Real-time in vivo assessment of levator ani muscle deformation in women

Objective

To study the deformation of the levator ani muscle in vivo with the use of real-time ultrasound imaging of the pelvic floor.

Study design

Thirty-two women with symptoms of pelvic floor dysfunction underwent real-time in vivo assessment of the strain of the pelvic floor during Valsalva effort. All participants underwent clinical examination, urodynamics and 3D/4D translabial ultrasound scan of the pelvic floor. The deformation curves of the levator ani muscle were plotted and the difference in compliance according to the grade of urogenital prolapse was measured. One-way ANOVA and Spearman's correlation were used to test for significance of the relationship between variables (significance level P < 0.05). Test–retest analysis of the ultrasound measurements of the levator hiatal dimensions was also conducted using intra-class correlation coefficient (ICC).

Results

The deformation curve of the levator hiatus showed a non-linear relationship with gradually increased Valsalva force, which was quite pronounced in the pubourethralis subdivision of the levator ani muscle complex. Women with significant pelvic organ prolapse demonstrated a less compliant levator ani muscle close to its origin from the pubic bone than women with non-significant prolapse (median maximum strain 26% vs 32%, respectively, P = 0.03).

Conclusions

Real-time in vivo assessment of levator ani muscle deformation in women is feasible and yields significant information.     

Clinical significance of obstructive defecatory symptoms in women with pelvic organ prolapse

Objective

To determine whether the presence of obstructive defecatory symptoms is associated with the site and severity of pelvic organ prolapse. Methods: A cross-sectional study was performed of women with pelvic organ prolapse of grade 2 or greater who had completed a validated questionnaire that surveyed pelvic floor symptoms. Associations between patient characteristics, site and severity of prolapse, and obstructive bowel symptoms were investigated.

Results

Among 260 women with pelvic organ prolapse, women with posterior vaginal wall prolapse were more likely to report obstructive symptoms, such as incomplete emptying (41% vs 21%, P = 0.003), straining at defecation (39% vs 19%, P = 0.002), and splinting with defecation (36% vs 14%, P < 0.001) compared with women without posterior vaginal wall prolapse. There was no significant association between any bowel symptom and increasing severity of prolapse.

Conclusions

Obstructive bowel symptoms are significantly associated with the presence of posterior vaginal wall prolapse, but not with the severity of prolapse.     

Influence of visual feedback on pelvic floor muscle strength

Objective

The objective of this study is to evaluate the visual feedback influence on pelvic floor muscle contraction.

Study design

Seventeen nulliparous, urinary-continent women participated in this study. Pelvic floor muscle strength with and without the use of visual feedback was measured with a dynamometric speculum in two directions (anteroposterior and left-right). To compare the mean strength values with and without the use of visual feedback, the t test was applied.

Results

There was no significant difference between the pelvic floor muscle anteroposterior strength values with and without the use of visual feedback (p = 0.30), and no significant difference for the left-right strength (p = 0.37).

Conclusion

There was no difference between the pelvic floor muscle strength values with and without the use of visual feedback.     

Vaginal support as determined by levator ani defect status 6 weeks after primary surgery for pelvic organ prolapse

Objective

To evaluate whether major levator ani muscle defects were associated with differences in postoperative vaginal support after primary surgery for pelvic organ prolapse (POP).

Methods

A retrospective chart review of a subgroup of patients in the Organ Prolapse and Levator (OPAL) study. Of the 247 women recruited into OPAL, 107 underwent surgery for prolapse and were the cohort for the present analysis. Major levator ani defects were diagnosed when more than 50% of the pubovisceral muscle was missing on MRI. Postoperative vaginal support was assessed via POP-quantification system. Postoperative anatomic outcome was analyzed according to levator ani defect status, as determined by MRI.

Results

Support of the anterior vaginal wall 2 cm above the hymen occurred among 62% of women with normal levator ani muscles/minor defects and 35% of those with major defects. Support of the anterior wall 1 cm above the hymen occurred among 32% women with normal muscles /minor defects and 59% of those with major defects. Levator ani defects were not associated with differences in postoperative apical/posterior vaginal support.

Conclusion

Six weeks after primary surgery for prolapse, women with normal levator ani muscles/minor defects had better anterior vaginal support than those with major levator defects.     

Effect of a pelvic floor muscle training program on gynecologic cancer survivors with pelvic floor dysfunction: a randomized controlled trial

Objective

To investigate the effects of a pelvic floor rehabilitation program (PFRP) on pelvic floor function and quality of life (QoL) in gynecological cancer survivors in a prospective, randomized, controlled trial.

Methods

Thirty-four patients with gynecological cancers recruited between July 2009 and December 2009 were randomly allocated into two groups: a PFRP group (n = 17), who participated in a 4-week PFRP exercise program, and a non-PFRP group (n = 17), who received the usual health care. The pelvic floor strength, the motor evoked potentials (MEPs) elicited by sacral and transcranial magnetic stimulation, the pelvic floor questionnaire, and the scores on two QoL questionnaires, (QLQ)-C30 and QLQ-CX 24, from the European Organization for Research and Treatment of Cancer (EORTC) were evaluated to assess changes in pelvic floor function and QoL before and after the exercise program.

Results

Twenty four patients (12 from each group) completed the exercise program. The PFRP group improved in pelvic floor strength (mean difference (MD) = 14.22, t₉ = 2.389, P = 0.036) and sexual functioning. The PFRP group also improved in physical and sexual function compared with the non-PFRP group.

Conclusions

The results suggest that the PFRP improved pelvic floor dysfunction and QoL of gynecological cancer patients. A larger randomized controlled trial is planned.     

Short-range clinical, dynamic magnetic resonance imaging and P-QOL questionnaire results after mesh repair in female pelvic organ prolapse

Objective

To evaluate clinical, quality-of-life (QoL) and dynamic magnetic resonance imaging (dMRI) results in patients with pelvic organ prolapse (POP) preoperatively, and 4 and 12 weeks after anterior and/or posterior mesh repair.

Study design

Thirty-six patients (mean age 65 years) with symptomatic pelvic floor descent underwent mesh repair. The prolapse was quantified using the POP-Q system. Before surgery as well as 4 and 12 weeks after surgery, the pelvic organ positions were measured on dynamic magnetic resonance imaging during Valsalva manoeuvre in relation to the pubococcygeal and mid-pubic lines to assess surgery outcome. Patients also completed the P-QOL questionnaire to evaluate subjective changes at each visit.

Results

Four and 12 weeks after surgery patients showed improvement of the POP on clinical examination and on dynamic MRI. The latter demonstrated high significance (p < 0.001) especially in bladder and vaginal cuff/cervix positions during maximal straining. All quality-of-life domains and some symptom questions of the P-QOL questionnaire significantly improved (p < 0.05) 12 weeks after surgery.

Conclusion

Significant anatomical and quality-of-life improvement was demonstrated after anterior and/or posterior mesh repair for POP using dynamic MRI and the P-QOL questionnaire.     

Risk factors for vaginal prolapse after hysterectomy

Objective

To identify risk factors for pelvic organ prolapse (POP) and their influence on the occurrence of vaginal prolapse after hysterectomy.

Methods

Medical records from 2 groups of women who had undergone hysterectomy were reviewed retrospectively. The study group was 82 women who had undergone surgery for vaginal prolapse after hysterectomy; the control group was 124 women who had undergone hysterectomy with no diagnosis of vaginal prolapse by the time of the study. All hysterectomy procedures had been performed for benign gynecological disease, including POP. Both groups of women completed a self-administered questionnaire to obtain additional information on the occurrence of POP.

Results

The incidence of vaginal prolapse after hysterectomy was significantly higher in women with a higher number of vaginal deliveries, more difficult deliveries, fewer cesareans, complications after hysterectomy, heavy physical work, neurological disease, hysterectomy for pelvic organ prolapse, and/or a family history of pelvic organ prolapse. Premenopausal women had vaginal prolapse corrected an average of 16 years after hysterectomy, and postmenopausal women 7 years post hysterectomy.

Conclusion

Before deciding on hysterectomy as the approach to treat a woman with pelvic floor dysfunction, the surgeon should evaluate these risk factors and discuss them with the patient.     

Pelvic organ prolapse in rural Ghana

Objective

To determine the prevalence of pelvic organ prolapse (POP) and its impact on the lives of women in Sekyidumasi, a rural Ghanaian community.

Methods

A cross-sectional study of 200 women was performed using a questionnaire and pelvic examination to detect symptoms and signs of prolapse. Main outcome measures were the presence of POP and its impact on quality of life.

Results

Out of 174 women included in the study, 21 women (12.07%) had POP. Seventeen of these women (81%) were symptomatic, of which only 6 women (35.3%) had sought treatment because of financial constraints. The odds of prolapse increased with increasing parity (P = 0.02) and age (P < 0.01). The main impacts of prolapse were on emotional well-being (52.4%), the women's relationship with their partner (46.2%), and sex life (25%).

Conclusion

Only about one-third of women with symptomatic prolapse sought treatment because the cost of medical care outweighed the impact of the condition on their lives.     

Concomitant surgical correction of occult stress urinary incontinence by TOT in patients with pelvic organ prolapse

Objectives

To assess the post-operative urinary incontinence states of pelvic organ prolapse cases operated on with concomitant trans-obturator tape (TOT) procedure.

Study design

Urodynamic evaluation of 79 patients with pelvic organ prolapse, before and after operation, while reducing the prolapsed organs by ring forceps placed bilaterally on the anterolateral sulcuses avoiding urethral compression. According to urodynamic tests, 25 patients were diagnosed as having occult stress urinary incontinence.

Results

Post-operative overactive bladder, stress urinary incontinence and mixed incontinence were found in three (12%), two (8%) and one (4%) patients of the occult stress urinary incontinence group, respectively. The corresponding numbers were six (11%), five (9%) and three (6%) in the continent group. No significant difference was found between the groups in terms of post-operative overactive bladder symptoms, stress urinary incontinence and mixed incontinence (Kruskal-Wallis test, X² = 0.52, p = 0.820).

Conclusions

This retrospective study suggests that a complete pre-operative urodynamic evaluation, including urodynamic tests at the time of POP reduction by placing ring forceps on the anterolateral sulcuses, is an efficient method for the diagnosis of occult symptomatic stress urinary incontinence (SUI). Prospective randomized studies are needed to establish the benefits and the risks of concomitant prophylactic surgery in patients with pelvic organ prolapse.     

Vaginal mesh colpopexy for the treatment of concomitant full thickness rectal and pelvic organ prolapse: a case series

Objective

To present our case series of concomitant rectal and pelvic organ prolapse (POP) treated with vaginal colpopexy with synthetic mesh.

Study design

Charts of patients with full thickness rectal prolapse and POP were reviewed for presenting symptoms, physical examination with POP-Q including rectal prolapse evaluation, and perioperative complications and outcomes.

Results

Four patients aged 63-78 were identified with full thickness rectal prolapse and POP. All of them had symptoms related to both conditions. Rectal prolapse protrusion ranged from 2 cm to 3 cm outside the anus. All patients had vaginal mesh colpopexy; two of them with anterior and posterior vaginal mesh and 2 with posterior mesh only. At a follow-up of 6-44 months, all patients had resolution of both POP and rectal prolapse signs and symptoms.

Conclusion

Vaginal colpopexy with mesh may be a unique treatment to address both POP and full thickness rectal prolapse in selected patients. Further research is needed to determine the safety and efficacy of this method.     

Evaluation of the effect of pelvic floor muscle training (PFMT or Kegel exercise) and assisted pelvic floor muscle training (APFMT) by a resistance device (Kegelmaster device) on the urinary incontinence in women: a randomized trial

Objective

To evaluate the effect of pelvic floor muscle training (PFMT) or Kegel exercise with and without assistance by a resistance device (Kegelmaster device) on the urinary incontinence in women.

Study design

A randomized clinical trial was performed on 91 women with the complaint of urinary incontinence.In the assisted pelvic floor muscle training (APFMT) group (n = 41), after complete training, Kegelmaster device were used twice daily for 15 min each session, for a total duration of 12 weeks.In the pelvic floor muscle training (PFMT) group (n = 50) after complete training, kegel exercises were done (including perineal muscle contractions for 6-8 s with 6 s rest in between), twice daily for 15 min each session and for a total duration of 12 weeks.These two groups were then compared according to the scores of special questionnaires for quality of life, strength of pelvic floor muscles, capability to participate in social activities, severity of urinary incontinence, and the number of involuntary urine passage, taken before, and after 1 and 3 months after finishing interventions.

Results

85 women out of 91 women finished the study (46 in the PFMT group and 39 in the APFMT group). Strength of pelvic floor muscles, capability to participate in social activities, score of quality of life according to three world questionnaires of IQOL (incontinence Quality Of Life), IIQ (Incontinence Impact Questionnaire), UDI (Urogenital Distress Inventory), showed no difference between the two groups 1 and 3 months after interventions.Pair t test showed a significant improvement in both groups 1 and 3 months after intervention, according to IQOL score (P = 0.000), UDI score (P = 0.000), IIQ score (P = 0.000), strength of pelvic floor muscles, (P = 0.000), capability to participate in social activities (P = 0.000), severity of urinary incontinence (P = 0.000) and the number of involuntary urine passage (P = 0.000).

Conclusion

Pelvic floor muscle training with or without Kegelmaster show no apparent difference to each other, however, these two methods are effective for improvement of urinary incontinence in women.     

Perioperative course and medium-term outcome of the transobturator and infracoccygeal hammock for posthysterectomy vaginal vault prolapse

Objective

To describe the perioperative course and medium-term anatomic and functional outcomes of the transobturator-infracoccygeal hammock for posthysterectomy vaginal vault prolapse repair.

Methods

A prospective consecutive series of 52 women with a stage 2 vaginal vault prolapse or higher that occurred after total hysterectomy who underwent surgery between 2003 and 2007. Principal outcome measures were anatomic cure (stage 1 or lower) and impact on quality of life measured using the pelvic floor distress inventory (PFDI) and pelvic floor impact self-reported questionnaire (PFIQ). Anatomical results were analyzed using χ² and Fisher exact tests, and PFDI and PFIQ scores were analyzed using the Wilcoxon test.

Results

With a median follow-up of 36 months, the anatomic cure rate was 96%. Significant improvements were noted in POPQ-S scores after surgery (P < 0.05). Stress urinary incontinence was cured in 73% of patients and improved in 15% of patients. The PFDI and PFIQ scores were improved (P < 0.05). One mesh extrusion was observed. The rates of mesh contraction and new cases of dyspareunia were 31% and 13%, respectively.

Conclusion

The transvaginal mesh hammock represents a useful treatment for recurrent and major vaginal vault prolapse, and has few complications.     

Wide genital hiatus is a risk factor for recurrence following anterior vaginal repair

Objective

To determine if a wide genital hiatus is a risk factor for recurrence of anterior vaginal wall prolapse following anterior vaginal repair.

Methods

A retrospective cohort study was performed on patients who had undergone an anterior vaginal wall repair. Patients were placed into 1 of 2 groups: wide genital hiatus (≥ 5 cm) or normal genital hiatus (< 5 cm). The wide genital hiatus group (n = 35) was compared with the normal genital hiatus group (n = 30) for surgical failure.

Results

There were no significant differences between the 2 groups in demographic data, additional operative procedures, or apical suspensions. The rate of postoperative anterior vaginal wall prolapse was greater in patients with a wide genital hiatus compared with those with a normal genital hiatus (34.3% vs 10% respectively; odds ratio 4.7 [95% confidence interval, 1.0-24.1]; P = 0.02).

Conclusion

The rate of recurrent anterior vaginal wall prolapse is higher in patients with a wide genital hiatus.     

Levator ani injury in primiparous women with forceps delivery for fetal distress, forceps for second stage arrest, and spontaneous delivery

Objective

To compare levator ani muscle injury rates in primiparous women who had a forceps delivery owing to fetal distress with women delivered by forceps for second stage arrest; and to compare these injury rates with a historical control group of women who delivered spontaneously.

Methods

Primiparous women who delivered by forceps were recruited retrospectively into 2 groups: forceps for fetal distress with short second stage (25 ± 11 minutes; n = 19); and forceps delivery for second stage arrest (137 ± 26 minutes; n = 19). MR images of the levator ani muscles were compared with a historical control group of women from a previous study who had delivered spontaneously (n = 129).

Results

Major defect rates were: 42% for forceps and short second stage; 63% for forceps and second stage arrest; and 6% for spontaneous delivery. The odds ratios for major injury were: 11.0 for forceps and short second stage compared with spontaneous delivery; 25.9 for forceps and second stage arrest compared with spontaneous delivery; and 2.3 for forceps and second stage arrest compared with short second stage (P = 0.07).

Conclusion

Women delivered by forceps have a higher rate of levator ani injury compared with spontaneous delivery controls; the difference between the forceps groups did not reach significance.     

Uterosacral-cardinal ligament stretching prior to vaginal hysterectomy increases uterine descent: a novel technique

Objective

To examine the effect of uterosacral-cardinal ligament complex stretching prior to vaginal hysterectomy on uterine descent.

Study design

A prospective trial of 25 consecutive women undergoing vaginal hysterectomy. Pre-operative, apical, anterior and posterior wall POP-Q measurements were recorded for each patient before and after uterosacral-cardinal ligament complex stretching during general anesthesia.

Results

Uterosacral-cardinal ligament complex stretching yielded a significant increase in mean stage of uterine and anterior wall descent (2.6 ± 0.6 vs. 3.2 ± 0.6 cm, p < 0.001, and 2.5 ± 0.8 vs. 2.9 ± 0.8 cm, respectively, p < 0.004). There was no significant change in posterior wall prolapse measurements (1.3 ± 0.7 vs. 1.4 ± 0.8 cm, p = 0.05).

Conclusion

Uterosacral-cardinal ligament complex stretching prior to vaginal hysterectomy increase uterine descent.     

Comparison of Burch colposuspension and transobturator tape when combined with abdominal sacrocolpopexy

Objective

To compare the treatment outcomes of Burch colposuspension and transobturator tape (TOT) when each is combined with abdominal sacrocolpopexy (ASC) to treat stress urinary incontinence (SUI) with pelvic organ prolapse (POP).

Methods

Consecutive cases of Burch colposuspension and TOT combined with ASC were retrospectively reviewed. Patients with SUI and POP beyond stage III—according to the POP-quantification system—were included.

Results

Mean hospital stay was longer in the Burch group (n = 49) than in the TOT group (n = 60) (11.3 vs 7.8 days; P < 0.001), as was operation time (202.7 vs 170.1 minutes; P < 0.001); furthermore, there were higher rates of urinary retention (53.1% vs 11.7%; P < 0.001), de novo urgency (18.4% vs 3.3%; P = 0.01), and recurrent SUI (18.4% vs 1.7%; P = 0.003) in the Burch group. The cure rate was significantly higher in the TOT group than in the Burch group (98.3% vs 69.7%; P < 0.001).

Conclusion

The use of TOT with ASC resulted in higher cure rates and better functional outcomes than did Burch colposuspension with ASC.     

Effectiveness of the association micronized N-Palmitoylethanolamine (PEA)-transpolydatin in the treatment of chronic pelvic pain related to endometriosis after laparoscopic assessment: a pilot study

Objective

Aim of our study was to evaluate the effectiveness of the association between N-Palmitoylethanolamine and transpolydatin in the management of chronic pelvic pain related to EMS.

Study design

This was a randomized, double-blind, parallel-group, placebo-controlled clinical trial involving 61 subjects, submitted to a first line laparoscopic conservative surgery, who were randomized into 3 groups receiving: group A (n = 21) the association N-Palmitoylethanolamine-transpolydatin 400 mg + 40 mg twice a day for 3 months; group B (n = 20) the placebo for 3 months; group C (n = 20) a single course of Celecoxib 200 mg twice a day for 7 consecutive days. Assessments of the severity of pelvic endometriosis (pelvic pain, dysmenorrhoea and dyspareunia) were recorded before and after treatment on a questionnaire and a 10-point VAS. Differences between groups were verified with Kruskal-Wallis ANOVA for non-parametric multiple comparisons.

Results

A marked decrease in dysmenorrhoea, dyspareunia and pelvic pain was observed in all groups, and the association between N-Palmitoylethanolamine and transpolydatin resulted to be more effective than placebo (P < .001). Additionally, the treatment with Celecoxib resulted in a decrease in pelvic pain more effective either than the association N-Palmitoylethanolamine and transpolydatin or placebo.

Conclusion

These preliminary results show that the association between micronized N-Palmitoylethanolamine and transpolydatin is effective in the management of pelvic pain related to endometriosis after laparoscopy. Additionally, this association seems to be safe, shows an optimal control of pain and can be used in patients who are unable to receive other therapies.     

Does levator avulsion increase urethral mobility?

Objective

It is often assumed that stress urinary incontinence may be due to abnormal pelvic floor muscle function or anatomy. This may be mediated through urethral hypermobility. The aim of the study was to determine the association between major levator ani defects (‘avulsion’) and urethral mobility.

Study design

Three hundred and five women were referred to a tertiary referral service for lower urinary tract and prolapse symptoms between December 2006 and July 2008. All patients had undergone an interview, clinical examination, multichannel urodynamic testing and 4D transperineal ultrasound. Ultrasound volume datasets of 198 women were analysed retrospectively. Tomographic ultrasound imaging was used to diagnose levator avulsion at the time of the original assessment. To determine urethral mobility, data analysis was performed on a desktop PC using proprietary software several months later. The urethra was divided into 5 equal segments with 6 points marked evenly along the urethra from the bladder neck (Point 1) to the external meatus (Point 6) as identified in the mid-sagittal view. Measurements of vertical and horizontal distances from the dorsocaudal margin of the pubic symphysis of these 6 points were taken in the mid-sagittal plane, using volume datatsets obtained at rest and on maximal Valsalva. Mobility vectors of these 6 points were calculated using the formula SQRT ((x_valsalva − x_rest)² + (y_valsalva − y_rest)²) and were correlated with levator status using two sample T tests.

Results

Levator avulsion was found in 18% of patients (n = 35). Except at the bladder neck which almost reached significance (32.5 mm in those with defects vs. 28.9 mm in those without, P = 0.07), there was no significant association between urethral mobility and avulsion (all P ≥ 0.17).

Conclusion

Major levator trauma does not seem to substantially affect urethral mobility, with the possible exception of the bladder neck.     

Dienogest in the treatment of endometriosis-associated pelvic pain: a 12-week, randomized, double-blind, placebo-controlled study

Objective

To investigate the efficacy and safety of oral dienogest 2 mg compared with placebo in the treatment of endometriosis-associated pelvic pain (EAPP).

Study design

This was a 12-week, randomized, double-blind, placebo-controlled, multicenter (n = 33) study in Germany, Italy, and Ukraine of 198 women aged 18-45 years with laparoscopically confirmed endometriosis and EAPP score ≥30 mm on a visual analog scale (VAS). Dienogest 2 mg or placebo was administered orally once daily. The primary efficacy variable was absolute change in EAPP from baseline to Week 12, as determined by the target variables of change in VAS score and change in intake of supportive analgesic medication (ibuprofen) for pelvic pain.

Results

Mean reductions in VAS score between baseline and Week 12 in the full analysis set were 27.4 mm and 15.1 mm in the dienogest and placebo groups, respectively—a significant score difference of 12.3 mm in favor of dienogest (P < 0.0001). Changes in intake of supportive analgesic medication were modest in both groups. The primary efficacy measure of absolute change in EAPP demonstrated the superiority of dienogest over placebo. Dienogest was generally well tolerated and few adverse events were associated with therapy.

Conclusions

Dienogest at a dose of 2 mg daily for 12 weeks was significantly more effective than placebo for reducing EAPP.