New insights into the pelvic organ support framework

Objective

It is important to understand the underlying mechanisms of the physiological framework of the pelvic organ support system to develop more effective interventions. Developing more successful interventions for restoration of defects of the pelvic floor will lead to symptomatic improvement of pelvic floor prolapse and stress incontinence disorders. The purpose of the current study was to investigate the physiological framework related to the pelvic organ support system and propose the underlying mechanisms of pelvic organ support based on the anatomical findings.

Study design

Ten female soft embalmed cadavers were dissected after a colorectal hands-on workshop to visualize components of the pelvic organ support system.

Results

The puborectalis attached at the superior pubic ramus above the arcus tendineus fasciae pelvis. The anterior half of the iliococcygeus originated at the level of the arcus tendineus fasciae pelvis but descended from the arcus tendineus fasciae pelvis before it reached the ischial spine. The fibrous visceral sheath of the endopelvic fascia covered both the bladder and the upper vagina and bound these structures together. The levator ani muscle was separated into a horizontal and a vertical part at the medial attachment of the fibrous visceral sheath. A well-circumscribed adipose cushion pillow, in the ischioanal fossa and its anterior recess, supported the horizontal part of the levator ani muscle and pressed the vertical part against the pelvic viscera. Perivascular sheaths and pelvic nerve plexuses were reinforced by condensed endopelvic fascia, they suspended the pelvic organs posterolaterally.

Conclusion

The pelvic organ support framework consists of two mechanical structures: (1) the supporting system of the levator ani muscle, the arcus tendineus fasciae pelvis and the adipose cushion pillow, and (2) the suspension system of the neurovascular structures and the associated endopelvic fascia condensation.     

Funktionelle MRT des Beckenbodens

Purpose. Functional cine MRI of the pelvic floor is a yet another modality in addition to various radiological fluoroscopic techniques. This article describes our own method in view of the recent literatur and provides morphometric reference values. Material and method. We examined 20 nulliparous women (range of age: 25–51 years) with normal findings in the gynecological and urodynamic examination. Functional cine MRI was performed on a 1.5 Tesla equipment after opacification of the vagina and rectum. We used a T2-weighted gradient- echo sequence (Ture-FISP) to determine the position of the reference organs at rest and during straining/defecation. Two different reference lines were used. In addition 29 morphometric and functional parameters were measured, all of them being observer independant. Results. Functional cine MRI was able to show the extent and interaction of the pelvic floor organs in all cases with the reference organs always remaining above the pubococcygeal reference line. The depht of the rectocele was 2 cm. With the exception of the diameter of urogenital hiatus the different parts of the levator ani muscle could not be determined. Discussion. Functional cine MRI using an appropiate organ opacification and slice positioning is an objective, unifying diagnostic approach of the pelvic floor. The reference data given can be of help to distinguish normal from abnormal findings.     

Structural anatomy of the posterior pelvic compartment as it relates to rectocele

OBJECTIVE: This study was undertaken to define posterior compartment structural anatomy relevant to rectocele. STUDY DESIGN: Dissection of 42 fresh and 22 fixed cadavers was supplemented by examination of histologic (n = 3) and macroscopic (n = 5) serial sections. RESULTS: Distal posterior compartment support involves connection of the halves of the perineal membrane (urogenital diaphragm) through the perineal body, preventing downward protrusion of the lower rectum. Above this level the posterior vaginal wall is held in place by sheets of bilateral endopelvic fascia that attach each side of the posterior vaginal wall to the pelvic diaphragm. Most of these fascial fibers attach to the vaginal wall and a few fibers unite in the midline. Pelvic floor closure by the levator ani muscles relieves pressure-induced stress on the midvaginal fascial supports. CONCLUSIONS: Midline perineal membrane union supports the distal posterior compartment and a fascial connection between the pelvic diaphragm and vagina supports the mid vagina. Muscular pelvic floor closure helps to relieve fascial stress.     

Functional interactions between the fossa ischioanalis, levator ani and gluteus maximus muscles of the female pelvic floor: a prospective study in nulliparous women

Purpose

We evaluated the role of the fossa ischioanalis (FI) in functional relations between the levator ani (LA) and gluteus maximus muscles (GM) in healthy female volunteers.

Methods

Twenty-three nulliparae were examined. Electromyogramms of LA and GM were simultaneously recorded during voluntary contraction of the pelvic floor muscles (PFM) and at rest in six body positions. The surface areas of LA (LAA), FI (FIA) and GM (GMA) were evaluated using MRI.

Results

Simultaneous LA and GM contractions were electromyographically observed irrespectively of body position in 97.2?%. MRI revealed synchronous movement of all structures: while LAA (?7.4?%) reduced, GMA increased (+6.8?%), FIA changed significantly (+3.4?%).

Conclusions

The LA, FI and GM are morphologically and functionally connected. We recommend considering these structures as the ‘LFG-Complex’, emphasising the importance of this unit for functional integration of the pelvic floor. The findings of this study may contribute to understanding of urinary continence mechanism and disorders after pelvic floor surgery and obstetrical trauma.     

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.     

Visibility of pelvic organ support system structures in magnetic resonance images without an endovaginal coil

OBJECTIVE: The aim of this study was to determine which elements of the pelvic organ support system are visible on magnetic resonance imaging performed without an endovaginal coil. STUDY DESIGN: Proton density-weighted pelvic magnetic resonance images were obtained for 20 healthy continent nulliparous women with a mean (+/-SD) age of 30.1 +/- 5.1 years (range, 22-42 years). Standardized analyses of transverse, coronal, and sagittal key images were carried out to describe pelvic organ support system anatomy. RESULTS: Details of both the muscular and fascial supports were clearly seen. The endopelvic fascia was visible on transverse images and could be seen to laterally attach the proximal vagina to the pelvic wall. Its appearance was consistent with its composition of a network of connective tissue, vessels, and nerves. The upward, lateral, and dorsal direction of its most cephalic suspending fibers was visible on both transverse and coronal images. The different nature of the uterosacral ligament relative to the cardinal ligaments was also demonstrated in transverse images. The endopelvic fascia's attachment to the pelvic walls was visible in the midvagina. The 3 parts of the levator ani muscle were likewise visible-the pubococcygeus, puborectalis, and iliococcygeus. Fusion of the levator ani muscle and the vagina at the level of the middle urethra could be recognized on transverse and coronal images. CONCLUSION: Magnetic resonance imaging depicted structures of the pelvic organ supports, including the endopelvic fascia and pelvic floor muscles, without the need for an endovaginal coil.     

Koloproktologische Erkrankungen des Beckenbodens

Purpose. The aim of this review is to describe the most frequent and important coloproctologic pelvic floor disorders. Relevant diagnostic procedures of the pelvic floor will be presented. Material and methods. A host of diagnoses and symptoms such as the descending perineum syndrome, rectocele, cystocele, enterocele, uterine and vaginal descensus, anal and rectal prolaps, outlet obstruction, anismus, inertia recti and intussusception are included under the heading “pelvic floor disorders”. Although symptoms are often varied, problems concerning urinary and/or faecal continence commonly lead to primary consultation of a physician. Results. Quite often, apparently divergent symptoms such as constipation and incontinence are simultaneously mentioned. A clear gender disposition is observed with female patients inflicted nine-fold in comparison to male patients. The primary consultant may belong to a variety of specialities such as urology, proctology, gynaecology or dermatology, depending upon the predominant symptom. A feeling of trust is essential for the treatment of a disorder involving highly intimate regions of the body. Discussion. An exact medical history and standardized proctologic evaluation consisting of inspection, palpation, rectoscopy and proctoscopy may be augmented by investigations such as anorectal manometry or endosonography. Conventional defecography has been replaced more and more by dynamic MRI of the pelvic floor in specialized institutions, enabling additional gynaecologic and urologic investigations avoiding ionizing radiation.     

妊娠晚期压力性尿失禁患者盆底三维超声的观察

目的 应用经会阴盆底三维超声观察妊娠晚期压力性尿失禁(SUI)患者的盆隔裂孔形态结构特征.方法 选取2008年10月至2009年3月在上海交通大学附属第六人民医院妇产科定期行产前检查的单胎妊娠、孕周为37-41周的初产孕妇145例(妊娠晚期组),其中有SUI症状者38例(SUI孕妇),无SUI症状者107例(非SUI孕妇);同期选择50例未孕、未产的健康妇女作为对照组.两组妇女均行经会阴盆底三维超声检查,观察并比较各组妇女的盆隔裂孔形态结构及特征,测量各组妇女在静息、Vasalva动作和缩肛动作3种状态下的盆隔裂孔大小、耻骨直肠肌厚度及耻骨直肠肌角度.结果 妊娠晚期组孕妇盆底结缔组织结构疏松,部分患者出现肛提肌撕脱的图像;对照组妇女盆隔裂孔形态呈菱形,结构完整紧凑,盆隔裂孔内尿道、阴道、直肠从前至后呈直线依次排列,盆隔裂孔两侧耻骨直肠肌对称且连续性好.在静息、Valsalva动作及缩肛动作3种状态下,妊娠晚期组孕妇的盆隔裂孔面积分别为(15.2±1.9)、(16.4±2.0)和(13.6±1.9)cm2,耻骨直肠肌厚度分别为(0.72±0.11)、(0.68±0.14)和(0.77±0.11)cm,耻骨直肠肌角度分别为(60±8)°、(57±10)°和(64±14)°,均明显大于对照组妇女[分别为(11.2±2.6)、(14.5±4.5)和(9.2±2.6)cm2,(0.66±0.10)、(0.67±0.14)和(0.71±0.14)cm,(50±4)°、(51±5)°和(46±5)°;P<0.05].妊娠晚期组SUI孕妇在各种状态下的盆隔裂孔前后径、周径及面积均明显大于非SUI孕妇(P<0.05);在缩肛动作时,除SUI孕妇的耻骨直肠肌厚度明显小于非SUI孕妇(P<0.05)外,其余状态下的耻骨直肠肌厚度及各种状态下的耻骨直肠肌角度两者间比较,差异均无统计学意义(P>0.05).结论 妊娠晚期女性盆底解剖结构发生重塑,与未育妇女比较,其盆底结缔组织结构疏松、盆隔裂孔增大.妊娠晚期SUI妇女比非SUI妇女盆隔裂孔增大,缩肛动作时肛提肌厚度减小.     

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.     

Anatomic variations in the levator ani muscle,endopelvic fascia,and urethra in nulliparas evaluated by magnetic resonance imaging

OBJECTIVE: The purpose of this study was to develop a system to quantify interindividual variation in the appearance of continence system structures in normal continent nulliparous women. STUDY DESIGN: Magnetic resonance imaging (1.5 T) was performed in 20 healthy continent nulliparous women (mean age, 30.1 +/- 5.1 years) with normal pelvic organ support and urodynamics. Morphometric measurements of the levator ani muscle, endopelvic fascia, and urethra were performed. RESULTS: The ratio of the maximum-to-minimum measured values shows that 2- to 3-fold differences occur in distance, area, or volume measures of continence system morphologic features. The mean urogenital hiatus area was 15.2 +/- 2.9 cm(2) in women without a visible connection of the levator ani muscle to the pubic bone (4/20 women) and 12.3 +/- 2.4 cm(2) in women with an levator ani muscle-pubic bone connection (16/20 women, P =.05). CONCLUSION: Considerable variation that was not attributable to limitations of the measuring technique that was used occurs in the size and configuration of the urethral support structures in nulliparous asymptomatic women.     

Neurourology and pelvic floor dysfunction

The levator ani muscles, endopelvic fascia, and muscular structures of the sphincter and the pelvic floor musculature (PFM) comprise one system. The physiological organization of Onuf's nuclei and of levator ani motorneurons as well as the reflex control of the tonic activity, that is essential for the generation of maintained force in slow-twitch muscle fibers, is an important part of the normal function of this system. In the human the motor cortex is crucial in voluntary motor control also of PFM, but other areas in the brain are involved in activities of the PFM related to emotional behavior e.g. micturition. Coordination between the urinary bladder, the urethra and the PFM is mediated by multiple reflex pathways organized in the brain and spinal cord. Some reflexes promote urine storage, whereas others facilitate voiding. It is also possible that individual reflexes might be linked together in a serial manner to create complex feedback mechanisms. The control of striated muscle in neurological lesions of the lower urinary tract is an active area of research and is producing results that are relevant to the problems of the neurogenic and idiopathic overactive bladder, whether these are caused by central nervous system or peripheral nerve lesions.     

How common is ballooning? Hiatal area on 3D transperineal ultrasound in urogynecological patients and its association with lower urinary tract symptoms

Introduction

Pelvic floor ultrasound plays a major role in urogynecologic diagnostics. Using 3D ultrasound we can identify integrity of levator ani and measure hiatal area in the axial plane. The main goal of our study was to measure hiatal area on Valsalva in a cohort of urogynecological patients. Furthermore, we aimed to correlate hiatal area with urogynecological symptoms, levator integrity and evaluate cut-off values for pelvic organ prolapse.

Materials and methods

In a retrospective analysis, we included 246 patients seen for urogynecological problems in our tertiary urogynecological unit. After a standardized interview and physical examination, a 3D pelvic floor ultrasound was performed. According to the cardinal urogynecological symptoms and signs, patients were categorized into three groups: pelvic organ prolapse, stress urinary incontinence and overactive bladder symptoms.

Results

Median age of our study population was 66 (range 29–94) years, median parity was 2.1 (range 0–9) with 17 (6.9 %) nulliparous women. Symptoms of overactive bladder in 71.1 % were most common, followed by 54.5 % symptoms of stress incontinence and 32.1 % symptoms of prolapse. On examination 49.2 % showed signs of prolapse. Levator avulsions on 3D ultrasound were detected in 20.7 %. Hiatal area was normally distributed with a median of 28.7 cm² (range 10.4–50.0 cm²). Patients with levator avulsion had a significantly larger hiatal area (p < 0.001). Also patients with signs of prolapse had a significantly larger hiatal area (p < 0.001). There was no correlation between hiatal area and symptoms of overactive bladder (p = 0.374). Although not reaching statistical significance there was evidence of a smaller hiatal area for patients with stress incontinence (p = 0.016). In our cohort there were 33.7 % (83) women without ballooning, 27.2 % (67) showed mild, 18.3 % (45) moderate, 12.3 % (30) marked and 8.5 % (21) severe ballooning. The ROC curve analysis for hiatal area on patients with prolapse yielded an AUC of 0.755 [95 % CI (0.696–0.814)]. Using the Youden-Index we obtained 27.53 cm² as a cut-off with a sensitivity of 0.70 and a specificity of 0.69.

Discussion

Hiatal area is a new repeatable diagnostic parameter. Its clinical application could improve our understanding of the pathophysiology of pelvic organ prolapse as a form of hiatal hernia.

     

Operative Therapie des Descensus

Surgery for pelvic organ prolapse is one of the most frequent gynecologic procedures. Pelvic organ prolapse is caused by three factors: high intra-abdominal pressure, connective tissue disorders, and dysfunction of the pelvic floor musculature. There are three anatomic compartments: anterior (anterior vaginal wall, bladder, and urethra), central (uterus, cervix, the apex of the vagina, and cul-de-sac), and posterior wall compartments (posterior vaginal wall and rectum). Vaginal support is provided by the perineal membrane, the arcus tendineus fascia pelvis, the cardinal-uterosacral ligament complex, and the crura of the levator ani muscles. These factors have to be taken into account when planning reconstructive surgery. Reconstruction of defects in the anterior vaginal wall consists of abdominal and vaginal paravaginal repair and anterior colporrhaphy. Abdominal sacral colpoperineopexy, sacrospinous vault suspension, and obliterative surgery are used for repair of defects in the central compartment, while defects in the posterior compartment are reconstructed by posterior colporrhaphy, perineorrhaphy, and culdoplasty (Halban, Moschcowitz and McCall).     

Visual pain mapping in endometriosis

Purpose

To construct pain maps in order to describe the distribution of pelvic pain in a group of endometriosis patients and endometriosis-free patients, to assess the feasibility of this method.

Methods

A total of 159 patients with pelvic pain who were scheduled for diagnostic laparoscopy.

Results

A total of 117 patients with and 42 patients without endometriosis were included. The pain distribution between these two patient groups appeared to differ in some peripheral anatomical structures. In the endometriosis patients, the pain was most frequently located in the rectouterine pouch.

Conclusions

In endometriosis patients, pain mapping to assess preoperative pain sensations relative to the anatomic location of endometriotic lesions is feasible. The pain provoked by vaginal examination is frequently perceived as median relative to the actual anatomic location of the endometriotic lesions. Several anatomic and neurophysiological factors may explain this phenomenon.     

超声评价肛提肌及其裂孔在女性盆腔器官脱垂中的进展

肛提肌及其裂孔是女性盆腔器官支持结构的重要部分，对女性盆腔器官起支撑作用。女性盆腔器官脱垂（pelvic organ prolapse，POP）是一种临床常见的盆底功能障碍性疾病，严重影响女性的心理和生理健康。POP病因复杂，与肛提肌损伤及肛提肌裂孔面积增大密切相关。因超声具有价廉、可重复性高、无辐射、患者易接受等优点，所以目前在女性盆腔器官检查中，经会阴超声技术得到越来越广泛的应用，应用经会阴超声技术评价肛提肌及其裂孔等盆腔结构的水平也逐渐提高。现主要从肛提肌及其裂孔的解剖结构、与POP的关系及经会阴超声技术在女性肛提肌及其裂孔检查中的应用进展进行综述。     

MRI morphology of the levator ani muscle, endopelvic fascia, and urethra in women with stress urinary incontinence

OBJECTIVE: To evaluate pathomorphologic changes of the levator ani muscle, endopelvic fascia, and urethra in women with stress urinary incontinence (SUI) by MRI. STUDY DESIGN: Fifty-four women with SUI were examined by MRI (1.5T): body phased-array coil, axial and coronal proton-density-weighted sequences. RESULTS: The urethral sphincter muscle showed a reduced thickness of its posterior portion (37%), an omega shape (13%) or higher signal intensity (50%); its abnormal configuration was associated with an increased signal intensity in 70% (p=0.001). The levator ani muscle comprised an unilateral loss of substance in 30%, a higher signal intensity in 28%, and altered origin in 19%. Central defects of the endopelvic fascia were present in 39% (n=21), lateral defects in 46%. There was a significant association between loss of the symphyseal concavity of the anterior vaginal wall and lateral fascial defects (p=0.001) and levator ani changes (p=0.016). CONCLUSION: MRI yields findings supporting current theories on the pathogenesis of SUI.     

Transperineal ultrasound imaging of the pelvic floor muscles in women with pelvic floor dysfunction symptoms: A cross-sectional study

Objective

Transperineal ultrasound (TPUS) assessment of the pelvic floor muscle (morphological and dynamic function) in women with pelvic floor dysfunction symptoms.

Magnetic resonance imaging of normal levator ani anatomy and function

OBJECTIVE: To evaluate the anatomy and function of the levator ani in normal women by dynamic magnetic resonance imaging. METHODS: Twelve asymptomatic, nulliparous, premenopausal women with no previous pelvic surgery underwent a dynamic magnetic resonance imaging scan of their pelvis. The origin, orientation, thickness, and function of the two components of the levator ani were studied. RESULTS: The ileococcygeus is a thin muscle with an upward convexity. It slopes forward and medially. It is of variable thickness (mean thickness 2.9 mm, standard deviation 0.8 mm). There are apparent gaps in the muscle diaphragm and at its site of origin from the obturator fascia. The puborectalis is a thicker muscle. It is shaped like a belt encasing the pelvic organs. It is taller posteriorly than anteriorly. It is not attached to the bladder neck, but the midurethra and lower urethra lie in close proximity to it. The puborectalis moves dorsoventrally, whereas the ileococcygeus moves craniocaudally. CONCLUSION: The levator ani is not a single muscle but has two functional components that vary in thickness, origin, and function. The ileococcygeus has a mainly supportive function, whereas the puborectalis has a sphincteric function. Gaps in the diaphragmatic portion of the ileococcygeus are a normal finding. Individual components of the levator ani may be prone to different types of childbirth trauma and should therefore be assessed separately when planning rehabilitation.     

Morphologische und funktionelle Beckenbodenstörungen aus gynäkologischer Sicht

Purpose. The following article is designed to describe the diagnostics and therapy of morphological and functional defects in the female pelvic floor from a gynaecological point of view. Assessment of the relevance of imaging techniques is of particular importance. Material and methods. The main diagnoses are: in the anterior compartment of the pelvic floor, urethro- cystocele; in the middle compartment, uterine descent/prolapse or enterocele; and in the posterior compartment, rectocele. They are clinically examined by means of a standardised gynaecological examination and classified according to recommendations from the International Continence Society ( ICS) in order to obtain internationally comparable results. Comparison with the usual imaging procedures (introitus- and perineal sonography, colpocystorectography/defaecography and functional MRI of the pelvic floor) are described and critically discussed.The most important functions affected are storage and evacuation of the bladder and rectum. They are clinically examined by means of stress test and pad-weigh test and technically examined using urodynamics, sphincter-rectum manometry and EMG. Imaging procedures play a very important role here also. Results. Comparison of clinical and imaging procedures shows that the two methods are at present limited in comparability, mainly because different points of reference are used to quantify results. The line of the hymen is a good point of reference in grading descent and prolapse. During the gynaecological examination, the three compartments can readily be assessed separately by use of split gynaecological specula.This is presently practically impossible using imaging procedures. The pubococcygeal line is generally used to describe findings. Discussion. Scientific progress can only be expected if and when these problems are studied as a whole. Imaging procedures have securely established themselves in the diagnostic repertoire, but do not as yet influence therapy decisions. The indication and choice of operation depend on the severity of the patient's symptoms the clinical findings and the results of urodynamic investigations. Dynamic CTG is presently the most reliable method of showing all three compartments at rest and during function. It has largely replaced colpocystorectography. Sonography is found to be varied in ist results at the moment.