Clinical relevance of neurological evaluation in patients suffering urinary retention in the absence of subvesical obstruction.

PURPOSE: Clinical relevance of neurological evaluation in patients suffered urinary retention in the absence of subvesical obstruction. Determining whether (1) women complaining residual bladder volume without prolapse and obstruction always suffer pudendal nerve damage; (2) neurogenic damage can be linked to patients history/clinical examination; (3) therapy alters regarding to neurological findings; and (4) electromyography (EMG) of musculus sphincter ani externus (MSAE) can be omitted with electronically stimulated pudendal nerve latency (ESPL) as the standard investigation. METHODS: Women with urinary retention without ≥stage 2 prolapse or obstruction have neurological investigation including vaginally and anally pudendal terminal nerve latency (PTNL) (>2.4 ms considered abnormal) and EMG seen 7/2005-04/2010. RESULTS: (1) 148/180 (82.2%) suffered at least moderate neurogenic damage and (2) severe neurogenic damage occurs with urge odds ratio (OR) = 3.1 or age (OR = 3.2). Correlations: spasticity with therapy changes (OR = 11.1), latencies. (a) Anally: (i) right and peripheral neuropathy (PNP) (OR = 2.5), chemotherapy (OR = 5.0); (ii) left and PNP (OR = 3.9), chemotherapy (OR = 4.8); (iii) left or right with PNP (OR = 3.9), chemotherapy (OR = 6.8); and (iv) left and right with chemotherapy (OR = 5.0). (b) Vaginally: (i) right with age >60 (OR = 3.2), radical operation (OR = 10.6); (ii) left with diabetes mellitus (OR = 2.5); and (iii) left or right with age (OR = 3.3), radical operation (OR = 8.7). (3) 19.6% therapy changes (36 patients). (4) Neither EMG nor ESPL can be replaced one by another (p = 0.12 anal, p = 0.05 vaginal). CONCLUSION: Red flags are neurogenic damage, age >60, chemotherapy, PNP, radical operation or diabetes. In unclear situations, EMG and ESPL need to be performed to gain relevant information.

Transvaginal single-incision mesh reconstruction for recurrent or advanced anterior vaginal wall prolapse.

AIMS: Single-incision transvaginal mesh for reconstruction of Level I and II prolapses in women with recurrent or advanced prolapse. We evaluated functional, anatomical, sonomorphological and quality-of-life outcome. METHODS: Data were collected retrospectively for preoperative parameters and at follow-up visits. Anatomical cure was assessed with vaginal examination using the ICS-POP-Q system; introital-ultrasound scan for postvoidal residual and description of mesh characteristics was performed. We applied a visual analogue scale (VAS) and the German Pelvic Floor Questionnaire to assess quality-of-life. RESULTS: Seventy women with cystocele (III: 61.3%/IV: 16%), all post-hysterectomy and in majority (81.4%) after previous cystocele repair, were operated using a single-incision transvaginal technique. Overall anatomical success rate was 95.7% with significant improvement in quality-of-life (p < 0.0001). Mesh erosion occurred in 5.7%, one patient presented symptomatic vaginal vault prolapse. Postvoidal residual declined significantly (58 vs. 2.9%). Sonographic mesh length was 55.7% of implanted mesh with a wide range of mesh position, but no signs of mesh dislocation. There was no de novo dyspareunia reported, one case of preoperative existing dyspareunia worsened. No severe adverse event was observed. CONCLUSIONS: We hereby present a trial of a high-risk group of patients requiring reconstruction of anterior and apical vaginal wall in mostly recurrent prolapse situation. Our data support the hypothesis of improved anatomical and functional results and less mesh shrinkage caused by the single-incision technique with fixation in sacrospinous ligament in combination with modification in mesh quality compared to former multi-incision techniques.

Levator ani muscle avulsion during childbirth: a risk prediction model.

OBJECTIVE: To establish the incidence of levator ani muscle (LAM) avulsion in primiparous women and to develop a clinically applicable risk prediction model. DESIGN: Observational longitudinal cohort study. SETTING: District General University Hospital, United Kingdom. SAMPLE: Nulliparous women at 36 weeks of gestation and 3 months postpartum. METHODS: Four-dimensional transperineal ultrasound was performed during both visits. Tomographic ultrasound imaging at maximum contraction was used to diagnose no, minor or major LAM avulsion. A risk model was developed using multivariable ordinal logistic regression. MAIN OUTCOME MEASURES: Incidence of LAM avulsion and its risk factors. RESULTS: Of 269 women with no antenatal LAM avulsion 71% (n = 191) returned postpartum. No LAM avulsion was found after caesarean section (n = 48). Following vaginal delivery the overall incidence of LAM avulsion was 21.0% (n = 30, 95% confidence interval [95% CI] 15.1-28.4). Minor and major LAM avulsion were diagnosed in 4.9% (n = 7, 95% CI 2.2-9.9) and 16.1% (n = 23, 95% CI 10.9-23.0), respectively. Risk factors were obstetric anal sphincter injuries (odds ratio [OR] 4.4, 95% CI 1.6-12.1), prolonged active second stage of labour per hour (OR 2.2, 95% CI 1.4-3.3) and forceps delivery (OR 6.6, 95% CI 2.5-17.2). A risk model and nomogram were developed to estimate a woman's individual risk: three risk factors combined revealed a 75% chance of LAM avulsion. CONCLUSIONS: Twenty-one percent of women sustain LAM avulsion during their first vaginal delivery. Our risk model and nomogram are novel tools to estimate individual chances of LAM avulsion. We can now target postnatal women at risk of sustaining a LAM avulsion.

The relationship between postpartum levator ani muscle avulsion and signs and symptoms of pelvic floor dysfunction.

OBJECTIVE: To establish the relationship between postpartum levator ani muscle (LAM) avulsion and signs and/or symptoms of pelvic floor dysfunction (PFD). DESIGN: Observational longitudinal cohort study. SETTING: District General University Hospital, UK. POPULATION OR SAMPLE: Primigravida at 36 weeks' gestation and 3 months postpartum. METHODS: Pelvic floor muscle strength (PFMS) and pelvic organ prolapse were assessed clinically using validated methods. Transperineal ultrasound was performed to identify LAM avulsion and measure hiatus dimensions. Validated questionnaires evaluated sexual function, urinary and faecal incontinence. MAIN OUTCOME MEASURES: PFD signs and symptoms related to LAM avulsion. RESULTS: Two hundred and sixty nine primigravida without LAM avulsion participated and 71% (n = 191) returned postpartum. LAM avulsion was found in 21% of vaginal deliveries (n = 30, 95%CI 15.1-28.4%). Women with minor and major avulsion had worse PFMS (P < 0.038) and more anterior compartment prolapse (maximum stage 2; P < 0.024). Antenatal hiatus antero-posterior diameter on ultrasound was significantly smaller in women sustaining avulsion (P = 0.011). Postnatal measurements were significantly increased following avulsion. Women with major avulsion were less sexually active at both antenatal and postnatal periods (P < 0.030). These women had more postnatal urinary incontinence and symptoms such as reduced vaginal sensation and 'too loose vagina'. No postnatal differences were found for faecal incontinence, prolapse symptoms or quality of life. The correlation of differences in variables was only slight-fair with avulsion severity. CONCLUSIONS: Twenty one percent of women sustain LAM avulsion during their first vaginal delivery with significant impact on signs and symptoms of PFD. As avulsion has been described as the missing link in the development of prolapse; longer term follow-up is vital.

Intra- and interobserver reliability of levator ani muscle biometry and avulsion using three-dimensional endovaginal ultrasonography.

OBJECTIVES: To test intra- and interobserver reliability of assessment of levator ani muscle (LAM) biometry and avulsion using antenatal and postnatal three-dimensional (3D) endovaginal ultrasonography (EVUS), and to determine levator-urethra gap (LUG) values on EVUS. METHODS: Primigravid women were scanned prior to delivery, early postpartum and 3 months postpartum, with EVUS performed at rest using a standardized protocol. During post-processing, measurements were taken in the plane of minimal hiatal dimensions by two independent investigators blinded to the clinical information and each other's results. LAM attachment to the pubic bone was assessed at the pubococcygeus and puborectalis levels using a score system: (1) intact; (2) partial avulsion (< 50%); (3) partial avulsion (≥ 50%); and (4) complete avulsion. Intraclass correlation coefficients (ICCs) and limits of agreement (LOAs) were calculated for each time point, with intraobserver analysis conducted in a random sample of 20 women scanned 3 months following delivery. RESULTS: One hundred and sixty-nine antenatal scans, 83 early postpartum scans and 75 scans at 3 months postpartum were performed. The intra- and interobserver ICCs, respectively, were 0.95 and 0.86-0.88 for hiatal area, 0.90 and 0.16-0.74 for hiatal transverse diameter, 0.91 and 0.73-0.80 for hiatal anteroposterior diameter, 0.50 and 0.32-0.52 for LAM thickness at the '9 o'clock position' and 0.55 and 0.33-0.45 for LAM thickness at the '3 o'clock position'. Both intra- and interobserver analysis revealed acceptable LOAs for hiatal measurements, but the LOAs were wide for thickness measurements. The correlation of LAM avulsion score was excellent on intra- and interobserver analysis. Antenatal mean ± SD LUGs were 18.8 ± 2.4 mm and 19.2 ± 2.3 mm on right and left sides, respectively; the intraobserver ICC was 0.82-0.91 but LOAs were wide, while interobserver ICC was 0.13-0.68 and also had wide LOAs. CONCLUSIONS: 3D-EVUS is a reliable tool for the assessment of hiatal measurements and LAM avulsion in women during pregnancy and after delivery, but performs less well for measurements of LAM thickness and LUG. EVUS can therefore be used in research studies involving childbirth and recurrent prolapse.

Recruitment of pregnant women in research.

The aim was to identify factors that could influence recruitment in a prospective longitudinal study involving pregnant women. A total of 269 nulliparous women were enrolled for a prospective longitudinal study, to establish the prevalence of levator ani muscle defects during childbirth. The project was explained verbally and potential participants were given an information leaflet. When eligible and interested, they provided their contact details to enquire if they were willing to participate. Out of the 1,473 women approached, 269 (18.3%) agreed to participate and 1,043 (70.8%) declined; 420 women (40.3%) did not provide a reason for non-participation (see text for further details). Most often mentioned reasons were 'being too busy', 'other pregnancy problems', 'no additional (internal) examination', 'moving (abroad)' and 'husband'. Women from different ethnicities and age groups gave a wide variety of reasons for non-participation. This information can now be used by researchers recruiting women for comparable studies, to enhance recruitment and participation of eligible patients.

Inter-rater reliability of assessment of levator ani muscle strength and attachment to the pubic bone in nulliparous women.

OBJECTIVES: The modified Oxford scale (MOS) has been found previously to have poor inter-rater reliability, whereas digital assessment of levator ani muscle (LAM) attachment to the pubic bone has been shown to have acceptable reliability. Our aim was to evaluate inter-rater reliability of the validated MOS and to develop a reliable classification system for digital assessment of LAM attachment, correlating this to findings on transperineal ultrasound (TPUS) examination. METHODS: Evaluation of the MOS by palpation was performed in nulliparous women by two investigators. LAM attachment was evaluated using digital palpation, for which a novel classification system was developed with four grades based on the position of the attachment and presence of discernible muscle. Findings were compared with those on TPUS examination. Inter-rater reliability was assessed using Cohen's kappa statistic. RESULTS: Twenty-five nulliparous women were examined. There was agreement in MOS scores between the investigators in 64% of women (n = 16), with a kappa of 0.66 (indicating substantial agreement). There was agreement in palpation of LAM attachment using the new grading system in 96% of women (n = 24), with a kappa of 0.90 (indicating almost perfect agreement). TPUS examination did not show LAM avulsion in any woman, with the exception of one with a partial avulsion. CONCLUSION: In this group of nulliparous patients, there was substantial agreement between the two investigators in evaluation of the MOS and there was good agreement between grades of LAM attachment using the new classification system, which correlated with findings on TPUS examination. It therefore appears that these results are reproducible in nulliparous women and the techniques can be readily learned and reliably incorporated into clinical practice and research after appropriate training. Further research is required to establish clinical utility of the grading system for LAM attachment in postpartum women and in women with symptomatic pelvic organ prolapse.

Obstetric levator ani muscle injuries: current status.

Levator ani muscle (LAM) injuries occur in 13-36% of women who have a vaginal delivery. Although these injuries were first described using magnetic resonance imaging, three-dimensional transperineal and endovaginal ultrasound has emerged as a more readily available and economic alternative to identify LAM morphology. Injury to the LAM is attributed to vaginal delivery resulting in reduced pelvic floor muscle strength, enlargement of the vaginal hiatus and pelvic organ prolapse. There is inconclusive evidence to support an association between LAM injuries and stress urinary incontinence and there seems to be a trend towards the development of fecal incontinence. Longitudinal studies with long-term follow-up assessing the LAM before and after childbirth are lacking. Furthermore, the consequence of LAM injuries on quality of life due to prolapse and/or urinary and fecal incontinence have not been evaluated using validated questionnaires. Direct comparative studies using the above-mentioned imaging modalities are needed to determine the true gold standard for the diagnosis of LAM injuries. This would enable consistency in definition and classification of LAM injuries. Only then could high-risk groups be identified and preventive strategies implemented in obstetric practice.