Genital Hiatus Size and the Development of Prolapse Among Parous Women.

OBJECTIVE: In cross-sectional studies, pelvic organ prolapse is strongly associated with genital hiatus (GH) size. The objective of this study was to estimate prolapse incidence by the size of the GH among parous women followed prospectively. METHODS: Data were derived from a longitudinal study of pelvic floor disorders. Participants were followed annually for 2-9 years. Genital hiatus size and prolapse beyond the hymen were assessed with annual pelvic organ prolapse quantification examinations. Kaplan-Meier methods described prolapse-free survival as a function of GH size. Accounting for changes over time in GH size, lognormal models were used to estimate prolapse-free survival by GH size. This analysis was repeated separately for women who gave birth exclusively by cesarean versus those with at least one vaginal birth. RESULTS: Among 1,492 participants, median age at enrollment was 38 years; 153 (10.3%) developed prolapse over 2-9 years. The cumulative probability of prolapse increased substantially as the size of the GH increased. Lognormal models predicted that the estimated median time to develop prolapse would be 33.4 years for women with a persistent GH of 3 cm; in contrast, the estimated median time to develop prolapse would be 5.8 years for a GH of 4.5 cm or greater. Considering separately women who gave birth by cesarean versus those with at least 1 vaginal birth, GH size drastically modified prolapse risk in both birth groups. CONCLUSIONS: Prolapse incidence is strongly associated with GH size, regardless of delivery mode. These findings suggest that a wider GH is an important predictor of future prolapse risk.

Levator Morphology and Strength After Obstetric Avulsion of the Levator Ani Muscle.

OBJECTIVES: Obstetric levator avulsion may be an important risk factor for prolapse. This study compares the size of the levator hiatus, the width of the genital hiatus, and pelvic muscle strength between vaginally parous women with or without levator avulsion, 5 to 15 years after delivery. METHODS: Parous women were assessed for levator ani avulsion, using 3-dimensional transperineal ultrasound. Women with and without levator ani avulsion were compared with respect to levator hiatus areas (measured on ultrasound), genital hiatus (measured on examination), and pelvic muscle strength (measured with perineometry). Further analysis also considered the association of forceps-assisted birth. RESULTS: At a median interval of 11 years from first delivery, levator avulsion was identified in 15% (66/453). A history of forceps-assisted delivery was strongly associated with levator avulsion (45% vs 8%; P < 0.001). Levator avulsion was also associated with a larger levator hiatus area (+7.3 cm; 95% confidence interval [CI], 4.1-10.4, with Valsalva), wider genital hiatus (+0.6 cm; 95% CI, 0.3-0.9, with Valsalva), and poorer muscle strength (-14.5 cm H2O; 95% CI, -20.4 to -8.7, peak pressure). Among those with levator avulsion, forceps-assisted birth was associated with a marginal increase in levator hiatus size but not genital hiatus size or muscle strength. CONCLUSIONS: Obstetric levator avulsion is associated with a larger levator hiatus, wider genital hiatus, and poorer pelvic muscle strength. Forceps-assisted birth is an important marker for levator avulsion but may not be an independent risk factor for the development of pelvic muscle weakness or changes in hiatus size in the absence of levator avulsion.

Longitudinal Changes in the Genital Hiatus Preceding the Development of Pelvic Organ Prolapse.

We aimed to explore relationships between changes in genital hiatus (GH) and development of pelvic organ prolapse using data from the Mothers' Outcomes After Delivery (MOAD) Study, a Baltimore, Maryland, cohort study of parous women who underwent annual assessments during 2008-2018. Prolapse was defined as any vaginal segment protrusion beyond the hymen or reported prolapse surgery. For each case, 5 controls (matched on birth type and interval from first delivery to study enrollment) were selected using incidence sampling methods. We used a mixed model whose fixed effects described the initial size and slope of the GH as a function of prolapse status (case vs. control) and with nested (women within matched sets) random effects. Among 1,198 women followed for 1.0-7.3 years, 153 (13%) developed prolapse; 754 controls were matched to those women, yielding 3,664 visits for analysis. GH was 20% larger among the cases at enrollment (3.16 cm in cases vs. 2.62 cm in controls; P < 0.001), and the mean rate of increase in the size of the GH was more than 3 times greater (0.56 cm per 5-year period vs. 0.15 cm per 5-year period in controls; P < 0.001). Thus, to identify women at highest risk for developing prolapse, health-care providers could evaluate not simply the size of the GH but also changes in the GH over time.

Pelvic Floor Disorders After Obstetric Avulsion of the Levator Ani Muscle.

OBJECTIVES: With vaginal childbirth, 10% to 30% of women sustain levator ani muscle avulsion. The objective of this study was to estimate the cumulative incidence of prolapse and other pelvic floor disorders (PFDs), comparing vaginally parous women with and without levator avulsion. METHODS: Parous women enrolled in a longitudinal study were assessed annually for PFDs with the Pelvic Organ Prolapse Quantification Examination (for prolapse) and the Epidemiology of Prolapse and Incontinence Questionnaire (for stress incontinence, overactive bladder, and anal incontinence). Three-dimensional transperineal ultrasound was used to identify levator avulsion. Women with and without levator avulsion after vaginal delivery were compared for the cumulative incidence of PFDs. Further analysis also stratified by forceps delivery. RESULTS: At the time of assessment, 453 participants were 6 to 17 years from first delivery (median, 11 years). Levator avulsion was identified in 15% (66/453) and was more common among those who had undergone forceps-assisted delivery (P < 0.001). Levator avulsion was strongly associated with prolapse beyond the hymen (odds ratio, 2.7; 95% confidence interval, 1.3-5.7) and with symptoms of prolapse (odds ratio, 3.0; 95% confidence interval-1.2, 7.3). These associations persisted after controlling for forceps-assisted delivery. In contrast, the odds of stress incontinence, overactive bladder, and anal incontinence were marginally (but not significantly) increased among women with levator avulsion in this cohort. CONCLUSIONS: Obstetric levator avulsion is strongly associated with pelvic organ prolapse. The relationship between levator avulsion and other PFDs may not be significant.

Vaginal and laparoscopic mesh hysteropexy for uterovaginal prolapse: a parallel cohort study.

BACKGROUND: There is growing interest in uterine conservation at the time of surgery for uterovaginal prolapse, but limited data compare different types of hysteropexy. OBJECTIVE: We sought to compare 1-year efficacy and safety of laparoscopic sacral hysteropexy and vaginal mesh hysteropexy. STUDY DESIGN: This multicenter, prospective parallel cohort study compared laparoscopic sacral hysteropexy to vaginal mesh hysteropexy at 8 institutions. We included women ages 35-80 years who desired uterine conservation, were done with childbearing, and were undergoing 1 of the above procedures for stage 2-4 symptomatic anterior/apical uterovaginal prolapse (anterior descent at or beyond the hymen [Aa or Ba ≥ 0] and apical descent at or below the midvagina [C ≥ -TVL/2]). We excluded women with cervical elongation, prior mesh prolapse repair, cervical dysplasia, chronic pelvic pain, uterine abnormalities, and abnormal bleeding. Cure was defined as no prolapse beyond the hymen and cervix above midvagina (anatomic), no vaginal bulge sensation (symptomatic), and no reoperations. Pelvic Organ Prolapse Quantification examination and validated questionnaires were collected at baseline and 12 months including the Pelvic Floor Distress Inventory Short Form, Female Sexual Function Index, and Patient Global Impression of Improvement. In all, 72 subjects/group were required to detect 94% vs 75% cure (80% power, 15% dropout). Intention-to-treat analysis was used with logistic regression adjusting for baseline differences. RESULTS: We performed 74 laparoscopic sacral hysteropexy and 76 vaginal mesh hysteropexy procedures from July 2011 through May 2014. Laparoscopic patients were younger (P < .001), had lower parity (P = .006), were more likely premenopausal (P = .008), and had more severe prolapse (P = .02). Laparoscopic procedure (174 vs 64 minutes, P < .0001) and total operating time (239 vs 112 minutes, P < .0001) were longer. There were no differences in blood loss, complications, and hospital stay. One-year outcomes for the available 83% laparoscopic and 80% vaginal hysteropexy patients revealed no differences in anatomic (77% vs 80%; adjusted odds ratio, 0.48; P = .20), symptomatic (90% vs 95%; adjusted odds ratio, 0.40; P = .22), or composite (72% vs 74%; adjusted odds ratio, 0.58; P = .27) cure. Mesh exposures occurred in 2.7% laparoscopic vs 6.6% vaginal hysteropexy (P = .44). A total of 95% of each group were very much better or much better. Pelvic floor symptom and sexual function scores improved for both groups with no difference between groups. CONCLUSION: Laparoscopic sacral hysteropexy and vaginal mesh hysteropexy had similar 1-year cure rates and high satisfaction.

Do symptoms of pelvic floor disorders bias maternal recall of obstetrical events up to 10 years after delivery?

OBJECTIVES: The aim of this prospective study was to investigate whether symptoms of incontinence and prolapse bias maternal recall of obstetrical events up to 10 years after delivery. METHODS: In this secondary analysis of data gathered from the Mothers' Outcomes After Delivery study, we compared obstetrical medical records with maternal recall of delivery events. We calculated the agreement between maternal recall and the medical record across 1821 deliveries from 1011 participants for events including macrosomia, mode of delivery, prolonged second of labor, episiotomy, spontaneous laceration, anal sphincter laceration, and operative delivery. Women with symptomatic pelvic floor disorders were identified through administration of the Epidemiology of Prolapse and Incontinence Questionnaire or a clinical history of therapy for a pelvic floor disorder. We determined whether agreement between maternal recall and the medical record differed for those with or without symptoms using the medical record as a criterion standard. RESULTS: Agreement between maternal recall and the medical record was excellent for macrosomia and forceps deliveries (κ > 0.8), fair to good for episiotomy (κ = 0.61) and anal sphincter laceration (κ = 0.57), and poor for spontaneous perineal laceration (κ = 0.41). Symptomatic pelvic floor disorders did not impact maternal recall of macrosomia, prolonged second stage, episiotomy, spontaneous laceration, or operative delivery. However, recall of anal sphincter lacerations was biased by symptoms of pelvic floor disorders. Specifically, symptomatic women were significantly more likely to report a history of anal sphincter laceration, regardless of whether a sphincter laceration was documented (P = 0.025). CONCLUSIONS: Maternal recall of anal sphincter laceration may be biased by symptomatic pelvic floor disorders. In research based on maternal recall of obstetrical events, this could strengthen the apparent association between sphincter laceration and pelvic floor disorders.

Changes in maternal weight 5-10 years after a first delivery.

AIM: The objective of this study was to identify maternal, obstetrical and reproductive factors associated with long-term changes in maternal weight after delivery. MATERIALS & METHODS: Participants were enrolled in a longitudinal cohort study of maternal health 5-10 years after childbirth. Data were obtained from obstetrical records and a self-administered questionnaire. Weight at the time of first delivery (5-10 years prior) was obtained retrospectively and each woman's weight at the time of her first delivery was compared with her current weight. RESULTS: Among 948 women, obesity was associated with race, parity, education, history of diabetes and history of cesarean at the time of first delivery. On average, the difference between weight at the time of first delivery and weight 5-10 years later was -11 kg (11 kg weight loss). In a multivariate model, black race and diabetes were associated with significantly less weight loss. Cesarean delivery, parity and breastfeeding were not associated with changes in maternal weight. CONCLUSION: Black women and those with a history of diabetes may be appropriate targets for interventions that promote a long-term healthy weight after childbirth.

Longitudinal changes in pelvic organ support among parous women.

OBJECTIVE: The objective of this study was to characterize changes in pelvic organ support and symptoms of prolapse over time and identify characteristics associated with worsening of support. METHODS: Participants were recruited based on the mode of delivery (cesarean vs vaginal delivery) of their first child. The Pelvic Organ Prolapse Quantification system was used to describe support at baseline and 12 to 18 months later. Symptoms were assessed using a validated questionnaire. Outcomes of interest included the proportion of women with a change in support greater than 1 cm at the anterior vaginal wall (Ba) or posterior vaginal wall (Bp) and a change in support greater than 2 cm at the apex (C). Characteristics associated with worsening of support were identified using 2-sided Fisher's exact test and multivariable logistic regression. RESULTS: Among 749 participants, 60% had delivered by cesarean delivery only. Worsening support at Ba, Bp, and C was observed in 8%, 2%, and 6%, respectively. Worsening at any point was observed in 110 women (15%). Women with prolapse symptoms at baseline were not more likely to experience worsening of support. In a multivariable model, age older than 40 years (odds ratio [OR], 1.64; 95% confidence interval [CI], 1.09-2.49), vaginal delivery (OR, 3.12; 95% CI, 1.38-7.07), and genital hiatus greater than or equal to 2 (OR, 2.36; 95% CI, 1.03-5.43) were all associated with worsening support in at least 1 compartment. CONCLUSIONS: Over 12 to 18 months, characteristics most strongly associated with worsening of pelvic support include genital hiatus size, vaginal birth, and age.

Abdominal sacrocolpopexy: anatomic outcomes and complications with Pelvicol, autologous and synthetic graft materials.

OBJECTIVE: The purpose of this study was to compare anatomic outcomes and graft-related complications (GRCs) for abdominal sacrocolpopexy (ASC) with Pelvicol (CR BARD, Murray Hill, NJ), autologous fascia, and synthetic grafts. STUDY DESIGN: This is a retrospective cohort study of ASC from 2001-2005. We reviewed anatomic outcomes and GRCs. Apical failure was defined as >stage 0. RESULTS: Of 259 ASC procedures, Pelvicol was used in 102 procedures (39%); synthetic mesh in 134 procedures (52%), and autologous fascia in 23 procedures (9%). Mean postoperative follow up was 1.1 years. Apical failure by graft group were Pelvicol 10 (11%), synthetics 1 (1%), and autologous 1 (7%; P = .011). All 7 reoperations for apical prolapse were in the Pelvicol group. GRCs occurred in 16% of the cases, with a higher proportion of erosions in the Pelvicol group (11% vs 3% and 4%; P = .045). Reoperations as a result of GRC were similar between groups. CONCLUSION: ASC is more likely to fail with Pelvicol than with synthetic or autologous grafts. The use of Pelvicol did not reduce graft-related complications in this population.

A comparison of anticipatory and postprocedure pain perception in patients who undergo urodynamic procedures.

OBJECTIVE: The purpose of this study was to compare anticipatory and postprocedure pain perception in female patients who undergo multichannel urodynamic evaluation in an office setting. STUDY DESIGN: One hundred consecutive patients completed a visual analogue pain scale before and after urodynamic testing. RESULTS: The mean postprocedure pain score of 2.32 cm was significantly lower than the anticipatory pain rating of 4.35 cm (P<.05). The lower postprocedure pain score was not influenced by previous hysterectomy, body mass index, menopausal status, estrogen replacement therapy, or analgesic or psychiatric medication usage. Patients who had undergone previous anti-incontinence surgery reported significantly higher levels of pain during the procedure (mean visual analogue pain scale score, 3.10 cm vs 2.06 cm; P=.027). CONCLUSION: Patients who undergo urodynamic testing anticipate higher degrees of discomfort than they perceive during the procedure. Previous anti-incontinence surgery appears to lower the pain threshold.

A comparison of anticipated pain before and pain rating after the procedure in patients who undergo cystourethroscopy.

OBJECTIVE: The purpose of this study was to compare anticipated pain before the procedure and actual pain rating after the procedure in female patients who undergo cystourethroscopy. STUDY DESIGN: Eighty-seven consecutive female patients completed a 10-cm visual analog pain scale before and after cystourethroscopy. A 24F urethroscope was used initially to inspect the urethra and was followed by a systematic survey of the bladder with a 17F cystoscope that was lubricated with 2% lidocaine gel. The visual analog pain scale scores were evaluated for significance with the use of the Student t test and the Pearson correlation coefficient. RESULTS: Visual analog pain scale analysis demonstrated a mean anticipated pain score of 3.75 cm before the procedure versus a mean pain rating score of 2.83 cm after the procedure (P <.05). Neither a history of previous cystoscopy (visual analog pain scale score, 3.03 vs 2.30 cm; P =.18) nor talking with someone about the procedure beforehand (visual analog pain scale score, 2.74 vs 2.89 cm; P =.76) influenced the lower pain rating after the procedure. There was no significant correlation between age, parity, body mass index, or presence of pelvic organ prolapse and anticipated or realized pain perception. CONCLUSION: Patients who undergo cystourethroscopy consistently anticipate higher degrees of discomfort than they actually perceive during the procedure.