Enlargement of the levator hiatus in female pelvic organ prolapse: cause or effect?

AIM: This study was undertaken to investigate whether female pelvic organ prolapse repair changes levator hiatal biometry. METHODS: Retrospective analysis of clinical and translabial ultrasound volume data of women who underwent prolapse surgery at a tertiary urogynaecological unit between March 2005 and April 2009. Data sets of 81 women were analysed who had undergone an interview, clinical assessment using POP-Q staging and 3D translabial ultrasound before and after prolapse surgery. Imaging data were obtained preoperatively and 3-12 months postoperatively to determine potential changes in levator hiatal dimensions. Type of surgery, mesh use, symptoms of recurrent prolapse, age, significant recurrent prolapse and length of follow-up were tested in linear regression as potential confounders. RESULTS: The mean preoperative hiatal area on Valsalva was 31.9 cm(2) (range 13.5-58.1 cm(2), SD 10.0 cm(2)). Mean postoperative hiatal area on Valsalva was 28.9 cm(2) (range 13.9-47.4 cm(2); SD 7.3 cm(2)), which implies a significant reduction of 9% (P = 0.001). None of the tested potential confounders were found to be significantly associated with a perioperative change in hiatal area on Valsalva on linear regression analysis. CONCLUSIONS: Surgery for female pelvic organ prolapse is associated with a small but significant reduction in hiatal area, but abnormal hiatal distensibility persists in most cases. This suggests that excessive hiatal distensibility is more likely the cause rather than the effect of prolapse.

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 < 0.001), and postpartum perineal mobility was associated with delivery mode (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.

Do women notice the effect of childbirth-related pelvic floor trauma?

INTRODUCTION: In 10-30% of women, vaginal birth results in levator ani tears ('avulsion') that are associated with pelvic floor dysfunction in later life. We hypothesised that women notice reduced pelvic floor muscle strength after childbirth, especially those with avulsion. METHODS: This is a secondary analysis of two perinatal studies. At 3-6 months postpartum, women were asked to estimate pelvic floor muscle strength relative to antepartum strength. Translabial ultrasound was performed to determine pelvic floor structure and function. RESULTS: Five hundred and thirteen primiparous women were seen at a median of 129 days after delivery of a singleton at a mean gestation of 40 weeks. At follow-up, 481 were able to rate pelvic floor strength (mean 89%). This reduction was associated with delivery mode (P < 0.001), episiotomy (P = 0.01), perineal tears (P = 0.025) and avulsion (n = 45, P = 0.04). CONCLUSION: After the birth of a first child, women notice a significant reduction in pelvic floor muscle strength, which is associated with delivery mode as well as perineal and pelvic floor muscle trauma. SUMMARY: Many women notice reduced pelvic floor function after childbirth, especially those who have suffered an avulsion of the puborectalis muscle.

Sonographic appearance of transobturator slings: implications for function and dysfunction.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to determine associations between the ultrasonic appearance of Monarc suburethral slings and postoperative bladder symptoms at an average follow-up time of 11 months. METHODS: A prospective clinical audit was conducted on 98 patients after Monarc suburethral sling. The assessment included pelvic floor ultrasound to determine the gap between the sling and symphysis pubis, the angle formed by cranial and caudal ends of the sling at rest and on Valsalva, and the location of the sling relative to the urethra. RESULTS: Patients who reported postoperative stress incontinence (SI) or urge incontinence (UI) had a significantly wider gap between the symphysis pubis and sling (P = 0.032 and P = 0.006, respectively). CONCLUSIONS: A narrower gap between the tape and symphysis pubis is associated with both SI and UI cure. Tighter transobturator sling placement seems to be advantageous for the cure of both SI and UI.

Does the Epi-No Birth Trainer reduce levator trauma? A randomised controlled trial.

INTRODUCTION AND HYPOTHESIS: The purpose of this study is to evaluate whether antepartum use of a birth trainer may reduce levator trauma. METHODS: Two hundred nulliparous women were examined with four-dimensional translabial ultrasonography at 35-37 weeks of gestation and 3 months postpartum in a randomised controlled pilot study. Women in the intervention group were instructed to use the birth trainer from 37 weeks onwards. RESULTS: One hundred forty-six women returned for follow-up 5.6 months (range 2.3-22.1) after childbirth. Seventy-eight of them had had normal vaginal deliveries (53%), 32 vacuum/forceps (22%) and 36 a caesarean section (25%). The risk of avulsion was halved in the intervention group (6% vs 13%, P = 0.19) on modified intention to treat analysis. A treatment received analysis revealed a nonsignificant 42% and 30% reduction in levator avulsion and microtrauma, respectively (P ≥ 0.22). CONCLUSIONS: This pilot randomised controlled trial showed a nonsignificantly lower incidence of pelvic floor muscle injury in women who used the Epi-No device from 37 weeks onwards.

Sonographic detection of puborectalis muscle avulsion is not associated with anal incontinence.

BACKGROUND: The puborectalis muscle is believed to play an important role in anal continence. However, to date, there is very limited evidence to support this hypothesis. AIMS: This study was designed to test for an association between puborectalis trauma and ballooning of the levator hiatus on the one hand and anal incontinence on the other hand. METHODS: The records of 397 women who had attended a tertiary urogynaecological clinic were reviewed in a retrospective study. The history included questions on faecal urgency, soiling, faecal and flatus incontinence. Examination included puborectalis muscle assessment by palpation and 4D pelvic floor ultrasound. RESULTS: Mean age on presentation was 54 (19-89) years. Median vaginal parity was 2 (0-9). Of 397 women, 89 complained of faecal urgency, 65 of faecal incontinence (FI), 67 of soiling and 91 of flatus incontinence. Seventy-seven patients were diagnosed with puborectalis avulsion, of which 38 were bilateral. Puborectalis avulsion was not associated with FI (P = 0.801), faecal urgency (P = 0.894), soiling (P = 0.768) and flatus incontinence (P = 0.187). Hiatal dimensions at rest or on Valsalva were also found not to be associated with symptoms of anal incontinence. CONCLUSIONS: Surprisingly, we found no association between avulsion of the puborectalis muscle and hiatal biometry on the one hand and anal continence on the other hand. These findings argue against a major role of the puborectalis muscle in anal continence.

The urethral motion profile before and after suburethral sling placement.

PURPOSE: We examined the effect of the Monarc suburethral sling on urethral mobility. MATERIALS AND METHODS: We retrospectively studied the records of 54 consecutive women who received a Monarc suburethral sling between July 2005 and November 2008. All patients were examined by volume ultrasound preoperatively and at followup (average 0.7 years). Volume data sets were analyzed using post-processing software. Urethral mobility was described by vectors of movement from rest to a maximum Valsalva maneuver of 6 equidistant points marked evenly along the urethra from bladder neck (point 1) to external urethral meatus (point 6), as identified in the mid sagittal view. Measurements were made of point coordinates relative to the pubic symphysis dorsocaudal margin at rest and during maximal Valsalva maneuver. To determine the urethral motion profile we calculated mobility vectors of the 6 points using the formula, square root [(x(val) - x(rest))(2) + (y(val) - y(rest))(2)], where val represents the value during the Valsalva maneuver and rest represents the value at rest. We compared values before and after sling placement. RESULTS: The subjective cure rate for stress urinary incontinence was 78% (42 cases). There was a statistically significantly decreased mobility at points 2 to 4, corresponding to the urethral central aspect (p = 0.002 to 0.018). No significant change in mobility was noted at the bladder neck and distal urethra (p = 0.39 to 0.89). CONCLUSIONS: Monarc suburethral sling placement decreases mid urethral mobility but does not seem to affect the bladder neck.

A comparative study of early postoperative feeding versus conventional feeding for patients undergoing cesarean section; a randomized controlled trial.

OBJECTIVE: To compare the efficacy and side effects of early postoperative feeding versus conventional feeding for patients undergoing cesarean section. MATERIAL AND METHOD: Women undertaking uncomplicated cesarean section under regional anesthesia were randomly assigned to early feeding or conventional feeding groups. Early-fed women were offered a liquid diet within 8 hours after surgery, advanced to a soft diet on the next meal and then a regular diet. Conventional-fed women were prohibited from mouth-fed for the first 24 hours after surgery, advanced to a liquid diet on the first postoperative day, and then a soft diet on the second postoperative day. RESULTS: Two hundred patients were enrolled in the study; 107 patients were assigned to the early feeding group and 93 patients to the conventional feeding group. There were no significant differences in the demographic data between the two groups. In all cases, consistent anesthetic method was applied with no intraoperative adhesion and no post operative complications were observed. The rate of mild ileus symptoms in the early feeding group was significantly less than the conventional group (19.6% versus 31.1%, p = 0.03). The early feeding group also had significantly shorter time interval to bowel movement (16.7 hours versus 25.3 hours, p < 0.001), duration of intravenous fluid administration (20.5 hours versus 24.8 hours, p < 0.001), and overall length of hospital stays (3.3 days versus 4.0 days, p < 0.001). CONCLUSION: The study results indicated that the early feeding after uncomplicated cesarean section had reduced the rate of ileus symptoms and offer potential benefits associated with shorter interval to bowel movement, intravenous fluid administration, and length of hospital stays. However, management of postoperative feeding requires proper counseling on details of both regimens and flexibilities should be provided to accommodate early feeding when requested by the patients.

Correlations of third-trimester hiatal biometry obtained using four-dimensional translabial ultrasonography with the delivery route in nulliparous pregnant women.

PURPOSE: The goal of this study was to evaluate normal hiatal dimensions in the third trimester in nulliparous Thai pregnant women and to establish which biometric factors were associated with various pregnancy outcomes. METHODS: Fifty-seven consecutive nulliparous pregnant Thai women in their third trimester were recruited on a voluntary basis from April to October 2014. All subjects underwent four-dimensional (4D) translabial ultrasonography. Hiatal biometric parameters were measured at rest, while performing a Valsalva maneuver, and during contraction. Information about the patients' eventual deliveries was obtained from their medical records. RESULTS: The mean values of the patients' age, body mass index, and gestational age at the time of examination were 27.4±5.47 years, 26.7±3.48 kg/m(2), and 36.6±1.49 weeks, respectively. No subjects had vaginal lumps or experienced prolapse greater than stage 1 of the Pelvic Organ Prolapse Quantification system. Ultrasonography showed that the mean values of the hiatal area at rest, while performing a Valsalva maneuver, and during contraction were 13.10±2.92 cm(2), 17.50±4.81 cm(2), and 9.69±2.09 cm(2), respectively. The hiatal area at rest, the axial measurement at rest, and the axial measurement while performing a Valsalva maneuver were significantly associated with the route of delivery (P=0.02, P=0.04, and P=0.03, respectively). CONCLUSION: The route of delivery was associated with hiatal biometric values measured using 4D translabial ultrasonography, based on the results of nulliparous Thai women in the third trimester.