma?

OBJECTIVES

Three-/four-dimensional translabial ultrasound (US) is increasingly used to image the levator ani and anal sphincters, especially in the form of tomographic US. The aim of the study was to evaluate the validity of these published methods.

METHODS

This work was a retrospective analysis of datasets of 172 nulliparous women who attended 2 tertiary urogynecologic centers for symptoms of pelvic floor dysfunction between June 2012 and September 2016. All patients had a standardized interview, clinical examination, and 4-dimensional translabial US examination. An evaluation of volume data was performed by the first author, who was blinded against all clinical data, including parity. An assessment for levator avulsion and anal sphincter defects was performed using stored US volume data.

RESULTS

Data sets of 162 and 153 nulliparous women were available for levator and anal sphincter assessments, respectively. On the assessment by the first author, a complete avulsion was diagnosed in 3 nulliparas. On a review by 2 senior authors, 1 was judged as positive and the other 2 as normal. On the sphincter assessment, 2 significant external anal sphincter defects were detected. On the review, 1 was judged as false-positive. The second was judged as highly abnormal by all authors. Therefore, 1 nullipara each was diagnosed with avulsion and a significant external anal sphincter defect.

CONCLUSIONS

Published diagnostic criteria for levator avulsion and external anal sphincter trauma on tomographic US imaging are highly unlikely to result in false-positive findings. This finding supports the clinical validity of this method.

Does Patient Posture Affect the Ultrasound Evaluation of Pelvic Organ Prolapse?

OBJECTIVES

Translabial ultrasound (US) imaging is an emerging method for the evaluation of pelvic organ prolapse (POP). Normative data to date are limited to imaging in the supine position. The purpose of this study was to evaluate the effect of posture changes on US pelvic organ mobility.

METHODS

This work was a retrospective study of 175 women seen in a tertiary urogynecologic center for symptoms of lower urinary tract and pelvic floor dysfunction. All underwent a standardized interview, POP quantification prolapse assessment, and 4-dimensional translabial US examination in supine and standing positions. Offline measurement of organ descent on the Valsalva maneuver was undertaken at a later date and was blinded against all other data.

RESULTS

The mean age was 58 (SD, 13.5; range, 17 to 89) years, with a mean body mass index of 29 (SD, 6.1; range, 18 to 53) kg/m² . In total, 58.9% (n = 103) presented with symptoms of prolapse. Clinically, 82.8% (n = 145) had substantial prolapse on the POP quantification assessment. On imaging, bladder, uterine, and rectal ampulla positions were significantly lower, and the hiatal area on the Valsalva maneuver was larger in the standing position (P < .03). On receiver operating characteristic statistics assessing correlations between POP symptoms and US pelvic organ descent, the area under the curve was higher in the standing position, but the difference was not statistically significant.

CONCLUSIONS

Measurements of organ descent and hiatal dimensions are generally higher in the standing position. However, they are not reflected in a stronger association between symptoms and organ descent. Hence, imaging in the standing position can be limited to those patients in whom a false-negative assessment result is suspected.

Levator Avulsion Is Associated With Pelvic Organ Prolapse 23 Years After the First Childbirth

OBJECTIVES

This study aimed to ascertain the association between levator avulsion and pelvic organ prolapse (POP).

METHODS

This was a cross-sectional study involving 195 women enrolled in a longitudinal cohort study and seen 20 years after an index birth. All had a standardized patient-administered questionnaire, the International Continence Society Pelvic Organ Prolapse Quantification assessment and 4D translabial ultrasound. Main outcome measures were objective POP clinically and on translabial ultrasound. Postimaging assessment of levator integrity and sonographically determined pelvic organ descent was done blinded against other data.

RESULTS

Of 195 women who were seen a mean of 23 (range, 19.4-46.2) years after their first birth, one declined ultrasound assessment and was excluded, leaving 194. Mean age was 50.2 (range 36.9-66.5) years with a mean body mass index (BMI) of 27.6 (range, 18.3-54.3) kg/m² . Median parity was 3 (range 1-14). Ninety-one percent (n = 176) had delivered vaginally. Eighteen percent (n = 34) were symptomatic of prolapse. Clinically, 36% (n = 69) had significant POP. Levator avulsion was diagnosed in 16% (n = 31). Mean levator avulsion defect score was 2.2 (range, 0-12). On univariate analysis, levator avulsion and levator avulsion defect score were associated with clinically and sonographically significant POP, that is, odds ratio 2.6 (1.2-5.7), P = .01; and odds ratio 3.3 (1.4-7.7); P = .003, respectively; Ba (P < .001); bladder (P < .001); uterine (P < .001) and rectal ampulla (P = .009) descent, but not POP symptoms, C, and Bp. Multivariate analysis controlling for potential confounders confirmed our findings.

CONCLUSIONS

Levator avulsion is associated with female pelvic organ prolapse, especially of the anterior and central compartments. This association may become stronger with aging.

The 'bother' of obstructed defecation

OBJECTIVE

To examine the relationship of visual analog scale (VAS) 'bother' scores for obstructed defecation (OD) with demographic data, physical examination and sonographic findings of the posterior compartment.

METHODS

All patients seen at a urogynecology clinic between January and October 2013 were included. Patients were diagnosed with OD if they had any of the following: incomplete bowel emptying, straining with bowel movement or need for digitation. Patients used a VAS to rate OD bother on a scale of 0-10 (0, no bother; 10, worst imaginable bother). For each patient, a comprehensive history was obtained, the International Continence Society Pelvic Organ Prolapse Quantification was performed and four-dimensional translabial ultrasound volumes were recorded on maximal Valsalva maneuver. Linear and multiple regression models were used to correlate bother VAS scores with demographic, clinical and sonographic findings.

RESULTS

Among 265 patients included in the analysis, 61% had OD symptoms with a mean VAS bother score of 5.6. OD bother scores were associated with a history of previous prolapse surgery (P = 0.0001), previous hysterectomy (P = 0.0006), descent of the posterior compartment (Bp; P = 0.004) and hiatal dimensions (Pb and Gh + Pb; P = 0.006 and P = 0.004). OD bother was associated with the following sonographic findings: true rectocele (P = 0.01), depth of rectocele (P = 0.04), descent of rectal ampulla (P = 0.02), enterocele (P = 0.03) and rectal intussusception (P < 0.0001).

CONCLUSIONS

VAS bother scores are associated with both clinical and sonographic measures of posterior compartment descent. Rectal intussusception was most likely to result in highly bothersome symptoms of OD. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Is it necessary to diagnose levator avulsion on pelvic floor muscle contraction?

OBJECTIVE

Avulsion of the levator ani muscle commonly occurs at vaginal birth. This condition is usually diagnosed by translabial ultrasound (TLUS) during pelvic floor muscle contraction (PFMC). Some patients are unable to achieve a satisfactory PFMC and in these cases avulsion is assessed at rest. The aim of this study was to validate the diagnosis of levator avulsion by means of TLUS at rest.

METHODS

This was a retrospective study of 233 women seen at a tertiary urogynecological center. All women underwent four-dimensional TLUS in the supine position and after voiding. Volumes were obtained on maximal PFMC and at rest. Analysis of the volumes was performed with the observer blinded against all clinical data. Avulsion was defined as an abnormal levator ani muscle insertion that was visible in at least three consecutive axial plane slices, at and above the level of minimal hiatal dimensions, at 2.5-mm intervals. We examined the correlation between both assessment methods using Cohen's kappa coefficient and tested the association of each method with female pelvic organ prolapse on clinical examination, organ descent on ultrasound and hiatal ballooning.

RESULTS

In total, datasets from 202 women were available for analysis. The correlation between a diagnosis of avulsion in volumes obtained at rest and those on PFMC was moderate, with a kappa value of 0.583 (95% CI, 0.484-0.683). Agreement for defects visualized on single slices was moderate, with a kappa value of 0.556 (95% CI, 0.520-0.591). When avulsion diagnoses at rest and on PFMC were tested against symptoms of prolapse, and prolapse on clinical examination and on ultrasound, neither of the two methods was superior.

CONCLUSION

Although tomographic ultrasound imaging during PFMC enhances tissue discrimination, this may not translate to superior diagnostic performance. Hence, volumes obtained at rest may be used in women unable to contract their pelvic floor. The diagnosis of levator avulsion by tomographic pelvic floor ultrasound is equally valid when performed at rest or on PFMC. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Does it matter whether levator avulsion is diagnosed pre- or postoperatively?

OBJECTIVE

Levator ani muscle avulsion is found in 15-30% of parturients and is associated with recurrence of pelvic organ prolapse (POP) following surgery, although most published evidence on recurrence relates to postoperative diagnosis. We performed a study to determine whether a diagnosis of avulsion after pelvic floor surgery can be used as a proxy for preoperative diagnosis.

METHODS

This was a retrospective study of 207 patients who were seen before and after surgery for POP between February 2007 and May 2013. All assessments included a three/four-dimensional transperineal tomographic ultrasound examination. Volume data were stored and analyzed at a later date by an operator who was blinded against all clinical data. The primary outcome measure was agreement between preoperative and postoperative diagnoses of avulsion, as evaluated by Cohen's kappa. Secondary outcome measures were the associations of pre- and postoperative diagnoses of levator avulsion with prolapse recurrence, defined as International Continence Society POP-Q Stage ≥ 2 in any compartment.

RESULTS

Mean follow-up after surgery was 1.3 (range, 0.3-5.5) years. Levator avulsion was found preoperatively in 111 (53.6%) patients and postoperatively in 109 (52.7%). The kappa value for the association between pre- and postoperative avulsion was 0.864 (95% CI, 0.796-0.933), signifying high agreement. The odds ratio of prolapse recurrence in women with a preoperative diagnosis of avulsion was 2.5 (95% CI, 1.3-4.5) and in those with a postoperative diagnosis it was 2.3 (95% CI, 1.3-4.2).

CONCLUSIONS

The diagnosis of levator avulsion by tomographic pelvic floor ultrasound is equally valid before and after pelvic reconstructive surgery for POP, and both diagnoses show excellent agreement. This implies that a postoperative diagnosis of avulsion can be used as a proxy for preoperative diagnosis. Hence, avulsion can be identified postoperatively and used for subgroup analysis in prospective surgical intervention trials to define high-risk patients. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Warping of the levator hiatus: how significant is it?

OBJECTIVES

The levator hiatus is the largest potential hernial portal in the human body. Excessive distensibility is associated with female pelvic organ prolapse (POP). Distension occurs not just laterally but also caudally, resulting in perineal descent and hiatal deformation or 'warping'. The aim of this study was to quantify the warping effect in symptomatic women, to validate the depth of the rendered volume used for the 'simplified method' of measuring hiatal dimensions and to determine predictors for the degree of warping.

METHODS

This was a retrospective study utilizing records of patients referred to a tertiary urogynecological service between November 2012 and March 2013. Patients underwent a standardized interview, clinical assessment using the POP quantification system of the International Continence Society and four-dimensional translabial ultrasound. The craniocaudal difference in the location of minimal distances in mid-sagittal and coronal planes was determined by offline analysis of ultrasound volumes, and provided a numerical measure of warping. We tested potential predictors, such as demographic factors, signs and symptoms of prolapse, levator avulsion and levator distensibility, for an association with warping.

RESULTS

Full datasets were available for 190 women. The mean craniocaudal difference in location of minimal distances in mid-sagittal and coronal planes was -1.26 mm (range, -6.7 to 4.6 mm; P < 0.001). This measure of warping was associated with hiatal area on Valsalva maneuver (r = - 0.284; P < 0.0001) and signs of significant prolapse on clinical and ultrasound examination (both P < 0.0001).

CONCLUSIONS

The plane of minimal dimensions of the levator ani hiatus is non-Euclidean, i.e. warped, and the degree of warping is associated with hiatal distension, or 'ballooning', and with POP. However, the degree of warping is minor, the largest difference we found in the location of the plane of minimal dimensions being 6.7 mm. Hence, our results support the determination of hiatal area in a rendered volume of 1-2 cm in depth. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Association of urinary and anal incontinence with measures of pelvic floor muscle contractility

OBJECTIVE

To assess the association between clinical and sonographic measures of pelvic floor muscle (PFM) function and symptoms of urinary and anal incontinence (AI).

METHODS

This was a retrospective study of women seen at a tertiary urogynecological unit. All women had undergone a standardized interview, clinical examination including Modified Oxford Scale (MOS) grading, urodynamic testing and four-dimensional translabial ultrasound (TLUS). Cranioventral shift of the bladder neck (BN) and reduction in the hiatal anteroposterior (AP) diameter were measured using ultrasound volumes acquired on maximal PFM contraction, blinded against all clinical data.

RESULTS

Data from 726 women with a mean age of 56 ± 13.7 (range, 18-88) years and a mean body mass index of 29 ± 6.1 (range, 17-55) kg/m(2) were analyzed. Stress (SI) and urge (UI) urinary incontinence were reported by 73% and 72%, respectively, and 13% had AI. Mean MOS grade was 2.4 ± 1.1 (range, 0-5). Mean cranioventral BN shift on TLUS was 7.1 ± 4.4 (range, 0.3-25.3) mm; mean reduction in AP hiatal diameter was 8.6 ± 4.8 (range, 0.3-31.3) mm. On univariate analysis, neither MOS nor TLUS measures were strongly associated with symptoms of urinary incontinence or AI; associations were non-significant except for BN displacement/SI (7.3 mm vs 6.5 mm; P = 0.028), BN displacement/UI (6.85 vs 7.75; P = 0.019), hiatal AP diameter/AI (9.6 mm vs 8.5 mm; P = 0.047) and MOS/SI (2.42 vs 2.19; P = 0.013).

CONCLUSIONS

In this large retrospective study we did not find any strong associations between sonographic or palpatory measures of PFM function and symptoms of urinary incontinence or AI. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Is intrapartum translabial ultrasound examination painless?

OBJECTIVES

To find out whether intrapartum translabial ultrasound examination is painless by comparing pain score of ultrasound-based versus digital vaginal examination of foetal head station.

METHODS

In 94 women carrying uncomplicated-term singleton pregnancies, labour progress was assessed by translabial ultrasound, followed immediately by conventional digital vaginal examination. Pain scores (0-10) using visual analogue pain scale were obtained for both examinations. Forty-eight and forty-six sets of data were obtained in first and second stage of labour, respectively. The difference in pain scores between digital vaginal examination and translabial ultrasound was analysed.

RESULTS

The median pain score for translabial ultrasound was 0 (range 0-8), while that for vaginal examination was 4.5 (range 0-10), p < 0.05. There was no significant difference in pain scores between first and second stages of labour for translabial ultrasound (p = 0.123) and for vaginal examination (p = 0.680). The pain score for vaginal examination was higher than that of translabial ultrasound in 81.9%, similar in 13.8% and lower in 4.3% of cases. There was no statistically significant difference in pain scores obtained for digital vaginal examination by clinicians with different experience (p = 0.941).

CONCLUSIONS

Intrapartum translabial ultrasound is generally better tolerated than digital vaginal examination for assessment of labour progress, making it an acceptable adjunctive assessment tool during labour.

Negative urodynamic testing in women with stress incontinence

INTRODUCTION

A minority of women with a subjective complaint of stress urinary incontinence will have negative urodynamic stress incontinence (USI) findings.

AIM

To test clinical and ultrasound measures as predictors of an unexpected absence of USI. We hypothesised that unexpectedly negative USI would be more common in young women with good pelvic floor and urethral function.

METHODS

A retrospective study analysing 398 data sets from women attending a urogynaecology clinic for evaluation of lower urinary tract and pelvic floor dysfunction. Clinical, urodynamic and translabial ultrasound data were tested as possible predictors of negative USI findings.

RESULTS

Women with unexpectedly negative USI findings were younger, had less anterior compartment prolapse and had a higher maximum urethral pressure. Measures of pelvic floor muscle function were not predictive.

CONCLUSIONS

Women with unexpectedly negative USI are younger and have better urethral function, but voluntary pelvic floor muscle function seems unrelated to this phenomenon.

Pelvic floor biometry in Chinese primiparous women 1 year after delivery: a prospective observational study

OBJECTIVES

To evaluate pelvic floor biometry in Chinese women 1 year following childbirth and to explore factors that affect it.

METHODS

Translabial ultrasound examination was performed at rest, on Valsalva maneuver (VM) and on pelvic floor muscle contraction (PFMC) in the first, second and third trimesters of pregnancy and at 8 weeks, 6 months and 12 months after delivery in a cohort of women delivering at term their first child. Offline analysis was undertaken to measure the position of the bladder neck, cervix, anorectal junction and hiatal dimensions at each posture and at each visit, and to detect levator ani muscle (LAM) injury on PFMC 8 weeks and 12 months after delivery. Results were analyzed according to mode of delivery.

RESULTS

We recruited 442 women, of whom 328 (74.2%) completed the study; there was LAM injury in 48 women at 8 weeks and in only 38 women at 12 months. When comparing first-trimester biometry to that at 12 months after delivery, the bladder neck was more distal on VM and bladder neck displacement was increased, and the cervix was lower at rest and on VM in the vaginal delivery group. In the Cesarean section group, bladder neck and anorectal junction were more distal on VM, the cervix was lower at rest, on VM and on PFMC, and the hiatal area was increased on VM. There was a greater increase in hiatal area after vaginal delivery. Overall, 34.8% had irreversible hiatal distension (> 20% increase in hiatal area after delivery as compared to first trimester). LAM injury was significantly associated with irreversible hiatal distension (odds ratios, 5.2-9.5 at different postures).

CONCLUSIONS

Pregnancy beyond 35 weeks of gestation has an effect on the pelvic floor of Chinese women, irrespective of mode of delivery. The pelvic organs remain more mobile after delivery when compared to in the first trimester, and there is no clear difference between the findings observed following vaginal delivery or Cesarean section, except in hiatal distension, which is greater after vaginal delivery. LAM injury is the factor most strongly associated with irreversible hiatal distension.

Pelvic floor biometry during a first singleton pregnancy and the relationship with symptoms of pelvic floor disorders: a prospective observational study

OBJECTIVE

To assess pelvic floor biometry during pregnancy and the correlation with symptoms of pelvic floor disorders in women.

DESIGN

A prospective observational study.

SETTING

Antenatal clinic between August 2009 and May 2011.

POPULATION

Nulliparous women in their first pregnancy.

METHODS

Pelvic floor was assessed by translabial ultrasound and symptoms of pelvic floor disorders were explored with a standardised questionnaire at each trimester.

MAIN OUTCOME MEASURES

Pelvic floor biometry during pregnancy.

RESULTS

A total of 405 (91.6%) women completed the study. As the pregnancy advanced, there was significant descent of the bladder neck (BN), cervix, and anorectal junction. The hiatal area (HA) was significantly enlarged, with a mean increase of 15.1 ± 24.8% at rest, and 24.7 ± 28.5% at Valsalva, at third trimester when compared with first trimester. Risk factors for stress urinary incontinence (SUI) were: descent of BN at Valsalva (OR 3.2, 95% CI 1.2-8.5), increase in HA at pelvic floor contraction (PFMC; OR 1.3, 95% CI 1.0-1.6), and increase in maternal age (OR 1.1, 95% CI 1.0-1.2), at first trimester; increase in HA at PFMC (OR 1.3, 95% CI 1.1-1.5) at second trimester; and descent of BN at rest (OR 2.3, 95% CI 1.1-4.9) and increase in maternal age (OR 1.1, 95% CI 1.02-1.2) at third trimester. Descent of anorectal junction (OR 1.5, 95% CI 1.1-1.9) and increase in HA at rest (OR 1.2, 95% CI 1.0-1.3) were factors for prolapse symptoms at second and third trimester, respectively.

CONCLUSIONS

Pelvic floor changes begin during pregnancy. There was significant descent of the BN, cervix, and anorectal junction, and enlargement of the hiatal area, as the pregnancy advanced. SUI was associated with descent of the BN, and prolapse symptoms were associated with an increase in the hiatal area.

Emerging concepts for pelvic organ prolapse surgery: What is cure?

The objective of this review is to discuss emerging concepts in pelvic organ prolapse, in particular, "What is cure?" In a post-trial data analysis of the CARE (Colpopexy and Urinary Reduction Efforts) trial, treatment success varied tremendously depending on the definition used (19.2%-97.2%). Definitions that included the absence of vaginal bulge symptoms had the strongest relationships with the patients' assessment of overall improvement and treatment success. As demonstrated by this study, there are several challenges in defining cure in prolapse surgery. Additionally, the symptoms of prolapse are variable. The degree of prolapse does not correlate directly with symptoms. There are many surgical approaches to pelvic organ prolapse. Multiple ways to quantify prolapse are used. There is a lack of standardized definition of cure. The data on prolapse surgery outcomes are heterogeneous. The goal of surgical repair is to return the pelvic organs to their original anatomic positions. Ideally, we have four main goals: no anatomic prolapse, no functional symptoms, patient satisfaction, and the avoidance of complications. The impact of transvaginal mesh requires thoughtful investigation. The driving force should be patient symptoms in defining cure of prolapse.