The impact of levator ani muscle trauma and contraction on recurrence after prolapse surgery.

INTRODUCTION AND HYPOTHESIS: The objective was to explore the impact of levator ani muscle (LAM) trauma and pelvic floor contraction on symptoms and anatomy after pelvic organ prolapse (POP) surgery. METHODS: Prospective study including 200 women with symptomatic POP ≥ grade 2 examined 3 months prior to and 6 months after surgery. Prolapse in each compartment was graded using the Pelvic Organ Prolapse Quantification (POP-Q) system, and women answered yes/no to a question about bulge sensation. Pelvic floor muscle contraction was assessed with transperineal ultrasound measuring proportional change in levator hiatal anteroposterior diameter from rest to contraction. LAM trauma was diagnosed using tomographic ultrasound imaging. Statistical analysis was performed using multivariate logistic regression analysis. RESULTS: A total of 183 women (92%) completed the study. Anatomical recurrence (POP ≥ grade 2) was found in 76 women (42%), and a bulge sensation was reported by 35 (19%). Ninety-two women (50%) had LAM trauma, and this was associated with increased risk of anatomical recurrence (OR 2.1 (95% CI 1.1-4.1), p = 0.022), but not bulge sensation (OR 1.1 (95% CI 0.5-2.4), p = 0.809). We found a reduced risk of bulge sensation for women with absent to weak contraction compared with normal to strong contraction (OR 0.4 (95% CI 0.1-0.9), p = 0.031), but no difference in risk for POP ≥ 2 after surgery (OR 1.5 (95% CI 0.8-2.9), p = 0.223). CONCLUSIONS: Levator ani muscle trauma was associated with increased risk of anatomical failure 6 months after POP surgery. Absent to weak pelvic floor muscle contraction was associated with reduced risk of bulge sensation after surgery.

Effect of preoperative pelvic floor muscle training on pelvic floor muscle contraction and symptomatic and anatomical pelvic organ prolapse after surgery: randomized controlled trial.

OBJECTIVES: To evaluate the effect of preoperative pelvic floor muscle training (PFMT) on pelvic floor muscle (PFM) contraction, symptoms of pelvic organ prolapse (POP) and anatomical POP, 6 months after prolapse surgery, and to assess the overall changes in PFM contraction, POP symptoms and pelvic organ descent after surgery. METHODS: This was a randomized controlled trial of 159 women with symptomatic POP, Stage 2 or higher, scheduled for surgery. Participants were randomized to intervention including daily PFMT from inclusion to surgery (n = 81) or no intervention (controls; n = 78). Participants were examined at inclusion, on the day of surgery and 6 months after surgery. PFM contraction was assessed by: vaginal palpation using the Modified Oxford scale (MOS; 0-5); transperineal ultrasound, measuring the percentage change in levator hiatal anteroposterior diameter (APD) from rest to maximum PFM contraction; vaginal manometry; and surface electromyography (EMG). POP distance from the hymen in the compartment with the most dominant prolapse and organ descent in the anterior, central and posterior compartments were measured on maximum Valsalva maneuver. POP symptoms were assessed based on the sensation of vaginal bulge, which was graded using a visual analog scale (VAS; 0-100 mm). Linear mixed models were used to assess the effect of PFMT on outcome variables. RESULTS: Of the 159 women randomized, 151 completed the study, comprising 75 in the intervention and 76 in the control group. Mean waiting time for surgery was 22 ± 9.7 weeks and follow-up was performed on average 28 ± 7.8 weeks after surgery. Postoperatively, no difference was found between the intervention and control groups with respect to PFM contraction assessed by vaginal palpation (MOS, 2.4 vs 2.2; P = 0.101), manometry (19.4 vs 19.7 cmH2 O; P = 0.793), surface EMG (33.5 vs 33.1 mV; P = 0.815) and ultrasound (change in hiatal APD, 20.9% vs 19.3%; P = 0.211). Furthermore, no difference between groups was found for sensation of vaginal bulge (VAS, 7.4 vs 6.0 mm; P = 0.598), POP distance from the hymen in the dominant prolapse compartment (-1.8 vs -2.0 cm; P = 0.556) and sonographic descent of the bladder (0.5 vs 0.8 cm; P = 0.058), cervix (-1.3 vs -1.1 cm; P = 0.569) and rectal ampulla (0.3 vs 0.4 cm; P = 0.434). In all patients, compared with findings at initial examination, muscle contraction improved after surgery, as assessed by palpation (MOS, 2.1 vs 2.3; P = 0.007) and ultrasound (change in hiatal APD, 17.5% vs 20.1%; P = 0.001), and sensation of vaginal bulge was reduced (VAS, 57.6 vs 6.7 mm; P < 0.001). In addition, compared with the baseline examination, POP distance from the hymen in the dominant prolapse compartment (1.9 vs -1.9 cm; P < 0.001) and sonographic descent of the bladder (1.3 vs 0.6 cm; P < 0.001), cervix (0.0 vs -1.2 cm; P < 0.001) and rectal ampulla (0.9 vs 0.4 cm; P = 0.001) were reduced. CONCLUSIONS: We found no effect of preoperative PFMT on PFM contraction, POP symptoms or anatomical prolapse after surgery. In all patients, PFM contraction and POP symptoms were improved at the 6-month follow-up, most likely due to the anatomical correction of POP. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

Efecto de los ejercicios preoperatorios de los músculos del suelo pélvico en la contracción de los músculos del suelo pélvico y en el prolapso sintomático y anatómico de los órganos pélvicos después de la cirugía: ensayo controlado aleatorizado OBJETIVOS: Evaluar el efecto de los ejercicios preoperatorios para los músculos del suelo pélvico (EMSP) en la contracción de los músculos del suelo pélvico (MSP), los síntomas del prolapso de órganos pélvicos (POP) y el POP anatómico, seis meses después de la cirugía de prolapso, y evaluar los cambios generales en la contracción de los MSP, los síntomas del POP y el descenso de los órganos pélvicos después de la cirugía. MÉTODOS: Este fue un ensayo controlado aleatorizado de 159 mujeres con POP sintomático, en Etapa 2 o superior, y en lista de espera para cirugía. Las participantes se asignaron al azar a una intervención que incluía EMSP diarios desde el ingreso hasta la cirugía (n=81) o ninguna intervención (controles; n=78). Las participantes fueron examinadas en el momento de su ingreso, el día de la cirugía y 6 meses después de la cirugía. La contracción de los MSP se evaluó mediante: palpación vaginal mediante la escala Oxford modificada (EOM; 0-5); ecografía transperineal, medición del porcentaje de cambio en el diámetro anteroposterior (DAP) del levador hiatal desde el reposo hasta la máxima contracción de los MSP; manometría vaginal; y electromiografía (EMG) de superficie. Se midió la distancia del POP desde el himen en el compartimento con el prolapso más dominante y el descenso de los órganos en los compartimentos anterior, central y posterior en la maniobra de Valsalva máxima. Los síntomas del POP fueron evaluados en base a la sensación de abultamiento vaginal, la cual fue calificada usando una escala análoga visual (EAV; 0-100 mm). Se utilizaron modelos mixtos lineales para evaluar el efecto de los EMSP en las variables de resultado. RESULTADOS: De las 159 mujeres asignadas al azar, 151 completaron el estudio, de las cuales 75 eran el grupo bajo intervención y 76 el grupo de control. El tiempo medio de espera para la cirugía fue de 22±9,7 semanas y el seguimiento se realizó en promedio a las 28±7,8 semanas después de la cirugía. En el postoperatorio, no se encontraron diferencias entre los grupos de intervención y de control con respecto a la contracción de los MSP evaluada mediante palpación vaginal (EOM, 2,4 vs 2,2; P=0,101), manometría (19,4 vs 19,7cm H2O; P=0,793), EMG de superficie (33,5 vs 33,1 mV; P=0,815) y ecografía (cambio en DAP del hiato, 20,9% vs 19,3%; P=0,211). Además, no se encontró ninguna diferencia entre los grupos en cuanto a la sensación de abultamiento vaginal (EAV, 7,4 vs 6,0 mm; P=0,598), la distancia del POP desde el himen en el compartimento dominante del prolapso (-1.8 vs -2,0 cm; P=0,556) y el descenso de la vejiga medido en ecografía (0,5 vs 0,8 cm; P=0,058), del cuello uterino (-1,3 vs -1,1 cm; P=0,569) y de la ampolla rectal (0,3 vs 0,4 cm; P=0,434). En todas las pacientes, en comparación con los hallazgos del examen inicial, la contracción muscular mejoró después de la cirugía, según se evaluó mediante la palpación (EOM, 2,1 vs 2,3; P=0,007) y la ecografía (cambio en la DPA del hiato, 17,5% vs 20,1%; P=0,001), y se redujo la sensación de abultamiento vaginal (EAV, 57.6 vs 6.7 mm; P<0.001). Además, en comparación con el examen de referencia, se redujeron la distancia del POP del himen en el compartimento dominante del prolapso (1,9 vs -1,9 cm; P<0.001) y el descenso de la vejiga medido en ecografía (1,3 vs 0,6 cm; P<0.001), del cuello uterino (0,0 vs −1,2 cm; P<0.001) y de la ampolla rectal (0,9 vs 0,4 cm; P=0.001). CONCLUSIONES: No se encontró ningún efecto de los EMSP preoperatorios en la contracción de los MSP, los síntomas del POP o el prolapso anatómico después de la cirugía. En todas las pacientes, la contracción de los MSP y los síntomas del POP mejoraron en el seguimiento a los 6 meses, debido muy probablemente a la corrección anatómica del POP. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

Ultrasound assessment of pelvic floor muscle contraction: reliability and development of an ultrasound-based contraction scale.

OBJECTIVES: To determine intra- and interrater reliability and agreement for ultrasound measurements of pelvic floor muscle contraction and to assess the correlation between ultrasound and vaginal palpation. We also aimed to develop an ultrasound scale for assessment of pelvic floor muscle contraction. METHODS: This was a cross-sectional study of 195 women scheduled for stress urinary incontinence (n = 65) or prolapse (n = 65) surgery or who were primigravid (n = 65). Pelvic floor muscle contraction was assessed by vaginal palpation using the Modified Oxford Scale (MOS) and by two- and three-dimensional (2D/3D) transperineal ultrasound. Proportional change in 2D and 3D levator hiatal anteroposterior (AP) diameter and 3D levator hiatal area between rest and contraction were used as measures of pelvic floor muscle contraction. One rater repeated all ultrasound measurements on stored volumes, which were used for intrarater reliability and agreement analysis, and three independent raters analyzed 60 ultrasound volumes for interrater reliability and agreement analysis. Reliability was assessed using the intraclass correlation coefficient (ICC) and agreement using Bland-Altman analysis. Tomographic ultrasound was used to identify women with major levator injury. Spearman's rank correlation coefficient (rS ) was used to assess the correlation between ultrasound measurements of pelvic floor muscle contraction and MOS score. The proportion of women allocated to each category of muscle contraction (absent, weak, moderate or strong) by palpation was used to determine the cut-offs for the ultrasound scale. RESULTS: Intrarater ICC was 0.81 (95% CI, 0.74-0.85) for proportional change in 2D levator hiatal AP diameter. Interrater ICC was 0.82 (95% CI, 0.72-0.89) for proportional change in 2D AP diameter, 0.80 (95% CI, 0.69-0.88) for proportional change in 3D AP diameter and 0.72 (95% CI, 0.56-0.83) for proportional change in hiatal area. The prevalence of major levator injury was 22.6%. The strength of correlation (rS ) between ultrasound measurements and MOS score was 0.52 for 2D AP diameter, 0.62 for 3D AP diameter and 0.47 for hiatal area (P < 0.001 for all). On the ultrasound contraction scale, proportional change in 2D levator hiatal AP diameter of < 1% corresponds to absent, 2-14% to weak, 15-29% to normal and > 30% to strong contraction. CONCLUSIONS: Ultrasound seems to be an objective and reliable method for evaluation of pelvic floor muscle contraction. Proportional change in 2D levator hiatal AP diameter had the highest ICC and moderate correlation with MOS score assessed by vaginal palpation, and we constructed an ultrasound scale for assessment of pelvic floor muscle contraction based on this measure. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Forceps delivery is associated with increased risk of pelvic organ prolapse and muscle trauma: a cross-sectional study 16-24 years after first delivery.

OBJECTIVES: To study possible associations between mode of delivery and pelvic organ prolapse (POP) and pelvic floor muscle trauma 16-24 years after first delivery and, in particular, to identify differences between forceps and vacuum delivery. METHODS: This was a cross-sectional study including 608 women who delivered their first child in 1990-1997 and were examined with POP quantification (POP-Q) and pelvic floor ultrasound in 2013-2014. Outcome measures were POP ≥ Stage 2 or previous prolapse surgery, levator avulsion and levator hiatal area on Valsalva. Univariable and multivariable logistic regression analyses and ANCOVA were applied to identify outcome variables associated with mode of delivery. RESULTS: Comparing forceps to vacuum delivery, the adjusted odds ratios (aOR) were 1.72 (95% CI, 1.06-2.79; P = 0.03) for POP ≥ Stage 2 or previous prolapse surgery and 4.16 (95% CI, 2.28-7.59; P < 0.01) for levator avulsion. Hiatal area on Valsalva was larger, with adjusted mean difference (aMD) of 4.75 cm(2) (95% CI, 2.46-7.03; P < 0.01). Comparing forceps with normal vaginal delivery, the adjusted odds ratio (aOR) was 1.74 (95% CI, 1.12-2.68; P = 0.01) for POP ≥ Stage 2 or surgery and 4.35 (95% CI, 2.56-7.40; P < 0.01) for levator avulsion; hiatal area on Valsalva was larger, with an aMD of 3.84 cm(2) (95% CI, 1.78-5.90; P < 0.01). Comparing Cesarean delivery with normal vaginal delivery, aOR was 0.06 (95% CI, 0.02-0.14; P < 0.01) for POP ≥ Stage 2 or surgery and crude OR was 0.00 (95% CI, 0.00-0.30; P < 0.01) for levator avulsion; hiatal area on Valsalva was smaller, with an aMD of -8.35 cm(2) (95% CI, -10.87 to -5.84; P < 0.01). No differences were found between vacuum and normal vaginal delivery. CONCLUSIONS: We found that mode of delivery was associated with POP and pelvic floor muscle trauma in women from a general population, 16-24 years after their first delivery. Forceps was associated with significantly more POP, levator avulsion and larger hiatal areas than were vacuum and normal vaginal deliveries. There were no statistically significant differences between vacuum and normal vaginal deliveries. Cesarean delivery was associated with significantly less POP and pelvic floor muscle trauma than were normal or operative vaginal delivery.

Pelvic organ prolapse and incontinence 15-23 years after first delivery: a cross-sectional study.

OBJECTIVE: To study the association between pelvic floor dysfunction (PFD) and mode of delivery and to calculate the risks of PFD comparing caesarean delivery and operative vaginal delivery to normal vaginal delivery 15-23 years after childbirth. A subgroup analysis comparing forceps and vacuum delivery was planned. DESIGN: Cross-sectional study. SETTING: Postal questionnaire. POPULATION: 1641 (53%) of 3115 women who delivered their first child in Trondheim, Norway, between January 1990 and December 1997. METHODS: A questionnaire including questions on symptomatic pelvic organ prolapse, urinary and fecal incontinence and surgery for these conditions. MAIN OUTCOME MEASURES: Prevalence of PFD measured by symptomatic pelvic organ prolapse or surgery (sPOP), urinary incontinence or surgery (UI) and fecal incontinence or surgery (FI). RESULTS: When caesarean delivery was compared to normal vaginal delivery the adjusted odds ratio (aOR) for sPOP was 0.42 (95% confidence interval, CI, 0.21-0.86) and the aOR for UI was 0.65 (95% CI 0.46-0.92). Operative vaginal delivery was associated with increased risk of sPOP (aOR 1.73, 95% CI 1.21-2.48) and FI (aOR 1.96, 95% CI 1.26-3.06) when compared with normal vaginal delivery. There were no differences in sPOP, UI or FI in a subgroup analysis comparing forceps and vacuum delivery. CONCLUSIONS: Caesarean delivery was associated with decreased risk and operative vaginal delivery with increased risk of pelvic floor dysfunction 15-23 years after first delivery, but there were no differences between forceps and vacuum delivery.

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.