Comparison of the puborectal muscle on MRI in women with POP and levator ani defects with those with normal support and no defect

Introduction and hypothesis  

The objective of this study was to compare puborectal muscle integrity and bulk in women with both major levator ani (LA) defects on MRI and pelvic organ prolapse (POP) to women with normal LA muscle and normal support.     

Anal sphincter defects and anal incontinence symptoms after repair of obstetric anal sphincter lacerations in primiparous women

A study was carried out to identify (1) incidence of anal incontinence symptoms, (2) incidence and size of both external anal sphincter (EAS) and internal anal sphincter (IAS) defects, and (3) relationship between anal incontinence symptoms and IAS or EAS defect size after repair of an obstetric anal sphincter laceration. Forty-seven vaginally primiparous women underwent obstetric anal sphincter laceration repair. At 8–12 weeks postpartum, anal incontinence symptoms were assessed, and endoanal ultrasound was performed. At 1–2 years postpartum, symptoms were reassesseds. The incidence of anal incontinence symptoms at 8–12 weeks was 43%. The incidence of IAS and EAS defects were 32% and 77%, respectively. IAS defects ≥45 degrees were predictive of symptoms (p = 0.02). After 18 months mean follow-up, 11% reported chronic symptoms. After anal sphincter laceration repair, anal incontinence symptoms occur in 43% of women and remain chronic in 11%. Anal incontinence symptoms are associated with increasing IAS defect size. Poster presentation at the American Urogynecologic Society Annual Meeting, Hollywood, Florida, USA, 27–29 September 2007.     

External intercostal muscles and external anal sphincter electromyographic activity during coughing

Few studies focused on concomitant electromyographic recordings of pelvic floor muscles and muscles involved in cough initiation. The objective of this study was to investigate the temporal course of external anal sphincter activation during coughing. Informed consent was obtained from ten healthy volunteers and ten women presenting with stress urinary incontinence (SUI). Simultaneously, recordings of electromyographic activity of external intercostal muscles (EIC EMGi) and external anal sphincter (EAS EMGi) during coughing have been performed. It was chosen to study intercostals muscles because they are synchronous to diaphragmatic muscle during cough initiation. Median (interquartile range) latency between the onset of the EAS EMGi and the onset of the EIC EMGi was −210 ms (−398; −135) and 0 ms (−30; +111.7) in volunteers’ group and in SUI group, respectively (p = 0.0009). Abnormal temporal course of external anal sphincter activation is observed during coughing in women presenting with SUI compared to healthy volunteers.     

Pelvic prolapse and urinary incontinence in nulliparous college women in relation to paratrooper training

The objective of this study was to determine whether paratrooper training is associated with pelvic support defects or urinary incontinence. Nulliparous women at The United States Military Academy were examined using the Pelvic Organ Prolapse Quantification System and completed a questionnaire regarding incontinence and exercise prior to undergoing summer military training. The exam and questionnaire were repeated following training. One hundred sixteen women completed the study (80.6%), 37 of whom had attended paratrooper training. Women who attended paratrooper training were significantly more likely to have stage II prolapse (RR = 2.72, 1.37 < RR < 5.40; p = 0.003). Additionally, women who attended paratrooper training were significantly more likely to have worsening in their pelvic support regardless of initial prolapse stage (RR = 1.57, 1.12 < RR < 2.20; p = 0.01). Twenty-four women complained of urinary incontinence; however, this was not associated with paratrooper training. The forces transmitted to the female pelvis during paratrooper training are significant and cause pelvic support defects. Presented at the combined AUGS/SGS Joint Scientific Meeting, July 2004.     

Does avulsion of the puborectalis muscle affect bladder function?

Introduction and hypothesis  The levator ani muscle is generally thought to play a role in urinary continence, with incontinence assumed to be due to abnormal muscle function or morphology. This study examined whether avulsion of the puborectalis muscle is associated with symptoms or signs of bladder dysfunction. Methods  In a retrospective observational study, we reviewed the records of 425 women who had attended a urogynecological unit for independent flowmetry, multichannel urodynamic testing, and 4D pelvic floor ultrasound. Results  Mean age was 55 years (range, 17–87 years). Of 420 women with complete datasets, 104 (25%) were diagnosed with a puborectalis muscle avulsion. These women were less likely to suffer from stress urinary incontinence (SUI; P < 0.001) and urodynamic stress incontinence (USI; P = 0.065) and more likely to present with symptoms of prolapse (P < 0.001) and show signs of voiding dysfunction (P = 0.005). The negative association between avulsion and SUI persisted in multivariate models. Conclusion  Puborectalis muscle trauma is not associated with an increased risk of SUI or USI in a urogynecological population, even when controlling for symptoms or signs of prolapse and previous surgery.     

3D pelvic floor ultrasound findings and severity of anal incontinence

Introduction and hypothesis

The aim of our study was to determine the association between the severity of anal incontinence and levator ani deficiency, anal sphincter defects, anorectal angle, and colonic motility abnormalities.

Methods

This was a retrospective study. Subjects were categorized into three groups: normal, minor anal incontinence, and major anal incontinence according to their answers to the PFDI-20 questionnaire. 3D endovaginal ultrasound was utilized to assess levator ani muscle and the anorectal angle. Levator ani muscle subdivisions were scored based on avulsion from the pubic bone and muscle thickness, based on our previous work. 3D endoanal ultrasound was utilized to assess anal sphincters. Colonic motility abnormalities were defined as diarrhea, constipation or both.

Results

Ninety-seven patients were included in the analysis: 45 with major anal incontinence, 29 with minor anal incontinence, and 23 continent women. On multivariate logistic regression, sphincter defect, anorectal angle, and colonic motility abnormalities were associated with anal incontinence severity. Women with an external anal sphincter defect had a 20.36-fold chance of having severe anal incontinence compared with patients with no defect (OR 20.36, 95 % CI 5.4, 76.6); those with both defective sphincters had a 102.5-fold chance of having severe anal incontinence (OR 102.5, 95 % CI 10.2, >999). Anorectal angle ≥170° was significantly associated with the severity of anal incontinence (OR = 4.07, 95 % CI 1.53, 10.79), as was the presence of colonic mobility abnormality (OR 5.31, 95 % CI 1.86, 15.19).

Conclusions

3D pelvic floor ultrasound can be an efficient tool for anal incontinence evaluation in women. Anal sphincter defects, colonic motility abnormalities, and anorectal angle were associated with the severity of anal incontinence. While there was a trend toward worsening levator ani deficiency among those with major anal incontinence, this did not reach statistical significance.     

Assessment of sexual function in women with pelvic floor dysfunction

Forty-seven women participated in a pilot study for a multi-centre randomized controlled trial of the effectiveness of pelvic floor muscle training (PFMT) for women with prolapse. Women with symptomatic stage I or II prolapse [measured by Pelvic Organ Prolapse Quantification (POP-Q)] were randomized to a 16-week physiotherapy intervention (PFMT and lifestyle advice; n = 23) or a control group receiving a lifestyle advice sheet (n = 24). Symptom severity and quality of life were measured via postal questionnaires. Blinded POP-Q was performed at baseline and follow-up. Intervention women had significantly greater improvement than controls in prolapse symptoms (mean score decrease 3.5 versus 0.1, p = 0.021), were significantly more likely to have an improved prolapse stage (45% versus 0%, p = 0.038) and were significantly more likely to say their prolapse was better (63% versus 24%, p = 0.012). The data support the feasibility of a substantive trial of PFMT for prolapse. A multi-centre trial is underway.     

It is the first birth that does the damage: a cross-sectional study 20 years after delivery

Introduction and hypothesis

Levator ani muscle (LAM) and anal sphincter tears are common after vaginal birth and are associated with female pelvic organ prolapse and anal incontinence. The impact of subsequent births on LAM and external anal sphincter (EAS) integrity is less well defined. The objective of this study was to determine the prevalence of LAM and EAS trauma in primiparous (VP1) and multiparous (VP2+) women who had delivered vaginally to assess if there were differences between the two groups. The null hypothesis was: there is no significant difference in the prevalence of LAM and EAS trauma between the two groups.

Methods

This was a cross-sectional study involving 195 women, participants of the Dunedin arm of the ProLong study (PROlapse and incontinence LONG-term research study) seen 20 years after their index birth. Assessment included a standardized questionnaire, ICS POP-Q and 4D translabial ultrasound. Post-imaging analysis of LAM and EAS integrity was undertaken blinded against other data. Statistical analysis was performed using Fisher’s exact test and results were expressed as odds ratios (OR).

Results

LAM avulsion and EAS defects were diagnosed in 31 (16%) and 24 (12.4%) women respectively. No significant difference in the prevalence of levator avulsion and EAS defects between primiparous (VP1) and multiparous (VP2+) women who had delivered vaginally (OR 1.9, 95% CI 0.72–5.01, p?=?0.26) and (OR 1.2, 95% CI 0.4–3.8, p?=?0.76) respectively.

Conclusions

Most LAM avulsions and EAS defects seem to be caused by the first vaginal birth. Subsequent vaginal deliveries after the first were unlikely to cause further LAM trauma.

     

Clarification and confirmation of the Knack maneuver: the effect of volitional pelvic floor muscle contraction to preempt expected stress incontinence

The aim of the study was to determine the immediate effect of timing a pelvic muscle contraction with the moment of expected leakage (the Knack maneuver) to preempt cough-related stress incontinence. Women performed a standing stress test using three hard coughs without and then with the Knack maneuver. Volume of urine loss under both conditions was quantified with paper-towel test. Two groups of women were tested: nonpregnant women (n = 64) and pregnant women (n = 29). In nonpregnant women, wetted area decreased from a median (range) of 43.2 (0.2–183.7) cm² without the Knack maneuver to 6.9 (range of 0 to 183.7 cm²) with it (p < 0.0001); while in pregnant women it decreased from 14.8 (0–169.7) cm² to 0 (0–96.5) cm², respectively (p = 0.001). This study confirms the effect from the Knack maneuver as immediate and provides a partial explanation for early response to widely applied pelvic muscle training regimens in women with stress incontinence.     

Estrogen and ghrelin decrease cytoplasmic expression of p27<Superscript>kip1</Superscript>, a cellular marker of ageing,in the striated anal sphincter and levator muscle of ovariectomized rats

A study was carried out to investigate the effect of estrogen and/or ghrelin on the cellular marker of ageing, p27^kip1, in pelvic floor muscles of ovariectomized rats. Virgin Wistar rats (13 months old) underwent ovariectomy followed (1 month) by 42 daily intraperitoneal 17-β estradiol (10 μg/kg), ghrelin (2 μg/kg), both hormones, or placebo vehicle (n=6×4 groups). Six more age-matched animals underwent sham surgery without ovariectomy. Cytoplasmic expression of p27^kip1 in the striated urethral and anal sphincters and levator muscle was measured by Western blot analysis in all animals (n=30). p27^kip1 signal intensity significantly increased postovariectomy in all muscles compared to sham animals. In the anal sphincter and levator, signal intensity decreased to sham levels with ghrelin or estrogen and decreased further after estrogen or ghrelin and estrogen/ghrelin administration. Urethral sphincter signal intensity decreased without reaching sham levels after drug administration. Estrogen and/or ghrelin replacement reverses the ovariectomy-induced exacerbation of biochemical cellular ageing in the anal sphincter and levator muscle of middle-aged rats.     

Interrater reliability of assessing levator ani muscle defects with magnetic resonance images

The objective of this study is to determine interrater reliability of assessing pubovisceral levator ani muscle defects with magnetic resonance images. Normal pubovisceral muscle was assigned a grade of 0; PVM defects were graded as mild = 1 (less than half missing), moderate = 2 (more than half missing), and severe = 3 (total or near total loss). Among six pairs of examiners, percent agreement and weighted kappa coefficients were calculated to determine agreement between pairs of examiners and among all examiners (i.e., “overall”). For unilateral scoring, exact agreement was found in 83.7%, and differences of one, two, and three grades were found in 14.7, 1.5, and 0.1%, respectively. For bilateral scoring, exact agreement and differences of one, two and three grades were found in 75.4, 15.9, 6.9, and 1.6%, respectively. Thus, exact agreement or a one-point difference was reached in 91.3% of cases. When defect status was categorized as none/normal, minor, and major, the overall weighted kappa coefficient was 0.86 (95% CI 0.83, 0.89). There was variation among examiner pairs with unilateral (p = 0.002) and bilateral (p = 0.02) scoring, but not when defect status was categorized as none/normal, minor, and major (p = 0.59). There was agreement to within one point in 91% of cases when six examiner pairs scored levator ani defects on a seven-point scale. Examiner pairs discriminated injury similarly when defect status was categorized as normal/none, minor, or major.     

Characteristics associated with pelvic organ prolapse in women with significant levator ani muscle deficiency

Introduction and hypothesis

Age is a factor associated with symptomatic pelvic organ prolapse (POP) among women with significant levator ani deficiency.

Methods

This cross-sectional study included patients who were referred for varied pelvic floor disorders, had 3D endovaginal ultrasound as part of their evaluation, and were diagnosed with significant levator ani muscle deficiency defined as a score of 12 or more on 3D endovaginal ultrasound. Patients were categorized as having no pelvic organ prolapse (stages 0 and 1), or symptomatic prolapse (stages 2–4).

Results

Seventy-six women were available for analysis and found to have significant levator ani muscle deficiency, including 51 with symptomatic POP and 25 without POP. Patients with symptomatic POP were older, (mean age 66 (SD?±?11.8) vs 48 (SD?±?17.3) years; p <0.0001), had greater mean minimal levator hiatus (MLH) area (19.7 cm² (SD?±?4.6) vs 17.5 cm² (SD?±?3.5); p?=?0.048), and were more likely to be menopausal (91.3 % vs 54.5 %; p <0.001) compared with those with no POP. In a modified Poisson regression analysis excluding nulliparous women, increasing age (RR?=?2.39, 95 % CI 1.03–5.55) and smoking (RR?=?1.34, 95 % CI 1.08–1.67) remained associated with symptomatic POP after controlling for one another and the MLH area.

Conclusions

Among women with significant levator ani deficiency, older women and smokers had an increased prevalence of symptomatic POP. On average, women without POP, but with significant levator ani deficiency were 18 years younger than women with POP and significant muscle deficiency.

     

Magnetic resonance assessment of pelvic anatomy and pelvic floor disorders after childbirth

To compare pelvic anatomy, using magnetic resonance imaging, between postpartum women with or without pelvic floor disorders. We measured postpartum bony and soft tissue pelvic dimensions in 246 primiparas, 6–12-months postpartum. Anatomy was compared between women with and without urinary or fecal incontinence, or pelvic organ prolapse; P < 0.01 was considered statistically significant. A deeper sacral hollow was significantly associated with fecal incontinence (P = 0.005). Urinary incontinence was marginally associated with a wider intertuberous diameter (P = 0.017) and pelvic arch (P = 0.017). There were no significant differences in pelvimetry measures between women with and without prolapse (e.g., vaginal or cervical descent to or beyond the hymen). We did not detect meaningful differences in soft tissue dimensions for women with and without these pelvic floor disorders. Dimensions of the bony pelvis do not differ substantially between primiparous women with and without postpartum urinary incontinence, fecal incontinence and prolapse.     

Pelvic architectural distortion is associated with pelvic organ prolapse

The aim of this study was to determine whether there is an association between architectural distortion seen on magnetic resonance (MR) scans (lateral “spill” of the vagina and posterior extension of the space of Retzius) and pelvic organ prolapse. Secondary analysis of MR imaging scans from a case-control study of women with prolapse (maximum point ≥+1cm; N = 144) and normal controls (maximum point ≤−1cm; N = 126) was done. Two independent investigators, blinded to prolapse status and previously established levator-defect scores, determined the presence of architectural distortion on axial MR scans. Women were categorized into three groups based on levator defects and architectural distortion. Among the three groups, women with levator defects and architectural distortion have the highest proportion of prolapse (78%; p < 0.001). Among women with levator defects, those with prolapse had an odds ratio of 2.2 for the presence of architectural distortion (95% CI = 1.1–4.6). Pelvic organ prolapse is associated with the presence of visible architectural distortion on MR scans. This work has been presented in abstract form at the Annual Scientific Meeting of the Society of Gynecologic Surgeons, April 11th–14th 2007, Orlando, FL, USA.     

Morphologic study on levator ani muscle in patients with pelvic organ prolapse and stress urinary incontinence

The objective of this study was to determine the morphologic changes of the levator ani muscle of patients with pelvic organ prolapse and stress urinary incontinence. Histological and histochemical analyses of the biopsy specimens of the levator ani muscle obtained from patients with stress urinary incontinence (SUI), pelvic organ prolapse (POP), and a control group were performed. The striated muscle-positive biopsy rate was 26.7% in the SUI group, 15.8% in the POP group, whereas it was 100% in the control group. The diameters of types I and II fibers decreased significantly with age and menopausal time in the control group. Splitting or fragmentation of fibers with red granules, which are called ragged-red fibers, were found in the SUI group. The diameters of levator ani muscle fibers in the control group were significantly larger than those in the SUI group (p=0.034<0.05). The degenerative change in histology and decrease in relative number of levator ani muscle might be associated with women suffering from SUI.     

Levator avulsion and grading of pelvic floor muscle strength

In a retrospective study investigating the relationship between levator avulsion and clinical grading of levator ani muscle strength, we analyzed the 3D/4D translabial ultrasound and digital assessment data of 1,112 women seen in a tertiary Urogynecological clinic. Levator avulsion was diagnosed whenever the examiner was unable to palpate the insertion of the pubovisceral muscle on the inferior pubic ramus and/or whenever a discontinuity between bone and muscle was detected on ultrasound. For clinical grading of levator muscle strength, we used the modified Oxford grading. Avulsion defects were found in 252 women (23%), and this was associated with a highly significant reduction in the overall Oxford grading (2.07 vs 2.81, P < 0.001). The prevalence of avulsion increased depending on the side differences in the modified Oxford grading: from 16% when there was no difference to 76% when the side difference was 1.5 or higher (P < 0.001). Avulsion of the puborectalis muscle seems to have a marked effect on pelvic floor muscle strength, which may help in diagnosing trauma.     

Fibulin-5 expression is decreased in women with anterior vaginal wall prolapse

The aim of this study was to compare fibulin-5 expression in women with and without anterior vaginal wall prolapse. Vaginal tissues were sampled in a standardized fashion from women with (n = 12) or without (n = 10) anterior vaginal wall prolapse. Quantitative real-time polymerase chain reaction was performed to measure mRNA levels of fibulin-5 (FIB-5). FIB-5 protein expression was assessed by immunohistochemistry. There were no significant differences in demographic data between the two groups. FIB-5 mRNA expression was significantly decreased in women with anterior vaginal wall prolapse compared to women without prolapse [(FIB-5 mean ± SD mRNA expression in relative units) 0.01 ± 0.01 vs. 0.09 ± 0.14, P = 0.04]. Fibulin-5 staining intensity was diminished in women with prolapse compared to women without prolapse [intensity score, median (range), 1 (1–2) vs. 3 (2–3), P = 0.04]. Fibulin-5 expression is decreased in vaginal biopsies from women with prolapse. Changes in fibulin expression may play a role in the development of pelvic organ prolapse.     

女性盆底肌磁共振弥散张量成像价值分析

目的探讨磁共振弥散张量成像(DTI)在女性盆底肌成像应用中的可行性。方法筛选35名无孕育史、无盆底疾病的年轻志愿者(对照组)和35名初产妇(研究组),分别行盆底肌常规磁共振成像(MRI)扫描和DTI扫描,测量肛提肌和肛门括约肌复合体的部分各向异性分数(FA)值,计算其平均值。并使用计算机软件描绘肛提肌和肛门括约肌复合体的三维纤维示踪图。结果对照组35名志愿者肛提肌平均FA值是(0.41±0.02),研究组35名初产妇肛提肌平均FA值是(0.34±0.03),差异有统计学意义(P0.05);对照组肛门括约肌复合体平均FA值为(0.70±0.03),研究组为(0.65±0.03),差异有统计学意义(P0.05)。DTI三维失踪成像可清晰显示初产妇肛提肌、肛门括约肌的肌肉形态改变。结论 DTI可以对女性盆底肌进行量化分析和三维形态学观察,有利于女性盆底肌肉损伤的早期诊断,值得临床推广。     

Comparison of muscle fiber directions between different levator ani muscle subdivisions: in vivo MRI measurements in women

Introduction and hypothesis

This study describes a technique to quantify muscle fascicle directions in the levator ani (LA) and tests the null hypothesis that the in vivo fascicle directions for each LA subdivision subtend the same parasagittal angle relative to a horizontal reference axis.

Methods

Visible muscle fascicle direction in the each of the three LA muscle subdivisions, the pubovisceral (PVM; synonymous with pubococcygeal), puborectal (PRM), and iliococcygeal (ICM) muscles, as well as the external anal sphincter (EAS), were measured on 3-T sagittal MRI images in a convenience sample of 14 healthy women in whom muscle fascicles were visible. Mean ± standard deviation (SD) angle values relative to the horizontal were calculated for each muscle subdivision. Repeated measures ANOVA and post-hoc paired t tests were used to compare muscle groups.

Results

Pubovisceral muscle fiber inclination was 41?±?8.0°, PRM was ?19?±?10.1°, ICM was 33?±?8.8°, and EAS was ?43?±?6.4°. These fascicle directions were statistically different (p?p?Conclusions The null hypothesis that muscle fascicle inclinations are similar in the three subdivisions of the levator ani and the external anal sphincter was rejected. The largest difference in levator subdivision inclination, 60°, was found between the PVM and PRM.     

The quantification of levator muscle resting tone by digital assessment

The biomechanical properties of the puborectalis muscle are likely to be important for pelvic organ support. However, neither elasticity nor its clinical correlate, muscle resting tone, have received much attention to date. We therefore conducted a prospective study to test a newly developed resting tone scale for validity and reproducibility. Ninety-eight patients underwent a physical examination including prolapse staging and palpation of the levator ani. They were also assessed by 4D translabial ultrasound for levator hiatal dimensions and prolapse assessment. Resting tone was negatively associated with anterior and posterior compartment prolapse. An independent test–retest series yielded a weighted kappa of 0.55 (CI 0.44–0.66), implying “moderate” repeatability. Resting tone of the puborectalis muscle can be determined by digital palpation. It is moderately repeatable and associated with pelvic organ prolapse. Palpation of resting tone may be a useful new tool for assessing women with pelvic floor dysfunction.