3D ultrasound strain imaging of puborectal muscle with and without unilateral avulsion.

INTRODUCTION AND HYPOTHESIS: The puborectal muscle (PRM), one of the female pelvic floor (PF) muscles, can get damaged during vaginal delivery, leading to disorders such as pelvic organ prolapse. Current diagnosis involves ultrasound (US) imaging of the female PF muscles, but functional information is limited. Previously, we developed a method for strain imaging of the PRM from US images in order to obtain functional information. In this article, we hypothesize that strain in the PRM would differ from intact to the avulsed end. METHODS: We calculated strain in PRMs at maximum contraction, along their muscle fiber direction, from US images of two groups of women, which consisted of women with intact (n1 = 8) and avulsed PRMs (unilateral) (n2 = 10). Normalized strain ratios between both ends of the PRM (avulsed or intact) and the mid region were calculated. Subsequently, the difference in ratio between the avulsed and intact PRMs was determined. RESULTS: We observe from the obtained results that the contraction/strain pattern of intact and undamaged PRMs is different from PRMs with unilateral avulsion. Normalized strain ratios between avulsed and intact PRMs were statistically significant (p = 0.04). CONCLUSION: In this pilot study, we were able to show that US strain imaging of PRMs can show differences between intact PRMs and PRMs with unilateral avulsion.

Pessary or surgery for a symptomatic pelvic organ prolapse: the PEOPLE study, a multicentre prospective cohort study.

OBJECTIVE: To compare the 24-month efficacy of pessary or surgery as the primary treatment for symptomatic pelvic organ prolapse (POP). DESIGN: Multicentre prospective comparative cohort study. SETTING: Twenty-two Dutch hospitals. POPULATION: Women referred with symptomatic POP of stage ≥2 and moderate-to-severe POP symptoms. METHODS: The primary outcome was subjective improvement at the 24-month follow-up according to the Patient Global Impression of Improvement (PGI-I) scale. Secondary outcomes included improvement in prolapse-related symptoms measured with the Pelvic Floor Distress Inventory (PFDI-20), improvement in subjective severeness of symptoms according to the Patient Global Impression of Severity (PGI-S) scale and crossover between therapies. The primary safety outcome was the occurrence of adverse events. MAIN OUTCOME MEASURE: PGI-I at 24 months. RESULTS: We included 539 women, with 335 women (62.2%) in the pessary arm and 204 women (37.8%) in the surgery arm. After 24 months, subjective improvement was reported by 134 women (83.8%) in the surgery group compared with 180 women (74.4%) in the pessary group (risk difference 9.4%, 95% CI 1.4-17.3%, P < 0.01). Seventy-nine women (23.6%) switched from pessary to surgery and 22 women (10.8%) in the surgery group underwent additional treatment. Both groups showed a significant reduction in bothersome POP symptoms (P ≤ 0.01) and a reduction in the perceived severity of symptoms (P ≤ 0.001) compared with the baseline. CONCLUSIONS: Significantly more women in the surgery group reported a subjective improvement after 24 months. Both therapies, however, showed a clinically significant improvement of prolapse symptoms. TWEETABLE ABSTRACT: Pessary treatment and vaginal surgery are both efficacious in reducing the presence and severity of prolapse symptoms, although the chance of significant improvement is higher following surgery.

Automatic identification and segmentation of slice of minimal hiatal dimensions in transperineal ultrasound volumes.

OBJECTIVE: To develop and validate a tool for automatic selection of the slice of minimal hiatal dimensions (SMHD) and segmentation of the urogenital hiatus (UH) in transperineal ultrasound (TPUS) volumes. METHODS: Manual selection of the SMHD and segmentation of the UH was performed in TPUS volumes of 116 women with symptomatic pelvic organ prolapse (POP). These data were used to train two deep-learning algorithms. The first algorithm was trained to provide an estimation of the position of the SMHD. Based on this estimation, a slice was selected and fed into the second algorithm, which performed automatic segmentation of the UH. From this segmentation, measurements of the UH area (UHA), anteroposterior diameter (APD) and coronal diameter (CD) were computed automatically. The mean absolute distance between manually and automatically selected SMHD, the overlap (dice similarity index (DSI)) between manual and automatic UH segmentation and the intraclass correlation coefficient (ICC) between manual and automatic UH measurements were assessed on a test set of 30 TPUS volumes. RESULTS: The mean absolute distance between manually and automatically selected SMHD was 0.20 cm. All DSI values between manual and automatic UH segmentations were above 0.85. The ICC values between manual and automatic UH measurements were 0.94 (95% CI, 0.87-0.97) for UHA, 0.92 (95% CI, 0.78-0.97) for APD and 0.82 (95% CI, 0.66-0.91) for CD, demonstrating excellent agreement. CONCLUSIONS: Our deep-learning algorithms allowed reliable automatic selection of the SMHD and UH segmentation in TPUS volumes of women with symptomatic POP. These algorithms can be implemented in the software of TPUS machines, thus reducing clinical analysis time and simplifying the examination of TPUS data for research and clinical purposes. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Deep learning enables automatic quantitative assessment of puborectalis muscle and urogenital hiatus in plane of minimal hiatal dimensions.

OBJECTIVES: To measure the length, width and area of the urogenital hiatus (UH), and the length and mean echogenicity (MEP) of the puborectalis muscle (PRM), automatically and observer-independently, in the plane of minimal hiatal dimensions on transperineal ultrasound (TPUS) images, by automatic segmentation of the UH and the PRM using deep learning. METHODS: In 1318 three- and four-dimensional (3D/4D) TPUS volume datasets from 253 nulliparae at 12 and 36 weeks' gestation, two-dimensional (2D) images in the plane of minimal hiatal dimensions with the PRM at rest, on maximum contraction and on maximum Valsalva maneuver, were obtained manually and the UH and PRM were segmented manually. In total, 713 of the images were used to train a convolutional neural network (CNN) to segment automatically the UH and PRM in the plane of minimal hiatal dimensions. In the remainder of the dataset (test set 1 (TS1); 601 images, four having been excluded), the performance of the CNN was evaluated by comparing automatic and manual segmentations. The performance of the CNN was also tested on 117 images from an independent dataset (test set 2 (TS2); two images having been excluded) from 40 nulliparae at 12 weeks' gestation, which were acquired and segmented manually by a different observer. The success of automatic segmentation was assessed visually. Based on the CNN segmentations, the following clinically relevant parameters were measured: the length, width and area of the UH, the length of the PRM and MEP. The overlap (Dice similarity index (DSI)) and surface distance (mean absolute distance (MAD) and Hausdorff distance (HDD)) between manual and CNN segmentations were measured to investigate their similarity. For the measured clinically relevant parameters, the intraclass correlation coefficients (ICCs) between manual and CNN results were determined. RESULTS: Fully automatic CNN segmentation was successful in 99.0% and 93.2% of images in TS1 and TS2, respectively. DSI, MAD and HDD showed good overlap and distance between manual and CNN segmentations in both test sets. This was reflected in the respective ICC values in TS1 and TS2 for the length (0.96 and 0.95), width (0.77 and 0.87) and area (0.96 and 0.91) of the UH, the length of the PRM (0.87 and 0.73) and MEP (0.95 and 0.97), which showed good to very good agreement. CONCLUSION: Deep learning can be used to segment automatically and reliably the PRM and UH on 2D ultrasound images of the nulliparous pelvic floor in the plane of minimal hiatal dimensions. These segmentations can be used to measure reliably UH dimensions as well as PRM length and MEP. © 2018 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

Echogenicity of puborectalis muscle, cervix and vastus lateralis muscle in pregnancy in relation to mode of delivery.

OBJECTIVES: To confirm our previous observation that levator hiatal dimensions and mean echogenicity of the puborectalis muscle (MEP) are significantly different at 12 weeks' gestation in women who delivered by Cesarean section due to failure to progress compared with those who delivered vaginally. The secondary objective was to assess the association between the echogenicity of the cervix and vastus lateralis muscle and mode of delivery. METHODS: In this prospective multicenter study, 306 nulliparous women with a singleton pregnancy underwent ultrasound assessments of the pelvic floor at rest, on maximum pelvic floor muscle contraction and on maximum Valsalva maneuver, of the cervix and of the vastus lateralis muscle at 12 weeks' gestation. Dimensions of the levator hiatus, MEP and mean echogenicity of the cervix and vastus lateralis muscle were measured and compared according to mode of delivery. RESULTS: Two hundred and forty-nine women were included in the analyses. We were unable to confirm our previous finding that MEP and levator hiatal transverse diameter and area at 12 weeks' gestation are associated significantly with mode of delivery. In addition, we could not demonstrate a significant association between echogenicity of the cervix or vastus lateralis muscle and mode of delivery. Overall, MEP was a mean of 20 points lower in women in the new database as compared with the previous study, despite the use of the same ultrasound equipment. CONCLUSION: In a second, independent multicenter dataset, we were unable to confirm our previous finding that levator hiatal dimensions and MEP on pelvic floor muscle contraction are associated significantly with mode of delivery. We also found no association between echogenicity of the cervix or vastus lateralis and mode of delivery. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Structural changes in puborectalis muscle after vaginal delivery.

OBJECTIVE: To evaluate the structural composition of the puborectalis muscle before and at several timepoints after first vaginal delivery, by the use of echogenicity and area measurements, in order to explore its recovery. METHODS: Twenty nulliparous women with a singleton pregnancy underwent 3D/4D transperineal ultrasound assessments at rest, on pelvic floor muscle contraction and on Valsalva maneuver at 12 weeks' gestation and at 1 day and 1, 2, 3, 4, 6, 12, 18 and 24 weeks after vaginal delivery. The puborectalis muscle was delineated for measurements of mean echogenicity (MEP) and area (PMA). To assess changes in MEP and PMA over time, linear mixed model analysis was used. The exact number of days after delivery at each ultrasound examination was used as a covariate. RESULTS: For all timepoints after delivery, MEP was significantly decreased compared with that at 12 weeks' gestation. MEP values increased significantly over time from 1 day to 24 weeks after delivery. Although not statistically significant, a decrease in MEP was observed between 3 and 4 weeks after delivery for all maneuvers. PMA at rest and on Valsalva maneuver remained constant after delivery. CONCLUSION: When compared with measurements taken during pregnancy, a sharp decrease in MEP was observed soon after vaginal delivery, which was most likely caused by stretch trauma to the puborectalis muscle and subsequent formation of (micro) hematoma and edema. Subsequent increases in MEP may reflect the disappearance of hematoma and edema, and also the formation of connective and scar tissue. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Prolapse surgery with or without incontinence procedure: a systematic review and meta-analysis.

BACKGROUND: To reduce the risk of postoperative stress urinary incontinence (POSUI) prolapse repair might be combined with incontinence surgery. OBJECTIVES: Compare efficacy and safety of prolapse surgery with and without incontinence surgery. SEARCH STRATEGY: Including our earlier review a systematic search in PubMed, EMBASE, the Cochrane Library and the Register of Current Controlled Trials was performed from 1995 to 2017. SELECTION CRITERIA: Randomised trials comparing prolapse surgery with a midurethral sling (MUS) or Burch colposuspension. DATA COLLECTION AND ANALYSIS: Two reviewers selected eligible articles and extracted data. Stress urinary outcomes were pooled for preoperative SUI. Urgency incontinence and adverse events were pooled for incontinence procedure. MAIN RESULTS: Ten trials were included. Women with preoperative SUI symptoms or occult SUI had a lower risk to undergo subsequent incontinence surgery for POSUI after vaginal prolapse surgery with a MUS than after prolapse surgery only: 0 versus 40% [relative risk (RR) 0.0; 95% CI 0.0-0.2] and 1 versus 15% (RR 0.1; 95% CI 0.0-0.6), respectively. These differences were not significant in continent women not tested for occult SUI or without occult SUI. Serious adverse events were more frequent after vaginal prolapse repair with MUS (14 versus 8%; RR 1.7; 95% CI 1.1-2.7), but not after sacrocolpopexy with Burch colposuspension. Combination surgery did not increase the risk of overactive bladder symptoms, urgency incontinence and surgery for voiding dysfunction. CONCLUSIONS: Vaginal prolapse repair with MUS reduced the risk of postoperative SUI in women with preoperative SUI symptoms or occult SUI, but serious adverse events were more frequent. TWEETABLE ABSTRACT: Less stress incontinence after vaginal prolapse repair with sling, but more adverse events.

Automatic segmentation of puborectalis muscle on three-dimensional transperineal ultrasound.

OBJECTIVES: The introduction of three-dimensional (3D) analysis of the puborectalis muscle (PRM) for diagnostic purposes into daily practice is hindered by the need for appropriate training of observers. Automatic segmentation of the PRM on 3D transperineal ultrasound may aid its integration into clinical practice. The aims of this study were to present and assess a protocol for manual 3D segmentation of the PRM on 3D transperineal ultrasound, and to use this for training of automatic 3D segmentation method of the PRM. METHODS: The data used in this study were derived from 3D transperineal ultrasound sequences of the pelvic floor acquired at 12 weeks' gestation from nulliparous women with a singleton pregnancy. A manual 3D segmentation protocol was developed for the PRM based on a validated two-dimensional segmentation protocol. For automatic segmentation, active appearance models of the PRM were developed, trained using manual segmentation data from 50 women. The performances of both manual and automatic segmentation were analyzed by measuring the overlap and distance between the segmentations. Intraclass correlation coefficients (ICCs) and their 95% CIs were determined for mean echogenicity and volume of the puborectalis muscle, in order to assess inter- and intraobserver reliabilities of the manual method using data from 20 women, as well as to compare the manual and automatic methods. RESULTS: Interobserver reliabilities for mean echogenicity and volume were very good for manual segmentation (ICCs 0.987 and 0.910, respectively), as were intraobserver reliabilities (ICCs 0.991 and 0.877, respectively). ICCs for mean echogenicity and volume were very good and good, respectively, for the comparison of manual vs automatic segmentation (0.968 and 0.626, respectively). The overlap and distance results for manual segmentation were as expected, showing an average mismatch of only 2-3 pixels and reasonable overlap. Based on overlap and distance, five mismatches were detected for automatic segmentation, resulting in an automatic segmentation success rate of 90%. CONCLUSIONS: This study presents a reliable manual segmentation protocol and automatic 3D segmentation method for the PRM, which will facilitate future investigation of the PRM, allowing for the reliable measurement of potentially clinically valuable parameters such as mean echogenicity. © 2017 The Authors. Ultrasound in Obstetrics & Gynecology Published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

Recovery of puborectalis muscle after vaginal delivery: an ultrasound study.

OBJECTIVES: To assess change in levator hiatal dimensions between pregnancy and different timepoints after vaginal delivery, and map recovery of the hiatus in order to contribute to secondary prevention of symptoms of pelvic floor disorders. METHODS: Twenty nulliparous women with a singleton pregnancy underwent ultrasound assessment of the pelvic floor at rest, on maximum pelvic floor muscle contraction (PFMC) and on Valsalva maneuver at 12 weeks' gestation and at 1 day and 1, 2, 3, 4, 6, 12, 18 and 24 weeks after vaginal delivery. Dimensions of the levator hiatus were measured and contractility and distensibility were calculated. The Wilcoxon signed rank test was used to compare each postpartum value with that at 12 weeks' gestation. RESULTS: Levator hiatal area at rest, on PFMC and on Valsalva maneuver was significantly increased at 1 day and at 1 and 2 weeks after vaginal delivery compared with measurements at 12 weeks' gestation. Hiatal area at rest and on PFMC from 3 weeks postpartum onward, as well as contractility from 6 weeks onward, were comparable to values at 12 weeks' gestation, whereas, a significant difference remained on Valsalva maneuver until 24 weeks after delivery. Moreover, distensibility was still increased at 24 weeks postpartum compared with measurements at 12 weeks' gestation. CONCLUSION: The puborectalis muscle has the ability to recover anatomically from a first vaginal delivery, and recovery occurs mainly during the first 3 weeks after delivery. Stretching of the puborectalis muscle, as reflected by distensibility, persisted 24 weeks after the first vaginal delivery. The data provide a better understanding of the early 'normal' regeneration process and we hypothesize that the first 3 weeks postpartum is the best window in which to start secondary prevention. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Changes in global strain of puborectalis muscle during pregnancy and postpartum.

OBJECTIVE: One of the functional parameters that can be assessed by ultrasound is muscle strain, which represents the extent of deformation of the muscle from its original shape when forces are applied to the tissue under study. The aim of this study was to evaluate the effect of pregnancy and delivery on the puborectalis muscle, by assessing changes in global strain of the muscle during and after pregnancy. METHODS: This was a secondary analysis of a prospective observational study on the association between stress urinary incontinence and levator ani muscle avulsion after delivery. Two-hundred and eighty nulliparous pregnant women underwent four-dimensional transperineal ultrasound assessments at 12 and 36 weeks of gestation, and 6 months postpartum. Tomographic ultrasound images were constructed and the puborectalis muscle was delineated by hand using programming software. After delineation, the length of the midline of the puborectalis muscle was measured at rest and during maximum pelvic floor muscle contraction, and global strain was expressed as percentile difference. Postpartum results were analyzed separately for vaginal, operative (vacuum) vaginal and Cesarean delivery. Differences in global strain of the puborectalis muscle according to mode of delivery were compared using a paired-sample t-test. The effect of partial or complete avulsion of the puborectalis muscle on postpartum strain was evaluated by ANOVA. RESULTS: In total, 254 datasets were analyzed. Global strain of the puborectalis muscle did not change during pregnancy, but after spontaneous or operative vaginal delivery the global strain diminished significantly. No significant change was observed in strain of the puborectalis muscle after Cesarean delivery. Women who suffered complete bilateral avulsion had significantly lower strain compared with women with an intact puborectalis muscle. CONCLUSION: Spontaneous or operative vacuum vaginal birth and complete bilateral avulsion of the puborectalis muscle influence negatively the strain of the puborectalis muscle. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Quality of reporting of diagnostic accuracy studies on pelvic floor three-dimensional transperineal ultrasound: a systematic review.

OBJECTIVE: In recent years, a large number of studies have been published on the clinical relevance of pelvic floor three-dimensional (3D) transperineal ultrasound. Several studies compare sonography with other imaging modalities or clinical examination. The quality of reporting in these studies is not known. The objective of this systematic review was to determine the compliance of diagnostic accuracy studies investigating pelvic floor 3D ultrasound with the Standards for Reporting of Diagnostic Accuracy (STARD) guidelines. METHODS: Published articles on pelvic floor 3D ultrasound were identified by a systematic literature search of MEDLINE, Web of Science and Scopus databases. Prospective and retrospective studies that compared pelvic floor 3D ultrasound with other clinical and imaging diagnostics were included in the analysis. STARD compliance was assessed and quantified by two independent investigators, using 22 of the original 25 STARD checklist items. Items with the qualifier 'if done' (Items 13, 23 and 24) were excluded because they were not applicable to all papers. Each item was scored as reported (score = 1) or not reported (score = 0). Observer variability, the total number of reported STARD items per article and summary scores for each item were calculated. The difference in total score between STARD-adopting and non-adopting journals was tested statistically, as was the effect of year of publication. RESULTS: Forty studies published in 13 scientific journals were included in the analysis. Mean ± SD STARD checklist score of the included articles was 16.0 ± 2.5 out of a maximum of 22 points. The lowest scores (< 50%) were found for reporting of handling of indeterminate results or missing responses, adverse events and the time interval between tests. Interobserver agreement for rating the STARD items was excellent (intraclass correlation coefficient, 0.77). An independent t-test showed no significant mean difference ± SD in total STARD checklist score between STARD-adopting and non-adopting journals (16.4 ± 2.2 vs 15.9 ± 2.6, respectively). Mean ± SD STARD checklist score for articles published in 2003-2009 was lower, but not statistically different, compared with those published in 2010-2015 (15.2 ± 2.5 vs 16.6 ± 2.4, respectively). CONCLUSION: The overall compliance with reporting guidelines of diagnostic accuracy studies on pelvic floor 3D transperineal ultrasound is relatively good compared with other fields of medicine. However, specific checklist items require more attention when reported. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

A nationwide survey concerning practices in pessary use for pelvic organ prolapse in The Netherlands: identifying needs for further research.

INTRODUCTION AND HYPOTHESIS: To identify practice variation in management of patients with a vaginal pessary for pelvic organ prolapse (POP). METHODS: A nationwide survey was sent to all Dutch gynecologists with a special interest in urogynecology. RESULTS: The response rate was 59 %. Of the respondents, 13 % had a written protocol for pessary treatment in their department. Pessary treatment was proposed by 69 % of respondents as a treatment option. Counseling about side effects varied. All respondents provided information concerning the possibility of serious vaginal discharge. Concerning this side effect, 15 % of the respondents stated that it occurs in 5 - 20 % of patients, 27 % that it occurs in 20 - 40 % of patients, and 57 % that it occurs in more than 40 % of patients. Another item concerned counseling for the likelihood of vaginal blood loss. All respondents provided information concerning the possibility of vaginal blood loss. Concerning this side effect, 53 % of the respondents stated that it occurs in 5 - 20 % of patients, 33 % that it occurs in 20 - 40 %, and 14 % that it occurs in more than 40 % of patients. Follow-up after initial placement was done by 69 % of the respondents at 2 - 6 weeks, by 2 % at 8 weeks, and by 29 % at 12 weeks or more. Most (98 %) of the respondents extended the interval between visits when the patient had no complaints, and 96 % of the respondents reported that they routinely instruct patients about self-management. CONCLUSIONS: Pessaries are suggested as a treatment option by a majority of gynecologists, but practice varies widely. We consider that the variation in practice is due to a lack of available protocols and lack of evidence.

Transvaginal prolapse repair with or without the addition of a midurethral sling in women with genital prolapse and stress urinary incontinence: a randomised trial.

OBJECTIVE: To compare transvaginal prolapse repair combined with midurethral sling (MUS) versus prolapse repair only. DESIGN: Multi-centre randomised trial. SETTING: Fourteen teaching hospitals in the Netherlands. POPULATION: Women with symptomatic stage two or greater pelvic organ prolapse (POP), and subjective or objective stress urinary incontinence (SUI) without prolapse reduction. METHODS: Women were randomly assigned to undergo vaginal prolapse repair with or without MUS. Analysis was according to intention to treat. MAIN OUTCOME MEASURES: The primary outcome at 12 months' follow-up was the absence of urinary incontinence (UI) assessed with the Urogenital Distress Inventory and treatment for SUI or overactive bladder. Secondary outcomes included complications. RESULTS: One hundred and thirty-four women were analysed at 12 months' follow-up (63 in MUS and 71 in control group). More women in the MUS group reported the absence of UI and SUI; respectively 62% versus 30% UI (relative risk [RR] 2.09; 95% confidence interval [CI] 1.39-3.15) and 78% versus 39% SUI (RR 1.97; 95% CI 1.44-2.71). Fewer women underwent treatment for postoperative SUI in the MUS group (10% versus 37%; RR 0.26; 95% CI 0.11-0.59). In the control group, 12 women (17%) underwent MUS after prolapse surgery versus none in the MUS group. Severe complications were more common in the MUS group, but the difference was not statistically significant (16% versus 6%; RR 2.82; 95% CI 0.93-8.54). CONCLUSIONS: Women with prolapse and co-existing SUI are less likely to have SUI after transvaginal prolapse repair with MUS compared with prolapse repair only. However, only 17% of the women undergoing POP surgery needed additional MUS. A well-informed decision balancing risks and benefits of both strategies should be tailored to individual women.

Predicting who will undergo surgery after physiotherapy for female stress urinary incontinence.

INTRODUCTION AND HYPOTHESIS: To predict who will undergo midurethral sling surgery (surgery) after initial pelvic floor muscle training (physiotherapy) for stress urinary incontinence in women. METHODS: This was a cohort study including women with moderate to severe stress incontinence who were allocated to the physiotherapy arm from a previously reported multicentre trial comparing initial surgery or initial physiotherapy in treating stress urinary incontinence. Crossover to surgery was allowed. RESULTS: Data from 198/230 women who were randomized to physiotherapy was available for analysis, of whom 97/198 (49 %) crossed over to surgery. Prognostic factors for undergoing surgery after physiotherapy were age <55 years at baseline (OR 2.87; 95 % CI 1.30-6.32), higher educational level (OR 3.28; 95 % CI 0.80-13.47), severe incontinence at baseline according to the Sandvik index (OR 1.77; 95 % CI 0.95-3.29) and Urogenital Distress Inventory; incontinence domain score (OR 1.03; per point; 95 % CI 1.01-1.65). Furthermore, there was interaction between age <55 years and higher educational level (OR 0.09; 95 % CI 0.02-0.46). Using these variables we constructed a prediction rule to estimate the risk of surgery after initial physiotherapy. CONCLUSION: In women with moderate to severe stress incontinence, individual prediction for surgery after initial physiotherapy is possible, thus enabling shared decision making for the choice between initial conservative or invasive management of stress urinary incontinence.

Association between levator hiatal dimensions on ultrasound during first pregnancy and mode of delivery.

OBJECTIVES: To determine the association between levator hiatal dimensions, measured using transperineal ultrasound, in women during their first pregnancy and the subsequent mode of delivery, stratified by the indication for intervention. METHODS: In this prospective observational study, 280 nulliparous women with a singleton pregnancy were invited for transperineal ultrasound examination at 12 and 36 weeks' gestation. Their levator hiatal dimensions were measured at rest, on pelvic floor muscle contraction and on Valsalva maneuver. The subsequent mode of delivery was classified into five categories: spontaneous vaginal delivery, instrumental vaginal delivery owing to fetal distress, instrumental vaginal delivery owing to failure to progress, Cesarean section owing to fetal distress and Cesarean section owing to failure to progress. Levator hiatal dimensions according to mode of delivery were compared by analysis of variance and Tukey's post-hoc test. Since multiple comparison tests were performed, the statistical significance level was corrected using the Bonferroni method. RESULTS: Of the 252 women included, those who delivered by Cesarean section because of failure to progress had a significantly smaller levator hiatal transverse diameter on pelvic floor contraction at 12 weeks' gestation than did women who had a spontaneous vaginal delivery (Tukey's post-hoc test, P < 0.001). There was also a trend towards a smaller hiatal area on pelvic floor contraction at 12 weeks' gestation in women who delivered by Cesarean section because of failure to progress compared to women who had a spontaneous vaginal delivery (Tukey's post-hoc test, P = 0.005). In women who had an instrumental vaginal delivery because of failure to progress there was a trend towards a smaller levator hiatal anteroposterior diameter on pelvic floor contraction at 36 weeks' gestation compared with women who had a spontaneous vaginal delivery (Tukey's post-hoc test, P = 0.033). CONCLUSIONS: Smaller levator hiatal dimensions on pelvic floor contraction during first pregnancy are associated with a subsequent instrumental vaginal delivery or a Cesarean section owing to failure to progress.

Measuring echogenicity and area of the puborectalis muscle: method and reliability.

OBJECTIVES: To develop a semi-automated method to assess puborectalis muscle echogenicity on three-dimensional/four-dimensional (3D/4D) volume transperineal ultrasound images using 4D View and Matlab® software and evaluate its intra- and interobserver reliability. METHOD: The data of 23 women in their first trimester were included. 3D/4D volume datasets were obtained at rest. Two inexperienced observers were trained by an experienced observer to construct tomographic ultrasound images (TUI) from the original data and to delineate all structures. Puborectalis muscle area (PMA) and the mean echogenicity of the puborectalis muscle (MEP) were calculated offline. Intra- and interobserver reliability were determined by intraclass correlation coefficients (ICC) and their 95% CIs. RESULTS: The development of a semi-automated method to calculate puborectalis area and echogenicity is described in detail. PMA and MEP measurements in pregnant women demonstrated almost perfect intraobserver reliability for both inexperienced observers, with ICC values ranging from 0.88 to 0.99. The interobserver reliability showed ICCs of 0.63 for PMA and almost perfect ICC values, of 0.96-0.98, for echogenicity. The majority of intraobserver mismatch between two delineations of PMA occurred near the borders. CONCLUSIONS: Matlab software can be used to provide reliable measurements of the area and echogenicity of the puborectalis muscle. As the latter can be used to assess structural changes in the puborectalis muscle, it appears a promising new tool for studying pelvic floor structural anatomy.

Diagnosing levator avulsions after first delivery by tomographic ultrasound: reliability between observers from different centers.

INTRODUCTION AND HYPOTHESIS: To evaluate the interobserver reliability of diagnosing levator avulsions between observers from different centers using tomographic ultrasound imaging (TUI) in women after their first delivery. METHODS: Transperineal ultrasound volume datasets of 40 women 6 months after their first delivery were analyzed by five observers from four different centers. Levator avulsions were diagnosed using TUI and datasets were assessed as optimal or suboptimal image quality and optimal or suboptimal pelvic floor contraction. Cohen's kappa was used to evaluate the interobserver reliability of diagnosing levator avulsions for the total group, the group with optimal and suboptimal image quality, and the group with optimal and suboptimal pelvic floor contraction. Consensus on the presence or absence of avulsions was scored according to the number of observers who diagnosed an avulsion (0 = consensus on the absence of avulsion, 1-4 = avulsion diagnosed by 1 to 4 observers, 5 = consensus on the presence of avulsion). RESULTS: For the total group, the interobserver reliability varied widely, with kappa values ranging from -0.07 to 0.72. Analyzes in the subgroups showed comparable results. Of the women who potentially have an avulsion (avulsion diagnosed by at least one observer), consensus on the presence of an avulsion was reached in 0.0 to 20.0 %. Of the women who potentially have no avulsion (no avulsion diagnosed by at least one observer), consensus on the absence of an avulsion was reached in 46.7 to 85.7 %. CONCLUSIONS: Diagnosing levator avulsions using TUI in women 6 months after their first delivery is strongly observer-dependent and therefore not generalizable.

Prolapse surgery with or without stress incontinence surgery for pelvic organ prolapse: a systematic review and meta-analysis of randomised trials.

OBJECTIVES: The combination of prolapse surgery with an incontinence procedure can reduce the incidence of stress urinary incontinence (SUI) after surgery, but may increase adverse events. We compared the effectiveness and safety of prolapse surgery versus combined prolapse and incontinence surgery in women with pelvic organ prolapse. DESIGN AND SETTING: Pubmed, EMBASE, DARE, the Cochrane Library and the register of Current Controlled Trials were searched for randomised trials (restricted to Burch colposuspension and midurethral sling as incontinence procedure) from 1995 to 2013 limited to the English literature. METHODS: Two reviewers selected eligible articles and extracted the data. Pooling for SUI was based on three patient groups: (1) women with coexisting SUI; (2) women asymptomatic for SUI; and (3) women with occult SUI. For adverse events, pooling was based on incontinence procedure. MAIN OUTCOME MEASURES: The primary outcome was SUI. The secondary outcomes were treatment for SUI, bladder storage symptoms, obstructive voiding and adverse events. RESULTS: Seven trials were included. Pooling for women with coexisting SUI was possible for objective SUI with two studies and showed no difference. Statistical (I(2) = 95%) and clinical heterogeneity was, however, high. The largest study showed a lower incidence of persisting SUI (5% versus 23%) and treatment for this (0% versus 57%) in women who underwent prolapse repair with a midurethral sling. The second study did not find a difference in women undergoing a sacrocolpopexy with or without Burch colposuspension. In asymptomatic women, combination surgery resulted in a lower incidence of de novo subjective SUI (two studies; 24% versus 41%; relative risk [RR], 0.6; 95% confidence interval [CI], 0.3-0.9; I(2) = 36%) and the need for subsequent anti-incontinence surgery (three studies; 2% versus 7%; RR, 0.4; 95% CI, 0.2-0.8; I(2) = 13%). For the outcome objective SUI, pooling was possible for five studies, but statistical heterogeneity was high (I(2) = 82%) and the difference was not statistically significant. In the subgroup of women with occult stress incontinence, we found a lower incidence of objective SUI after combination surgery (two studies; 22% versus 52%; RR, 0.4; 95% CI, 0.3-0.8; I(2) = 32%). There were no differences in bladder storage symptoms, urgency incontinence or long-term obstructive voiding symptoms. Adverse events (two studies; 15% versus 10%; RR, 1.6; 95% CI, 1.0-2.5; I(2) = 0%) and prolonged catheterisation (three studies; 6% versus 1%; RR, 4.5; 95% CI, 1.5-13.3; I(2) = 0%) were more frequent after vaginal prolapse repair with a midurethral sling. CONCLUSIONS: Combination surgery reduces the risk of postoperative stress incontinence, but short-term voiding difficulties and adverse events were more frequent after combination surgery with a midurethral sling.