Multiomic analysis of uterine leiomyomas in self-described Black and White women: molecular insights into health disparities.

BACKGROUND: Black women are at an increased risk of developing uterine leiomyomas and experiencing worse disease prognosis than White women. Epidemiologic and molecular factors have been identified as underlying these disparities, but there remains a paucity of deep, multiomic analysis investigating molecular differences in uterine leiomyomas from Black and White patients. OBJECTIVE: To identify molecular alterations within uterine leiomyoma tissues correlating with patient race by multiomic analyses of uterine leiomyomas collected from cohorts of Black and White women. STUDY DESIGN: We performed multiomic analysis of uterine leiomyomas from Black (42) and White (47) women undergoing hysterectomy for symptomatic uterine leiomyomata. In addition, our analysis included the application of orthogonal methods to evaluate fibroid biomechanical properties, such as second harmonic generation microscopy, uniaxial compression testing, and shear-wave ultrasonography analyses. RESULTS: We found a greater proportion of MED12 mutant uterine leiomyomas from Black women (>35% increase; Mann-Whitney U, P<.001). MED12 mutant tumors exhibited an elevated abundance of extracellular matrix proteins, including several collagen isoforms, involved in the regulation of the core matrisome. Histologic analysis of tissue fibrosis using trichrome staining and secondary harmonic generation microscopy confirmed that MED12 mutant tumors are more fibrotic than MED12 wild-type tumors. Using shear-wave ultrasonography in a prospectively collected cohort, Black patients had fibroids that were firmer than White patients, even when similar in size. In addition, these analyses uncovered ancestry-linked expression quantitative trait loci with altered allele frequencies in African and European populations correlating with differential abundance of several proteins in uterine leiomyomas independently of MED12 mutation status, including tetracoidpeptide repeat protein 38. CONCLUSION: Our study shows that Black women have a higher prevalence of uterine leiomyomas harboring mutations in MED12 and that this mutational status correlates with increased tissue fibrosis compared with wild-type uterine leiomyomas. Our study provides insights into molecular alterations correlating with racial disparities in uterine leiomyomas and improves our understanding of the molecular etiology underlying uterine leiomyoma development within these populations.

Levator ani muscle volume and architecture in normal vs. muscle damage patients using 3D endovaginal ultrasound: a pilot study.

INTRODUCTION AND HYPOTHESIS: This study aimed to compare the difference in levator ani muscle (LAM) volumes between 'normal' and those with sonographically visualized LAM defects. We hypothesized that the 'muscle damage' group would have a significantly lower muscle volume. METHODS: The study included patients who had undergone a 3D endovaginal ultrasound. The normal (NM) and damage (DM) muscle groups' architectural changes were evaluated based on anterior-posterior (AP), left-right (LR) diameter, and minimal levator hiatus (MLH) area. The puboanalis-puboperinealis (PA), puborectalis (PR), and pubococcygeus-iliococcygeus (PC) were manually segmented using 2.5 vs. 1.0 mm to find the optimal sequence and to compare the volumes between NM and DM groups. POPQs were compared between the NM and DM groups. RESULTS: The 1.0-mm segmentation volumes created superior volume analysis. Comparing NM to the DM group showed no significant difference in LAM volume. Respectively, the mean total LAM volumes were 17.27 cm3 (SD = 3.97) and 17.04 cm3 (SD = 4.32), p = 0.79. The mean MLH measurements for both groups respectively were 10.06 cm2 (SD = 2.93) and 12.18 cm2 (SD = 2.93), indicating a significant difference (p = 0.01). POPQ analysis demonstrated statistically significant differences at Ba and Bp parameters suggesting that the DM group had worse prolapse (p = 0.05, 0.01, respectively). CONCLUSIONS: While LAM volumes are similar, there is a significant difference in the physical architecture of the LAM and the POPQ parameters in muscle-damaged patients compared to the normal group.

The Correlation Between the Sonographic Course of Transobturator Slings and Sling-Related Pain.

OBJECTIVES: To determine whether transobturator slings follow a consistent path and whether there is an association between ultrasonographically visualized sling pattern or position with sling-related pain. METHODS: This was a cross-sectional retrospective pilot study. We evaluated women who were presented to our clinic for pain or other urogynecologic symptoms following transobturator sling placement between 2009 and 2014. Patients had undergone a 3-dimensional endovaginal pelvic floor ultrasound, assessing minimal levator hiatus, antero-posterior diameter, left-right diameter, and the hiatal shape. The mesh patterns were categorized as seagull patterns (normal), lopsided, flat, and convoluted. RESULTS: A total of 68 cases were reviewed. Fifty patients reported pain, and 18 did not. There were wide variations in the course of the slings. The sling center- minimal levator hiatus position ranged 14.8 mm below and 17.9 mm above the minimal levator hiatus. The lateral arm insertion points ranged between 17.1 mm below and 16.6 mm above the minimal levator hiatus. The right arm insertion points ranged between 9.6 mm below and 18.8 mm above the minimal levator hiatus. Thirty-five of 68 (70%) patients with pain and 13 of 18 (72.2%) without had abnormal sling patterns. The abnormal sling shape was not correlated with pain (P = 1). The levator shape trended toward a statistical significant correlation with sling shape abnormality (P = .084). CONCLUSIONS: This population of women with transobturator sling complications demonstrated wide variations in anatomic paths. Neither the abnormal sling shape nor the distance of the center of the tape from the minimal levator hiatus level were correlated with pain.

Does aging affect the elastic properties of the bladder and the urethra in nulliparous women: An ultrasound shear-wave elastography study.

OBJECTIVE: To investigate how aging and menopausal status in absence of pregnancy and childbirth affect the elasticity of the bladder and urethra. STUDY DESIGN: A single-center prospective observational study including nulliparous 10 pre- and 12 postmenopausal women. Data collection included baseline characteristics, physical examination data, questionnaire scores, PDFI and the Pelvic Floor Impact Questionnaire, and pelvic floor sonographic measurements as well as elastography measurements. The shear wave elastography (SWE) of tissue was measured using Kilopascal (kPa). The elastography measurements were taken over the rhabdosphincter, the suburethra smooth muscle, and the trigonal areas. RESULTS: A total of 22 nulliparous subjects were enrolled in the study. The cohort's mean age was 43.5 years, the mean body mass index (BMI) was 26.8, and 86% were of Caucasian ethnicity. The postmenopausal group was older and with higher BMI (p < 0.001 and p = 0.05). They also had higher scores in all the questionnaires (p < 0.05 for all) and did not demonstrate prolapse in any compartments. The SWE results for the whole group were 35.2 kPa in the rhabdosphincter measuring point, 40.2 kPa in the sub-urethra point, and 20.6 kPa in the trigone point. Comparing the premenopause and postmenopause groups, we found lower measurements in the rhabdosphincter area and equivocal measurements for the suburethral zone. No statistically significant differences were found between the groups CONCLUSIONS: The elastic properties of the different bladder components and the urethra change with age and menopause. Using elastic properties of the tissues, we can further explore both stress urinary incontinence and overactive bladder.

Correlation between pelvic floor ultrasound parameters and vaginal pressures in nulliparous women: a subanalysis of the SUM-AN study.

INTRODUCTION AND HYPOTHESIS: Pelvic floor ultrasound is used as a validated technique for measuring levator ani dimensions. Vaginal manometry has been used in the past as a method to assess levator ani muscle (LAM) strength. Whether the combination of both methods can contribute to our understanding of pelvic floor pathophysiology has not yet been described. We hypothesized that as female pelvic floor muscular hiatus increases, the vaginal pressure and strength decrease. METHODS: We recruited 20 asymptomatic nulliparous women ages 18-85 years. Minimal levator hiatus (MLH) area, anteroposterior/left-right (AP/LR) diameter ratio, the distance between levator plate and the pubic symphysis (LP-PS) while at rest and squeeze were measured using endovaginal ultrasound (US). Vaginal pressure at rest, squeeze (Kegel) and Valsalva were measured using 3D manometry. Logistic and linear regression analysis was performed to assess correlations. RESULTS: MLH area was negatively correlated with the sum of all the squeeze pressures produced on the four walls of the vagina (p = 0.049, R2 = 0.197). There was also a borderline negative correlation between MLH and the sum of rest pressures (p = 0.09, R2 = 0.15). AP/LR ratio was negatively correlated with the sum of squeeze pressures (p = 0.056, R2 = 0.197). LP-PS distances, both while at rest and during squeeze, were negatively correlated with the vaginal squeeze pressure (p = 0.046, R2 = 0.21; p = 0.011, R2 = 0.31, respectively). LP-V distance, both at rest and during squeeze, was negatively correlated with the sum of squeeze pressures on four vaginal walls (p = 0.02, R2 = 0.25; p = 0.005, R2 = 0.36, respectively). CONCLUSIONS: Stronger levator ani muscles, smaller MLH area and a more oval shape of pelvic floor hiatus as assessed by pelvic floor ultrasound are associated with higher squeeze vaginal pressures as assessed by 3D manometry.

Biomechanical integrity score of the female pelvic floor.

INTRODUCTION AND HYPOTHESIS: The aim of this study is to develop and validate a new integral parameter, the Biomechanical Integrity score (BI-score), for the characterization of the female pelvic floor. METHODS: A total of 253 subjects with normal and pelvic organ prolapse (POP) conditions were included in the multi-site observational, case-control study; 125 subjects had normal pelvic floor conditions, and 128 subjects had POP stage II or higher. A Vaginal Tactile Imager (VTI) was used to acquire and automatically calculate 52 biomechanical parameters for eight VTI test procedures (probe insertion, elevation, rotation, Valsalva maneuver, voluntary muscle contractions in two planes, relaxation, and reflex contraction). Statistical methods were applied (t-test, correlation) to identify the VTI parameters sensitive to the pelvic conditions. RESULTS: Twenty-six parameters were identified as statistically sensitive to POP development. They were subdivided into five groups to characterize (1) tissue elasticity, (2) pelvic support, (3) pelvic muscle contraction, (4) involuntary muscle relaxation, and (5) pelvic muscle mobility. Every parameter was transformed to its standard deviation units against the patient age similar to T-score for bone density. Linear combinations with specified weights led to the composition of five component parameters for groups (1)-(5) and the BI-score in standard deviation units. The p-value for the BI-score has p = 4.3 × 10-31 for POP versus normal conditions. A reference BI-score curve against age for normal pelvic floor conditions was defined. CONCLUSIONS: Quantitative transformations of the pelvic tissues, support structures, and functions under diseased conditions may be studied with the BI-score in future research and practical applications.

Clinical and Patient Reported Outcomes of Pre- and Postsurgical Treatment of Symptomatic Uterine Leiomyomas: A 12-Month Follow-up Review of TRUST, a Surgical Randomized Clinical Trial Comparing Laparoscopic Radiofrequency Ablation and Myomectomy.

STUDY OBJECTIVE: The objective of this study was to determine the efficacy, safety, and healthcare resource use of laparoscopic radiofrequency ablation (LAP-RFA) compared with myomectomy in patients with symptomatic uterine leiomyomas (ULs). DESIGN: This was a secondary analysis of the original postmarket randomized, multicenter, longitudinal, comparative TRUST (Treatment Results of Uterine Sparing Technologies) United States trial in patients with symptomatic ULs. After the procedure, subjects were followed over a 12-month period. SETTING: Multicenter trial, including hospitals with or without an academic affiliation, surgery centers, and fertility centers performing outpatient procedures for uterine myomas. PARTICIPANTS: A total of 57 patients were randomized to either LAP-RFA (n = 30) or myomectomy (n = 27). INTERVENTIONS: LAP-RFA or myomectomy (laparoscopic or abdominal). MEASUREMENTS AND MAIN RESULTS: The main outcome measures of this study were part of the secondary outcomes of the original TRUST trial. The primary outcome of this study was the reduction of UL symptoms and the improvement in patient-reported outcomes scores over time. Secondary outcomes included postprocedure hospitalization, length of stay, complications, reinterventions, and recovery time. There was a significant improvement in UL symptoms at 3 and 12 months after the procedure within each treatment group, and these improvements were similar between treatment groups. There was a significant reduction in UL symptoms per month between baseline and 12-months after the procedure for both LAP-RFA and myomectomy of 72% and 85%, respectively. A significant improvement was seen in all patient-reported outcomes scores over time for both groups. At 3 and 12 months after the procedure, the percentages of patients who were hospitalized in the LAP-RFA group were 74% and 49% lower than those of patients in the laparoscopic myomectomy group, respectively, with the 3-month difference being statistically significant. The length of hospital stay was significantly shorter in the LAP-RFA group compared with the myomectomy group (8.0 ± 5.7 hours vs 18.8 ± 14.6 hours; p < .05). Doctors recommended taking significantly less time off before returning to work for the patients in the LAP-RFA group compared with those in the myomectomy group (10.3 ± 5.1 days vs 14.5 ± 5.4 days; p < .05). The total number of days until back to normal activity was significantly lower in the LAP-RFA group compared with the myomectomy group (16.3 ± 15.2 days vs 26.5 ± 15.9 days; p < .05). CONCLUSION: The results from this 12-month follow-up study suggest that LAP-RFA is a safe, effective, uterine-sparing alternative to laparoscopic myomectomy in the treatment of ULs. These data points build on previously published studies showing that LAP-RFA has lower healthcare resource use overall, including lower postprocedure hospitalization rate and shorter length of stay. In clinical practice, LAP-RFA is a promising treatment approach to ULs for women.

Consensus Definitions and Interpretation Templates for Magnetic Resonance Imaging of Defecatory Pelvic Floor Disorders: Proceedings of the Consensus Meeting of the Pelvic Floor Disorders Consortium of the American Society of Colon and Rectal Surgeons, the Society of Abdominal Radiology, the International Continence Society, the American Urogynecologic Society, the International Urogynecological Association, and the Society of Gynecologic Surgeons.

The Pelvic Floor Disorders Consortium (PFDC) is a multidisciplinary organization of colorectal surgeons, urogynecologists, urologists, gynecologists, gastroenterologists, radiologists, physiotherapists, and other advanced care practitioners. Specialists from these fields are all dedicated to the diagnosis and management of patients with pelvic floor conditions, but they approach, evaluate, and treat such patients with their own unique perspectives given the differences in their respective training. The PFDC was formed to bridge gaps and enable collaboration between these specialties. The goal of the PFDC is to develop and evaluate educational programs, create clinical guidelines and algorithms, and promote high quality of care in this unique patient population. The recommendations included in this article represent the work of the PFDC Working Group on Magnetic Resonance Imaging of Pelvic Floor Disorders (members listed alphabetically in Table 1). The objective was to generate inclusive, rather than prescriptive, guidance for all practitioners, irrespective of discipline, involved in the evaluation and treatment of patients with pelvic floor disorders.

The Fresh Frozen Cadaveric Study of Direct Pouch of Douglas Laparoscopic and Robotic Trocar Insertion for Vaginal Natural Orifice Transluminal Endoscopic Surgery.

STUDY OBJECTIVE: To determine the distances and angles that assure a safe entry into the pouch of Douglas (POD) during blind laparoscopic and robotic trocar entry. DESIGN: Trocars were inserted into the POD of 4 intact fresh frozen female pelves. Cadaveric dissection was performed, and the distance from the POD to the sacrum at rest and with maximal pressure to POD with the trocar was measured. In addition, the optimal angle for trocar insertion and entry was evaluated. SETTING: Inova Advanced Simulation and Technology Evaluation Center. PATIENTS: Fresh frozen cadavers with intact reproductive organs. INTERVENTIONS: Vaginal POD trocar insertion. MEASUREMENTS AND MAIN RESULTS: Measurements were recorded from the sacrum to the POD at rest and from the sacrum to the hymen with trocar pressure. The dissection demonstrated correct trocar placement in the POD of human cadaveric specimens. The mean distances from the sacrum to the hymen, the sacrum to the POD, and the sacrum to the POD with pressure were 18.75 cm, 9.75 cm, and 7.25 cm, respectively. After the deployment of the trocar, the tip was observed to be 2 cm below the cervix in the POD. The mean trocar angle to clear the sacral promontory and the neurovascular structures without injury to the uterus was 25° to 40° from the horizontal plane and 15° to 30° from the coronal plane. CONCLUSION: A direct trocar entry into the POD has been found to be feasible in fresh frozen cadaveric specimens. This study provided valuable information for the angle of entry into the POD to facilitate vaginal and robotic trocar entry for minimally invasive gynecologic procedures.

Ultrasongraphic age-related changes of the pelvic floor muscles in nulliparous women and their association with pelvic floor symptoms: A pilot study.

OBJECTIVE: To assess age-related changes in the pelvic floor muscular hiatus and their association with symptoms of pelvic organ prolapse, urinary and fecal incontinence, and sexual function. METHODS: In this pilot study we performed 3D endovaginal ultrasonography in two age groups of nulliparous women: 18 to 40 years and 52 to 85 years. Anterior-posterior (AP) diameter, left-right (LR) diameter, and the Minimal Levator Hiatus area were measured. The AP/LR ratio was calculated to compare the shape of the pelvic floor muscles between participants (oval vs circular). Other measurements included length of the urethra, and levator plate lift. Participants were assessed for (1) distress symptoms of pelvic floor prolapse, urinary, and fecal symptoms by the Pelvic Floor Distress Inventory-20, (2) quality of life via the pelvic floor impact inventory-7, and (3) sexual function by the female sexual function inventory (FSFI-19). RESULTS: A total of 12 women into the younger group and 10 to the older group were recruited. Older women had higher AP/LR ratio and longer distance levator plate lift while performing the squeeze maneuver ( P = 0.017 and 0.038, respectively). Older women had worse urinary and pelvic organ prolapse symptoms ( P = 0.002 and 0.004, respectively). Fewer women in the older group were sexually active (60% vs 92%) and their quality of sexual life was lower based on their FSFI-19 results. CONCLUSION: Levator ani muscle hiatus changes to a more oval form in older nulliparous postmenopausal women and this change in shape is associated with increased pelvic floor symptoms.

IUGA committee opinion: laser-based vaginal devices for treatment of stress urinary incontinence, genitourinary syndrome of menopause, and vaginal laxity.

This committee opinion reviews the laser-based vaginal devices for treatment of genitourinary syndrome of menopause, vaginal laxity, and stress urinary incontinence. The United States Food and Drug Administration has issued a warning for unsubstantiated advertising and use of energy-based devices. Well-designed case-control studies are required to further investigate the potential benefits, harm, and efficacy of laser therapy in the treatment of genitourinary syndrome of menopause, vaginal laxity, and stress urinary incontinence. The therapeutic advantages of nonsurgical laser-based devices in urogynecology can only be recommended after robust clinical trials have demonstrated their long-term complication profile, safety, and efficacy.

Twelve years' experience with fascia lata autograft to replace complicated anterior vaginal mesh.

OBJECTIVES: To report 12-year experience with replacing transvaginal mesh (TVM) with fascia lata autograft. METHODS: This was a chart review of TVM removal and replacement with a fascia lata autograft placement by a single surgeon between 2005 and 2017. The Pelvic Organ Prolapse Quantification (POP-Q) system before and 1 year following the procedure, patient-reported recurrence of symptoms, changes in the POP-Q examination and complication rates are analyzed. RESULTS: Twenty-four patients were included. Mean age was 57.2 (95% CI 53.2-61.2) years. Mean number of days to Foley catheter removal was 3.2 days (95% CI 1.6-4.9) and mean number of days to drain removal was 10.9 days (95% CI 9.9-12.0). Following the surgery, no leg seroma, infection or numbness was reported. UTI occurred in four (16.7%) of the participants postoperatively. At 3-month follow-up, mild urinary symptoms were reported in five participants (20.8%). At 1-year follow-up, one participant was symptomatic of pelvic organ prolapse. Paired t-test analysis revealed statistically significant retraction of Aa and Ba vaginal points (p < 0.001). C, GH and PB points were also statistically significantly retracted. CONCLUSION: Fascia lata autograft for anterior compartment reconstruction due to TVM complications is associated with high safety and efficacy rates.

How does 3D endovaginal ultrasound compare to magnetic resonance imaging in the evaluation of levator ani anatomy?

INTRODUCTION AND HYPOTHESIS: To compare magnetic resonance imaging (MRI) to 3D endovaginal ultrasound (EVUS) in the evaluation of major levator ani defects in women with pelvic floor disorders. METHODS: A total of 21 subjects with pelvic floor with complaints of pelvic floor disorders were included in this study. EVUS imaging of the levator ani muscle (LAM) was performed in all subjects, and the LA muscle groups of interest evaluated were the puboanalis (PA), puborectalis (PR), and pubovisceralis (PV) muscles. The right and left subdivisions were evaluated separately, and classified as (i) normal, normal with only minor irregularities, grossly abnormal, or absent, or (ii) by the levator ani deficiency (LAD) score and classified by no defect (complete attachment of muscle to the pubic bone), <50% detachment or loss, >50% detachment or loss, and completely detached or complete muscle loss. Paired data were analyzed with McNemar's test or Bowker's test of symmetry. RESULTS: When unilateral LAM subdivisions were classified as "normal," "normal with minor irregularity," "grossly abnormal," and "absent," there were no significant differences between MRI and EVUS by categorization of LAM defects. Comparing "normal" versus "abnormal," there was no difference between imaging modalities. When compared by LAD score evaluation, there were no differences in the categorization of unilateral defects between MRI and EVUS. CONCLUSIONS: Endovaginal 3D US is comparable to MRI in its ability to identify both normal and abnormal LAM anatomy. Neurourol. Urodynam. 36:409-413, 2017. © 2015 Wiley Periodicals, Inc.

A Feasibility Study to Determine Whether Clinical Contrast Enhanced Magnetic Resonance Imaging can Detect Increased Bladder Permeability in Patients with Interstitial Cystitis.

PURPOSE: Interstitial cystitis/bladder pain syndrome is a bladder pain disorder associated with voiding symptomatology and other systemic chronic pain disorders. Currently diagnosing interstitial cystitis/bladder pain syndrome is complicated as patients present with a wide range of symptoms, physical examination findings and clinical test responses. One hypothesis is that interstitial cystitis symptoms arise from increased bladder permeability to urine solutes. This study establishes the feasibility of using contrast enhanced magnetic resonance imaging to quantify bladder permeability in patients with interstitial cystitis. MATERIALS AND METHODS: Permeability alterations in bladder urothelium were assessed by intravesical administration of the magnetic resonance imaging contrast agent Gd-DTPA (Gd-diethylenetriaminepentaacetic acid) in a small cohort of patients. Magnetic resonance imaging signal intensity in patient and control bladders was compared regionally and for entire bladders. RESULTS: Quantitative assessment of magnetic resonance imaging signal intensity indicated a significant increase in signal intensity in anterior bladder regions compared to posterior regions in patients with interstitial cystitis (p <0.01) and significant increases in signal intensity in anterior bladder regions (p <0.001). Kurtosis (shape of probability distribution) and skewness (measure of probability distribution asymmetry) were associated with contrast enhancement in total bladders in patients with interstitial cystitis vs controls (p <0.05). Regarding symptomatology interstitial cystitis cases differed significantly from controls on the SF-36®, PUF (Pelvic Pain and Urgency/Frequency) and ICPI (Interstitial Cystitis Problem Index) questionnaires with no overlap in the score range in each group. ICSI (Interstitial Cystitis Symptom Index) differed significantly but with a slight overlap in the range of scores. CONCLUSIONS: Data suggest that contrast enhanced magnetic resonance imaging provides an objective, quantifiable measurement of bladder permeability that could be used to stratify bladder pain patients and monitor therapy.

Clinical and ultrasonographic study of patients presenting with transvaginal mesh complications.

AIM: The objective of this study was to investigate the clinical and ultrasonographic findings of women who had three-dimensional endovaginal ultrasound (EVUS) for the management of vaginal mesh complications. METHODS: This was a retrospective study of patients that had EVUS due to mesh complications at a tertiary care center. The clinical charts were reviewed. The stored 3D volumes were reviewed regarding mesh information by two examiners independently. The predictive value of physical examination for detection of vaginal mesh was calculated. Patient outcomes were reviewed. RESULTS: Seventy-nine patients presented to our center because of their, or their physicians' concern regarding mesh complications. Forty-one (51.9%) had vaginal/pelvic pain, and 51/62 (82.2%) of sexually active women experienced dyspareunia. According to ultrasonographic findings, mesh or sling was not demonstrated in six patients who believed they have had mesh/sling implantation. The positive predictive value for vaginal examination was 94.5% (95% CI: 84.9%-98.8%), negative predictive value was 12.5% (95% CI: 2.8%-32.4%), sensitivity was 72.2% (95% CI: 59.4%-81.2%), and specificity was 50.0% (95% CI: 12.4%-87.6%). Fifty-four patients were indicated for surgical treatment. Median postoperative review was 12 (range, 3-18) months and 38/53 (71.7%) patients were satisfied. CONCLUSIONS: The most common complaints of vaginal mesh complications were pain and dyspareunia. EVUS appeared to be helpful for assessing mesh presence, location, and extent including planning for surgical intervention.

Characteristics associated with pelvic organ prolapse in women with significant levator ani muscle deficiency.

INTRODUCTION AND HYPOTHESIS: Age is a factor associated with symptomatic pelvic organ prolapse (POP) among women with significant levator ani deficiency. METHODS: This cross-sectional study included patients who were referred for varied pelvic floor disorders, had 3D endovaginal ultrasound as part of their evaluation, and were diagnosed with significant levator ani muscle deficiency defined as a score of 12 or more on 3D endovaginal ultrasound. Patients were categorized as having no pelvic organ prolapse (stages 0 and 1), or symptomatic prolapse (stages 2-4). RESULTS: Seventy-six women were available for analysis and found to have significant levator ani muscle deficiency, including 51 with symptomatic POP and 25 without POP. Patients with symptomatic POP were older, (mean age 66 (SD ± 11.8) vs 48 (SD ± 17.3) years; p <0.0001), had greater mean minimal levator hiatus (MLH) area (19.7 cm(2) (SD ± 4.6) vs 17.5 cm(2) (SD ± 3.5); p = 0.048), and were more likely to be menopausal (91.3 % vs 54.5 %; p <0.001) compared with those with no POP. In a modified Poisson regression analysis excluding nulliparous women, increasing age (RR = 2.39, 95 % CI 1.03-5.55) and smoking (RR = 1.34, 95 % CI 1.08-1.67) remained associated with symptomatic POP after controlling for one another and the MLH area. CONCLUSIONS: Among women with significant levator ani deficiency, older women and smokers had an increased prevalence of symptomatic POP. On average, women without POP, but with significant levator ani deficiency were 18 years younger than women with POP and significant muscle deficiency.