经会阴三维超声评价女性盆底肌肉形态及功能

目的应用经会阴三维超声测量年轻未育女性的耻骨内脏肌宽度及肛提肌裂孔大小,探讨女性盆底的形态及功能。方法对100例18～31岁年轻未育女性在安静状态下、最大瓦氏动作及提肛动作时采集盆底经会阴三维超声图像,脱机分析,分别测量肛提肌裂孔的前后径、左右径、面积及耻骨内脏肌的宽度,并通过计算组内相关系数评估观察者之间的一致性。结果肛提肌裂孔呈菱形,两侧耻骨内脏肌基本对称,呈带状高回声,在肛直肠角后方形成U型襻。安静状态下肛提肌裂孔面积(11.15±1.70)cm2,最大瓦氏动作时增大至(14.35±2.43)cm2,而提肛动作时缩小至(9.20±1.46)cm2。两名观察者测量安静状态及提肛动作时的肛提肌裂孔大小及不同状态下耻骨内脏肌宽度一致性较好,但在最大瓦氏动作时测量肛提肌裂孔大小的一致性稍差。结论经会阴三维超声能直观观察盆底耻骨内脏肌的宽度及肛提肌裂孔的动态变化。     

Impact of episiotomy on the urogenital hiatus using transperineal ultrasound

Aims

To analyze whether episiotomy affects the urogenital hiatal area and the difference in the hiatus at rest and during contraction, as an indirect measurement of the contractile capacity of the levator ani muscle.

Methods

We performed an observational, comparative, retrospective study of primiparous women who had normal vaginal deliveries. The urogenital hiatal area was compared in women with and without episiotomy. All women underwent transperineal ultrasound scanning after delivery, and all the images were analyzed offline by the principal investigator who was blinded to all clinical data. The urogenital hiatal area was measured at rest and during both Valsalva and contraction manoeuvres. The difference in the hiatus at rest and during contraction was also calculated. These scanning variables were compared between the study groups.

Results

In total, 194 women were analysed (101 with, and 93 without, episiotomy). There were no statistically significant differences between the groups regarding the area of the hiatus at rest (P = 0.583), on Valsalva (P = 0.158), and on contraction (P = 0.468), or in the difference in the hiatus at rest and during contraction (P = 0.095).

Conclusions

In normal vaginal delivery, neither the area of the urogenital hiatus nor its difference at rest and during contraction, as measured by ultrasound, were modified by performing an episiotomy.     

Can levator avulsion be repaired surgically? A prospective surgical pilot study

Introduction and hypothesis

Avulsion of the puborectalis muscle from its bony insertion is common in women presenting with prolapse. We present a simple vaginal technique for levator reconstruction.

Methods

This is a prospective surgical pilot study comprising 17 patients enrolled to undergo levator repair in the context of prolapse surgery. This was performed through a lateral colpotomy at the level of the hymen using a mesh patch for reinforcement.

Results

We performed 20 levator repairs in 17 women (three bilateral). There were no intraoperative complications. Recovery was unremarkable in all cases. Results are given for a mean follow-up of 1.3 years. Most (13/17, 76 %) women were satisfied with the outcome. Six patients complained of symptoms of recurrent prolapse, three of de novo dyspareunia, and four of pain related to the repair site on palpation. There were two mesh erosions, one of which healed with oestrogen treatment. Prolapse recurrence beyond the hymen was observed in five patients. The mean hiatal area on Valsalva was reduced from 36.84 cm² to 30.71 cm² (P?=?0.001).

Conclusions

Direct surgical repair of a levator avulsion is feasible at the time of prolapse surgery. However, its effect on prolapse recurrence and hiatal dimensions is relatively disappointing, suggesting that there often is microscopic trauma and functional muscle impairment in addition to the avulsion.     

Pelvic floor muscle variables and levator hiatus dimensions: a 3/4D transperineal ultrasound cross-sectional study on 300 nulliparous pregnant women

Introduction and hypothesis

The aims of the present study were to investigate the correlation among vaginal resting pressure and pelvic floor muscle (PFM) strength and endurance, and the correlation between the same variables and levator hiatus (LH) dimensions in nulliparous pregnant women.

Methods

This was a cross-sectional study of 300 nulliparous pregnant women, mean age 28.7 years (SD 4.3) and pre-pregnancy BMI 23.9 kg/m² (SD 3.9), assessed at mean gestational week 20.8 (±1.4). Vaginal resting pressure and PFM strength and endurance were measured using a high precision pressure transducer connected to a vaginal balloon. LH dimensions (transverse and anterior–posterior diameters_ and LH area were assessed using 3/4D transperineal ultrasound in the axial plane of minimal hiatal dimensions using render mode. The Pearson correlation was used to analyze correlations among vaginal resting pressure and PFM strength and endurance, and between PFM variables and LH dimensions. Level of significance was set at 0.05.

Results

Pelvic floor muscle strength and vaginal resting pressure were significantly, but weakly correlated (r?=?0.198, p?r?=?0.929, p?r?=??0.451, p?r?=??0.012, p?=?0.84) nor between muscle endurance and LH area at rest (r?=??0.014, p?=?0.81). A strong PFM contraction correlated moderately with reduction of the LH area (r?=??0.367, p?Conclusions Pelvic floor muscle strength and endurance are strongly correlated, butdo not correlate with a smaller LH area at rest.     

Levator function and voluntary augmentation of maximum urethral closure pressure

Introduction and hypothesis

The aim of the study was to test whether women with symptoms of pelvic floor dysfunction can augment maximum urethral closure pressure (MUCP) with a pelvic floor muscle contraction (PFMC) and whether augmentation is associated with structure and function of the levator ani muscle.

Methods

Between January and December 2009, 300 women attended a tertiary referral service for multichannel urodynamic testing and 4D pelvic floor ultrasound. The MUCP was obtained with a perfused fluid-filled catheter. Augmented MUCPs were obtained during directed PFMC. Levator contraction strength was assessed digitally, using the Modified Oxford Grading (MOS). Levator integrity was determined using tomographic ultrasound, and we also measured dimensions of the levator hiatus at rest and on PFMC, blinded against all clinical data.

Results

The MUCP was measured at a mean of 36?cm H₂O (range 2–111). Augmented MUCP was 42?cm H₂O on average (4–125). Of those who attempted augmentation (n?=?275), 80 produced a reduction in MUCP and were excluded, leaving 195. There was a significant correlation between MOS and augmentation (r?=?0.24, P?=?0.001). Women with an intact levator muscle were able to augment more effectively (P?=?0.038).

Conclusions

Urethral closure pressure can be augmented voluntarily by symptomatic patients, on average by about 20?%. The degree of augmentation is positively associated with levator contractility as measured by digital palpation and negatively with levator avulsion.     

Mobility of the perineal body and anorectal junction before and after childbirth

Introduction and hypothesis

The perineal body is an important structure which is often injured during labor. It is believed to play a role in pelvic organ support. Vaginal delivery is likely to increase the mobility of perineal body and anorectal junction. The aim of this study was to determine changes in the mobility of perineal body and anorectal junction before and after delivery using pelvic floor ultrasound.

Methods

Two hundred nulliparous women were enrolled and underwent pelvic floor ultrasound at 36–38?weeks gestation and 3–6?months postpartum. Levator hiatal dimensions and mobility of the perineal body and anorectal junction were measured in volume ultrasound datasets using postprocessing software, blinded against all clinical data, before and after childbirth.

Results

Ultrasound measures of mobility of perineal body and anorectal junction were shown to be reproducible (ICC 0.74 and 0.76). After delivery, mobility of both structures had increased significantly (both P?P?=?0.015). A significant correlation was found between these outcome measures and levator hiatal area on Valsalva, both before and after delivery. Perineal trauma, episiotomy, epidural block, augmentation of labor, and length of first and second stage of labor were not associated with postpartum mobility of perineal body and anorectal junction.

Conclusions

Vaginal delivery increases the mobility of perineal body and anorectal junction. Perineal mobility may be partly determined by distensibility of the levator hiatus.     

The effect of pregnancy on hiatal dimensions and urethral mobility: an observational study

Introduction and hypothesis

Childbirth is an established risk factor of pelvic floor dysfunction. The role of pregnancy is, however, not fully understood. This study was designed to evaluate the potential effect of pregnancy on pelvic floor function. The hypothesis was: Pregnancy has no effect on urethral mobility and levator hiatal dimensions.

Methods

This was a reanalysis of the translabial 3D/4D ultrasound volume data of 688 nulliparous pregnant women seen in the late 3rd trimester and again 4?months postpartum and that of 74 nulliparous, nonpregnant volunteers in previously reported studies. Hiatal dimensions and urethral mobility were determined as the outcome parameters. Multivariate regression analysis was performed after adjusting for age and BMI between the pregnant and nonpregnant cohorts.

Results

Comparison of 3rd trimester data of the pregnant cohort with that of the nonpregnant nulliparae revealed a 27?% and 41?% increase in hiatal area at rest and on Valsalva and an increase in segmental urethral mobility by 64?% to 91?% in late pregnancy. About 70?% of this difference in hiatal dimensions, but virtually identical differences in urethral mobility, were observed when comparing nonpregnant controls with women 4?months after prelabour or 1st stage caesarean section.

Conclusion

Both hiatal dimensions and urethral mobility were markedly higher in women in late pregnancy and at 4?months after prelabour/1st stage caesarean section compared to nulliparous controls. The hormonal and mechanical changes of pregnancy may have an irreversible effect on the pelvic floor.     

Prospective evaluation of change in levator hiatus dimensions using 3D endovaginal ultrasound before and 1 year after treatment for female pelvic organ prolapse

Introduction and hypothesis

We aimed to determine the change in levator hiatal (LH) dimensions using 3D high-frequency endovaginal ultrasound (EVUS) before and 1 year after treatment for pelvic organ prolapse (POP).

Methods

Women with prolapse attending the urogynecology clinic between July and October 2009 were recruited. EVUS was performed using multifrequency (9–16 MHz) 360° rotational probe with a built-in 3D automatic acquisition system (Type 2052, ProFocus Ultra view, B-K Medical, Herlev, Denmark). The levator hiatal dimensions that were measured comprised anteroposterior (AP), left-to-right width, and area. Patients were followed up at 1 year, when EVUS was repeated.

Results

Eighty-nine women had symptomatic prolapse. Of these, 43 opted for surgery and 46 for nonsurgical treatment. Levator hiatal dimensions decreased in AP, width, and area at 12 months after surgery compared with baseline (p <0.05). However, there was no change in any of the dimensions after nonsurgical treatment.

Conclusion

In contrast to conservative management, there is a significant decrease in levator hiatal dimensions 12 months following surgery for POP.     

Do women notice the impact of childbirth-related levator trauma on pelvic floor and sexual function? Results of an observational ultrasound study

Introduction and hypothesis

The levator ani is thought to play an important role in sexual function; however, to date little literature has been published on the impact of delivery–related levator trauma on female sexual function. We hypothesised that delivery-related levator trauma has a negative impact on women’s reports of pelvic floor and sexual function postpartum.

Methods

In 294 primigravid women with a singleton pregnancy, four-dimensional (4D) translabial ultrasound imaging was used to assess delivery–related levator avulsion and levator hiatal over-distension, and postpartum pelvic floor and sexual function was assessed by an in-house validated questionnaire. Associations between questionnaire responses and levator avulsion and hiatal over-distension were investigated using standard linear modelling methods.

Results

Levator avulsion was diagnosed in 14 % of women (42 out of 292; 25 unilateral, 17 bilateral) and was found to be significantly associated with lower scores for the pelvic floor integrity and function domain of the questionnaire (P?p?=?0.013). Avulsion was not associated with any of the other domains of sexual function and levator hiatal over-distension was not associated with scores for any of the questionnaire domains.

Conclusions

The effect of levator avulsion on pelvic floor and sexual function an average of 5.2 months after childbirth seems to be limited to a perception of increased vaginal and pelvic floor muscle laxity, and reduced pelvic floor muscle efficiency. The impact of levator hiatal over-distension on postpartum pelvic floor and sexual function appears to be negligible.     

Association between pelvic floor muscle trauma and pelvic organ prolapse 20 years after delivery

Introduction and hypothesis

It is known that pelvic floor muscle trauma (PFMT) after vaginal delivery is associated with pelvic organ prolapse (POP) symptoms (sPOP) and signs (POP-Q ≥2) in patient populations. Our aims were to establish the prevalence and investigate a possible association between PFMT and sPOP and POP-Q ≥2 in healthy women 20 years after their first delivery.

Methods

During 2013 and 2014 we conducted a cross-sectional study among 847 women who delivered their first child between 1990 and 1997. Women responded to a postal questionnaire and were offered a clinical examination including prolapse grading and pelvic floor ultrasonography. The main outcome measures were sPOP, POP-Q ≥2 and PFMT, defined by levator avulsion or a levator hiatal area on Valsalva manoeuvre of >40 cm² on ultrasonography.

Results

Of the 847 eligible women, 608 (72 %) were examined. Data on POP symptoms, POP-Q stage, levator avulsion and levator hiatal area were available in 598, 608, 606 and 554 women, respectively, and of these 75 (13 %) had sPOP, 275 (45 %) had POP-Q ≥2, 113 (19 %) had levator avulsion and 164 (30 %) had a levator hiatal area >40 cm². Levator avulsion was associated with POP-Q ≥2 with an odds ratio (OR) of 9.91 and a 95 % confidence interval (CI) of 5.73 – 17.13, and with sPOP (OR 2.28, 95 % CI 1.34 – 3.91). Levator hiatal area >40 cm² was associated with POP-Q ≥2 (OR 6.98, 95 % CI 4.54, – 10.74) and sPOP (OR 3.28, 95 % CI 1.96 – 5.50).

Conclusion

Many healthy women selected from the general population have symptoms and signs of POP 20 years after their first delivery, and PFMT is associated with POP-Q ≥2 and sPOP.

     

Effectiveness of adding voluntary pelvic floor muscle contraction to a Pilates exercise program: an assessor-masked randomized controlled trial

Introduction and hypothesis

The purpose of this study was to evaluate the effectiveness of adding voluntary pelvic floor muscle contraction (PFMC) to a Pilates exercise program in sedentary nulliparous women.

Methods

Fifty-seven healthy nulliparous and physically inactive women were randomized to a Pilates exercise program (PEP) with or without PFMC. Forty-eight women concluded this study (24 participants for each group). Each woman was evaluated before and after the PEP, by a physiotherapist and an urogynecologist (UG). Neither of the professionals was revealed to them. This physiotherapist measured their pelvic floor muscle strength by using both a perineometer (Peritron) and vaginal palpation (Oxford Scale). The UG, who performed 3D perineal ultrasound examinations, collected their data and evaluated the results for pubovisceral muscle thickness and the levator hiatus area (LA). Both professionals were blinded to the group allocation. The protocol for both groups consisted of 24 bi-weekly 1-h individual sessions of Pilates exercises, developed by another physiotherapist who specializes in PFM rehabilitation and the Pilates technique.

Results

The PEP+ PFMC group showed significantly greater strength improvements than the PEP group when comparing the Oxford scale, vaginal pressure and pubovisceral muscle thickness during contraction measurements at baseline and post-treatment.

Conclusions

Our findings suggest that adding a voluntary PFMC to a Pilates exercise program is more effective than Pilates alone in improving PFM strength in sedentary nulliparous women.

     

Interethnic variation in pelvic floor morphology in women with symptomatic pelvic organ prolapse

Introduction and hypothesis

There is a lack of epidemiological studies evaluating female pelvic organ prolapse in developing countries. Current studies have largely focused on women of white ethnicity. This study was designed to determine interethnic variation in pelvic floor functional anatomy, namely, levator hiatal distensibility and pelvic organ descent, in women with symptomatic pelvic organ prolapse in a multi-ethnic South African population.

Methods

This prospective observational study included 258 consecutive women referred for pelvic organ prolapse assessment and management at a tertiary urogynaecological clinic. After a detailed history and clinical examination, including POPQ assessment, patients underwent a 4D transperineal ultrasound. Offline analysis was performed using 4D View software. Main outcome measures included levator muscle distensibility, pelvic organ descent, and levator ani defects (avulsion).

Results

Mean age was 60.6 (range, 25–91) years, mean BMI 29.83 (range, 18–53). Points Ba and C were lower and the genital hiatus more distensible in black women (all p < 0.05). They were found to have greater hiatal area (p = 0.017 at rest, p = 0.006 on Valsalva) compared with South Asians and whites and showed greater pelvic organ mobility (all p < 0.05) than Caucasians on ultrasound. Levator defects were found in 32.2% (n = 83) of patients and most were bilateral (48.2%, n = 40), with significant interethnic differences (p = 0.014).

Conclusion

There was significant variation in clinical prolapse stage, levator distensibility, and pelvic organ descent in this racially diverse population presenting with pelvic organ prolapse, with South Asians having a lower avulsion rate than the other two ethnic groups (p = 0.014).

     

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.

     

The assessment of levator trauma: a comparison between palpation and 4D pelvic floor ultrasound

AIMS: Major morphological abnormalities of the pubovisceral muscle are observed in 10-20% of women symptomatic of pelvic floor disorders. Such defects arise in childbirth and are associated with prolapse. While they are clearly evident on 3D ultrasound and MR imaging, such defects can be difficult to detect clinically. We intended to compare findings on palpation with the results of ultrasound imaging. MATERIAL AND METHODS: Fifty-five women were recruited in a prospective observational study and assessed by interview, vaginal examination by a trained pelvic floor physiotherapist, and 3D/4D pelvic floor ultrasound. The vaginal examination involved digital assessment of muscle strength (modified Oxford grading) and morphological abnormalities. The ultrasound examination involved acquisition of volume datasets taken at rest, on Valsalva and pelvic floor muscle contraction. Assessments were undertaken supine and after voiding. Ultrasound operator and physiotherapist were blind to each other's findings. RESULTS: A comparison of 3D ultrasound and palpation was possible in 54 cases. Average Oxford grading was weakly associated with reduction in hiatal dimensions on contraction (r = -0.32, P = 0.024). A marked increase in hiatal dimensions detected on palpation was associated with increased hiatal area on Valsalva (P = 0.027). Defects were observed in 7/54 (13%) on ultrasound and in 10/55 (18%) on palpation. There was poor agreement between the methods, with only two defects picked up equally by both methods. CONCLUSIONS: Palpation of the pubovisceral muscle correlates poorly with 3D/4D pelvic floor ultrasound imaging for the assessment of muscular defects.     

Impact of levator trauma on pelvic floor muscle function

Introduction and hypothesis

Levator trauma is common after vaginal delivery, either as macrotrauma, i.e., levator avulsion, or microtrauma, i.e., irreversible overdistension of the levator hiatus. The effect of microtrauma on muscle function is unknown. We tested the hypothesis that levator trauma is associated with reduced contractile function of the levator ani.

Methods

Pregnant nulliparous women were recruited and seen before and after childbirth. All underwent an interview, a clinical examination including pelvic floor muscle (PFM) assessment using the Modified Oxford scale (MOS) [as an optional component] and translabial ultrasound. Sonographic and clinical parameters of PFM function were assessed before and after childbirth.

Results

Out of 560 women, 446 returned at a median of 5 months after childbirth and 433 were suitable for analysis. There was a significant reduction in all measures of PFM function except for MOS. Change in MOS was associated with delivery mode [analysis of variance (ANOVA) P?=?0.006). Forty-seven (15 %) vaginally parous women were diagnosed with levator avulsion, which was associated with a reduction in PFM contractility on sonographic parameters and MOS. However, only clinical assessment reached statistical significance. Sixty-five of 312 (21 %) women were diagnosed with microtrauma. We found no evidence of impairment in PFM contractility on ultrasound, but there was a statistically significant reduction in MOS.

Conclusions

Both levator avulsion (macrotrauma) and irreversible overdistension (microtrauma) are associated with reduced contractile function. This effect is more easily detected by palpation than by sonographic indices of levator function.     

Calculation of membrane tension in selected sections of the pelvic floor

Introduction and hypothesis

A mathematical model to estimate membrane tensions (Mt) at the urogenital hiatus and midpelvis in patients with and without prolapse is proposed. For that purpose the complex structures of the pelvic floor were simplified and, based on assumptions concerning geometry and loading conditions, Laplace’s law was used to calculate Mt. The pelvic cavity is represented by an ellipsoid in which the midpelvic and hiatal sections are described by an ellipse. The downwards forces within the pelvis (F_in) are in equilibrium with the support forces within its walls (F_w). F_in is the abdominal pressure (P_ABD) multiplied by the area A of the ellipse. The force inside the tissues (F_w) is distributed along the circumference of the ellipse C. The Mt can be approximated as Mt?=?(P_ABD.A)/C (N/m). Mt-α accounts for the angle α which describes tissue orientation with respect to the anatomical section and is calculated as Mt-α?=?Mt/sin(α).

Methods

We conducted a retrospective study on archived magnetic resonance imaging scans (n?=?20) and ultrasound images in patients with (n?=?50) or without prolapse (n?=?50) and measured actual geometrical variables. P_ABD was measured in patients with and without prolapse (n?=?20).

Results

Mt at the urogenital hiatus at rest is 0.35 N/cm. They significantly increase with the Valsalva manoeuvre, by a factor of 2.3 (without prolapse) to 3.6 (with prolapse).

Conclusions

Calculated Mt are much lower than what is reported for the abdominal cavity. Prolapse patients have significantly larger Mt, which during the Valsalva manoeuvre increase more than in healthy subjects.     

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.     

Does levator avulsion cause distension of the genital hiatus and perineal body?

Introduction and hypothesis

Levator avulsion is associated with prolapse and prolapse recurrence after reconstructive surgery. We set out to determine whether clinical measurement of the genital hiatus and the perineal body (gh + pb) on maximum Valsalva can predict levator avulsion.

Methods

A total of 295 women attending a tertiary referral service underwent 4D translabial ultrasound imaging and clinical examination using the International Continence Society (ICS) Pelvic Organ Prolapse Quantification system (POP-Q). Analysis of ultrasound data sets for levator avulsion was performed using tomographic ultrasound imaging. The predictive performance of gh + pb for avulsion was tested using receiver-operating characteristic curves.

Results

Optimal sensitivity [70 %, 95 % confidence interval (CI) 59–79 %] and specificity (70 %, 95 % CI 66–72 %) were achieved with a cut-off of 8.5 cm for gh + pb.

Conclusions

A gh + pb measurement ≥ 8.5 cm may help to identify women with levator avulsion who are at increased risk of prolapse recurrence.     

Review of current status of female sexual dysfunction evaluation in urogynecology

A new theory claims that the pelvic floor muscles (PFM) can be trained via the transversus abdominis (TrA). The aim of the present study was to compare the effect of instruction of PFM and TrA contraction on constriction of the levator hiatus, using 4D perineal ultrasonography. Thirteen women with pelvic organ prolapse participated in the study. Perineal ultrasound in standing position was used to assess constriction of the levator hiatus. Analyses were conducted off-line with measurements in the axial plane of minimal hiatal dimensions. The reduction of all the hiatal dimensions was significantly greater during PFM than TrA contraction. All patients had a reduction of the levator hiatus area during PFM contraction (mean reduction 24.0%; range 6.1–49.2%). In two patients, there was an increase of the levator hiatus area during TrA contraction. Instruction of PFM contraction is more effective than TrA contraction. An abstract containing these results is accepted as a discussion poster to be presented at the ICS Annual Meeting in Cairo, October 2008.     

Mean echogenicity and area of puborectalis muscle in women with stress urinary incontinence during pregnancy and after delivery

Introduction and hypothesis

Pregnancy and childbirth are risk factors for the development of stress urinary incontinence (SUI). Urinary continence depends on normal urethral support, which is provided by normal levator ani muscle function. Our objective was to compare mean echogenicity and the area of the puborectalis muscle between women with and those without SUI during and after their first pregnancy.

Methods

We examined 280 nulliparous women at a gestational age of 12 weeks, 36 weeks, and 6 months after delivery. They filled out the validated Urogenital Distress Inventory and underwent perineal ultrasounds. SUI was considered present if the woman answered positively to the question “do you experience urine leakage related to physical activity, coughing, or sneezing?” Mean echogenicity of the puborectalis muscle (MEP) and puborectalis muscle area (PMA) were calculated. The MEP and PMA during pregnancy and after delivery in women with and without SUI were compared using independent Student’s t test.

Results

After delivery the MEP was higher in women with SUI if the pelvic floor was at rest or in contraction, with effect sizes of 0.30 and 0.31 respectively. No difference was found in the area of the puborectalis muscle between women with and those without SUI.

Conclusions

Women with SUI after delivery had a statistically significant higher mean echogenicity of the puborectalis muscle compared with non-SUI women when the pelvic floor was at rest and in contraction; the effect sizes were small. This higher MEP is indicative of a relatively higher intramuscular extracellular matrix component and could represent diminished contractile function.