Soft-tissue dystocia due to paradoxical contraction of the levator ani as a cause of prolonged second stage: concept, diagnosis, and potential treatment.

Smaller pelvic floor dimensions seem to have been an evolutionary need to provide adequate support for the pelvic organs and the fetal head. Pelvic floor dimension and shape contributed to the complexity of human birth. Maternal pushing associated with pelvic floor muscle relaxation is key to vaginal birth. Using transperineal ultrasound, pelvic floor dimensions can be objectively measured in both static and dynamic conditions, such as pelvic floor muscle contraction and pushing. Several studies have evaluated the role of the pelvic floor in labor outcomes. Smaller levator hiatal dimensions seem to be associated with a longer duration of the second stage of labor and a higher risk of cesarean and operative deliveries. Furthermore, smaller levator hiatal dimensions are associated with a higher fetal head station at term of pregnancy, as assessed by transperineal ultrasound. With maternal pushing, most women can relax their pelvic floor, thus increasing their pelvic floor dimensions. Some women contract rather than relax their pelvic floor muscles under pushing, which is associated with a reduction in the anteroposterior diameter of the levator hiatus. This phenomenon is called levator ani muscle coactivation. Coactivation in nulliparous women at term of pregnancy before the onset of labor is associated with a higher fetal head station at term of pregnancy and a longer duration of the second stage of labor. In addition, levator ani muscle coactivation in nulliparous women undergoing induction of labor is associated with a longer duration of the active second stage of labor. Whether we can improve maternal pelvic floor relaxation with consequent improvement in labor outcomes remains a matter of debate. Maternal education, physiotherapy, and visual feedback are promising interventions. In particular, ultrasound visual feedback before the onset of labor can help women increase their levator hiatal dimensions and correct levator ani muscle coactivation in some cases. Ultrasound visual feedback in the second stage of labor was found to help women push more efficiently, thus obtaining a lower fetal head station at ultrasound and a shorter duration of the second stage of labor. The available evidence on the role of any intervention aimed to aid women to better relax their pelvic floor remains limited, and more studies are needed before considering its routine clinical application.

Assessment of the bearing-down manoeuvre in pregnancy and detection of paradoxical levator ani muscle contraction using 2D transperineal ultrasound and vaginal palpation: a concurrent validity and inter-rater reliability study.

OBJECTIVE: To examine the concurrent validity and inter-rater reliability of vaginal palpation as a measure of the quality of the bearing-down manoeuvre (BDM) and the detection of a paradoxical levator ani muscle contraction (LAM) in pregnant women, compared with 2D transperineal ultrasound (TPUS). DESIGN: Concurrent validity and inter-rater reliability study. SETTING: Physiotherapy clinic. POPULATION: Twenty pregnant women in their third trimester. METHODS: The anterior posterior diameter (APD) was measured during the BDM using TPUS by one experienced physiotherapist. An APD that shortened by >2 mm from rest was described as LAM shortening, an APD that moved by 0-2 mm was described as no change and an APD that lengthened by >2 mm was described as LAM lengthening. Vaginal palpation described the LAM during the BDM as no movement, shortening or lengthening. Participants were allowed two attempts and the best attempt was measured. MAIN OUTCOME MEASURES: APD using TPUS and the assessor's subjective description of LAM during the BDM using vaginal palpation. RESULTS: TPUS detected more paradoxical LAM contractions during the BDM than palpation. Agreement between vaginal palpation and TPUS assessment for BDM was poor. The Fleiss kappa coefficients were 0.457 (90% CI 0.16-0.71) between TPUS and one assessor and 0.326 (90% CI 0.01-0.6) between TPUS and the other assessor. In addition, inter-rater reliability was poor between observers palpating the BDM, with a Fleiss kappa coefficient of 0.375 (90% CI 0.13-0.64). CONCLUSIONS: This study did not find vaginal palpation of the BDM in pregnant women to have concurrent validity or inter-rater reliability. Clinicians should be aware of potential inaccuracies when palpating the BDM, and, where possible, seek an assessment via TPUS.

Prevalence of levator ani muscle injuries in primiparous women after delivery and their influence on pelvic floor disorders-systematic review.

BACKGROUND: Studies show a significant association between the first vaginal delivery and injuries of the levator ani muscle (LAM), which can cause pelvic floor disorders (PFDs). OBJECTIVES: This study aims to identify the prevalence of short and long-term LAM injuries after vaginal delivery in primiparous women and its influence on PFDs. METHOD: A systematic review was conducted according to the PRISMA methodology. The databases used were Pubmed, Cochrane, and PEDro. The quality assessment of the evidence was carried out using the Critical Appraisal Skills Programme (CASP). Both the selection of studies and their evaluation were done by two researchers and a third reviewer in cases of disagreement. RESULTS: From the search, 57 articles were gathered, and 19 were included to match the eligibility criteria. The prevalence of avulsion of the LAM was found in association with vaginal delivery between 13% and 28% ≤ 1 year after delivery and between 16% and 29% > 1 year after delivery. Ballooning was detected between 20% and 37% ≤ 1 year, and 33% of women > 1 year after delivery, appearing to be more common when compared to avulsion. Pelvic organ prolapse (POP) was considered the most common disorder associated with injuries of the LAM, and there seems to be some connection with sexual dysfunction. CONCLUSION: Avulsion of the LAM and ballooning of the hiatal area have a high prevalence in primiparous women after vaginal delivery and have a strong direct relation to the development of POP.

Feasibility and reproducibility of new technique for measurement of transverse diameter of levator ani muscle hiatus using two-dimensional transperineal ultrasound in nulliparous women with term pregnancy.

OBJECTIVES: The aim of the present study was two-fold. Firstly, we aimed to develop and describe a technique for measurement of the transverse diameter (TD) of the levator ani muscle (LAM) hiatus in the coronal view using two-dimensional (2D) transperineal ultrasound (TPUS) in nulliparous women with a term pregnancy. Secondly, we aimed to evaluate the feasibility and reproducibility of 2D-TPUS assessment of LAM hiatal TD and assess intermethod agreement between 2D-TPUS and three-dimensional (3D) TPUS measurement of TD in the axial plane, which is considered the gold standard in nulliparous women with term pregnancy. METHODS: We recruited a group of nulliparous women with term pregnancy before the onset of labor. The study was conducted in two phases: Phase 1 involved developing and describing the 2D-TPUS technique for measuring LAM hiatal TD, and Phase 2 focused on assessing the technique's feasibility, reproducibility and intermethod agreement with 3D-TPUS measurement of LAM hiatal TD. In Phase 1, we enrolled 30 women. Each woman underwent acquisition of a 3D-TPUS volume, which was analyzed using multiplanar mode to identify and determine the appearance of the lateral borders of the LAM in the coronal plane, at the level of the plane of minimal hiatal dimensions. These borders were used as landmarks for TD measurement. Additionally, we measured the distance between the plane used for TD measurement and the center of the urethra in the axial view. In Phase 2, we recruited 100 women. Each woman underwent acquisition of three 2D-TPUS videoclips in the coronal plane, each encompassing a sweep of the entire LAM hiatus, and a 3D volume, all obtained during rest. On the 2D videoclips, TD was measured twice by one operator and once by another operator. In the 3D volume, TD was measured once, by one operator, in the axial plane; this measurement was considered the gold standard. Each operator was blinded to all other measurements during their assessments. We analyzed intraobserver and interobserver reproducibility and performed an intermethod (2D vs 3D) comparison. Bland-Altman analysis was conducted, and Levene's W0 test and Student's t-test were performed to explore clinical factors that might contribute to systematic differences. RESULTS: In Phase 1, we identified successfully the landmarks denoting the lateral borders of the LAM hiatal TD in the coronal view. These appeared as two symmetrical hypoechogenic indentations located at the inner border of the hyperechogenic structure of the LAM, at the point of maximum distance between the two sides of the LAM. The distance between the urethra and the plane where TD should be measured using 3D-TPUS in the axial plane had a median of 4 mm and varied from 0 to 9 mm. This enabled us to describe a method for assessing LAM hiatal TD in the coronal plane using 2D-TPUS. In Phase 2, LAM hiatal TD was measured successfully in all 2D and 3D acquisitions from the entire group of 100 women. The analyses for intraobserver and interobserver reproducibility and the intermethod comparison (2D vs 3D) revealed almost perfect agreement in TD measurements using 2D-TPUS, with intraclass correlation coefficients of 0.95 (95% CI, 0.92-0.96), 0.87 (95% CI, 0.78-0.92) and 0.85 (95% CI, 0.78-0.90), respectively. The average differences between measurements were 0.1 mm for intraobserver, 1.0 mm for interobserver and 0.2 mm for intermethod repeatability. No systematic differences were observed in any of the measurement sets, except in the interobserver analysis, although this difference was clinically not significant (38.2 vs 37.2 mm, P = 0.01). None of the examined clinical factors (maternal body mass index and maternal age) exhibited a statistically significant impact on intraobserver, interobserver or intermethod reliability. CONCLUSIONS: Utilizing our technique, described herein, to measure the LAM hiatal TD in the coronal view using 2D-TPUS is not only feasible but also highly reproducible and accurate in nulliparous women with term pregnancy. Moreover, it yields measurements that are comparable to those obtained in the reconstructed axial plane generated by 3D-TPUS. © 2024 International Society of Ultrasound in Obstetrics and Gynecology.

Levator ani muscle avulsion and subsequent vaginal delivery: 8-year longitudinal follow-up.

OBJECTIVES: To assess the evolution of levator ani muscle (LAM) avulsion from 1 year to 8 years after first delivery in women with and those without subsequent vaginal delivery. In addition, to assess whether women with full or partial avulsion 8 years after first delivery have larger LAM hiatal area and more symptoms of pelvic organ prolapse compared to women with normal LAM insertion. METHODS: In this single-center longitudinal study, 195 women who were primiparous at the start of the study were included and underwent transperineal ultrasound examination 1 year and 8 years after first delivery. Muscle insertion was assessed by tomographic ultrasound imaging in the axial plane. Full LAM avulsion was defined as abnormal muscle insertion in all three central slices. Partial LAM avulsion was defined as abnormal muscle insertion in one or two central slices. Eight years after the first delivery, LAM hiatal area was assessed at rest, during maximum pelvic floor muscle contraction and on maximum Valsalva maneuver. To assess symptoms of pelvic organ prolapse, the vaginal symptoms module of the International Consultation on Incontinence Questionnaire was used. RESULTS: At 1-year follow-up, 25 (12.8%) women showed signs of LAM avulsion, of whom 20 fulfilled the sonographic criteria of full avulsion and five of partial avulsion. Eight years after the first delivery, 35 (17.9%) women were diagnosed with avulsion, of whom 25 were diagnosed with full avulsion and 10 with partial avulsion. No woman with partial or full avulsion at 1 year had improved avulsion status at 8-year follow-up. Of the 150 women who had subsequent vaginal delivery, 21 (14.0%) women were diagnosed with partial or full LAM avulsion 1 year after first delivery, and 31 (20.7%) women were diagnosed with partial or full avulsion 8 years after first delivery. Of the 45 women without subsequent vaginal delivery, one woman with partial avulsion 1 year after first delivery was diagnosed with full avulsion at 8-year follow-up. All women with full avulsion at 1-year follow-up were diagnosed with full avulsion at 8-year follow-up regardless of whether they had subsequent vaginal delivery. At 8-year follow-up, women with full avulsion had statistically significantly larger LAM hiatal area compared to women with normal muscle insertion. Mean ± SD vaginal symptom scores ranged between 5.5 ± 5.7 and 6.0 ± 4.0 and vaginal symptom quality of life scores ranged between 0.9 ± 1.4 and 1.5 ± 2.2 and did not differ significantly between women with normal muscle insertion and women with partial or full avulsion at 8-year follow-up. CONCLUSIONS: More LAM avulsions were present 8 years compared with 1 year after first delivery in women with subsequent vaginal delivery. Except for one primipara, all women without subsequent vaginal delivery had unchanged LAM avulsion status between 1 year and 8 years after their first delivery. Larger LAM hiatal area was found in women with full avulsion compared to those with normal muscle insertion at 8-year follow-up. Vaginal symptoms scores were low and did not differ between women with normal muscle insertion and those with partial or full avulsion at 8-year follow-up. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Validation of a built-in software in automatically reconstructing the tomographic images of the levator ani muscle.

INTRODUCTION AND HYPOTHESIS: Transperineal ultrasound (TPUS) is an effective tool for evaluating the integrity of the levator ani muscle (LAM). Several operating steps are required to obtain the standard multi-slice image of the LAM, which is experience dependent and time consuming. This study was aimed at evaluating the feasibility and reproducibility of the built-in software, Smart-pelvic™, in reconstructing standard tomographic images of LAM from 3D/4D TPUS volumes. METHODS: This study was conducted at a tertiary teaching hospital, enrolling women who underwent TPUS. Tomographic images of the LAM were automatically reconstructed by Smart-pelvicTM and rated by two experienced observers as standard or nonstandard. The anteroposterior diameter (APD) of the levator hiatus was also measured on the mid-sagittal plane of the automatically and manually reconstructed images. The APD measurements of each approach were compared using Bland-Altman plots, and interclass correlation coefficient (ICC) was used to evaluate intra- and inter-observer reproducibility. Meanwhile, the time taken for the reconstruction process of both methods was also recorded. RESULTS: The ultrasound volume of a total of 104 patients were included in this study. Using Smart-pelvicTM, the overall success rate of the tomographic image reconstruction was 98%. Regarding measurements of APD, the ICC between the automatic and manual reconstruction methods was 0.99 (0.98, 0.99). The average time taken for reconstruction per case was 2.65 ± 0.52 s and 22.08 ± 3.45 s, respectively. CONCLUSIONS: Using Smart-pelvicTM to reconstruct tomographic images of LAM is feasible, and it can promote TPUS by reducing operator dependence and improving examination efficiency in a clinical setting.

Applicability of Deep Learning to Dynamically Identify the Different Organs of the Pelvic Floor in the Midsagittal Plane.

INTRODUCTION AND HYPOTHESIS: The objective was to create and validate the usefulness of a convolutional neural network (CNN) for identifying different organs of the pelvic floor in the midsagittal plane via dynamic ultrasound. METHODS: This observational and prospective study included 110 patients. Transperineal ultrasound scans were performed by an expert sonographer of the pelvic floor. A video of each patient was made that captured the midsagittal plane of the pelvic floor at rest and the change in the pelvic structures during the Valsalva maneuver. After saving the captured videos, we manually labeled the different organs in each video. Three different architectures were tested-UNet, FPN, and LinkNet-to determine which CNN model best recognized anatomical structures. The best model was trained with the 86 cases for the number of epochs determined by the stop criterion via cross-validation. The Dice Similarity Index (DSI) was used for CNN validation. RESULTS: Eighty-six patients were included to train the CNN and 24 to test the CNN. After applying the trained CNN to the 24 test videos, we did not observe any failed segmentation. In fact, we obtained a DSI of 0.79 (95% CI: 0.73 - 0.82) as the median of the 24 test videos. When we studied the organs independently, we observed differences in the DSI of each organ. The poorest DSIs were obtained in the bladder (0.71 [95% CI: 0.70 - 0.73]) and uterus (0.70 [95% CI: 0.68 - 0.74]), whereas the highest DSIs were obtained in the anus (0.81 [95% CI: 0.80 - 0.86]) and levator ani muscle (0.83 [95% CI: 0.82 - 0.83]). CONCLUSIONS: Our results show that it is possible to apply deep learning using a trained CNN to identify different pelvic floor organs in the midsagittal plane via dynamic ultrasound.

The Application of Shear Wave Elastography to Determine the Elasticity of the Levator Ani Muscle and Vaginal Tissue in Patients With Pelvic Organ Prolapse.

OBJECTIVES: The changes of the extracellular matrix of the connective tissue have significantly contributed to the incidence of pelvic organ prolapse (POP). It seems reasonable that sonoelastography could be a useful tool to evaluate the elasticity of pelvic floor tissue in patients with POP and compare it to those without POP. The main aim of this pilot study was to determine if there are differences in the elasticity of the levator ani muscle (LAM) and vaginal tissue between patients with and without POP. METHODS: Prospective observation study, including 60 patients (30 with POP and 30 without POP). Sonoelastography was performed to evaluate the elasticity (in kilopascals, kPa) of the following regions of interest: vagina at the level of middle third of the urethra; vagina at the level of the bladder trigone; vagina in the anterior and posterior fornix; vagina at the level of middle third of the anorectal canal; posterior third of the LAM. RESULTS: A total of 60 patients completed the study (30 with POP, 30 without POP). In the POP group, 18/30 (60%) had an anterior vaginal wall prolapse, 3/30 (10%) a uterine prolapse, 15/30 (50%) a rectocele, and 6/30 (20%) a enterocele. Patients with POP had higher elasticity in all anatomical study areas, with statistically significant differences in the anterior fornix (13.6 vs 11.2 kPa; P: .012). A multiple regression (controlling age, menopausal stage, and parity) allowed to detect statistically significant differences in the elasticity of the middle third of the urethra (P: .03) and the middle third of the anorectal canal (P: .019). CONCLUSION: It is possible to evaluate the elasticity of the LAM and vaginal tissue using sonoelastography, detecting a higher elasticity in patients with POP than in those without POP.

A unified pelvic floor conceptual model for studying morphological changes with prolapse, age, and parity.

Several 2-dimensional and 3-dimensional measurements have been used to assess changes in pelvic floor structures and shape. These include assessment of urogenital and levator hiatus dimensions, levator injury grade, levator bowl volume, and levator plate shape. We argue that each assessment reflects underlying changes in an individual aspect of the overall changes in muscle and fascial structures. Vaginal delivery, aging, and interindividual variations in anatomy combine to affect pelvic floor structures and their connections in different ways. To date, there is no unifying conceptual model that permits the evaluation of how these many measures relate to one another or that reflects overall pelvic floor structure and function. Therefore, this study aimed to describe a unified pelvic floor conceptual model to better understand how the aforementioned changes to the pelvic floor structures and their biomechanical interactions affect pelvic organ support with vaginal birth, prolapse, and age. In this model, the pelvic floor is composed of 5 key anatomic structures: the (1) pubovisceral, (2) puborectal, and (3) iliococcygeal muscles with their superficial and inferior fascia; (4) the perineal membrane or body; and (5) the anal sphincter complex. Schematically, these structures are considered to originate from pelvic sidewall structures and meet medially at important connection points that include the anal sphincter complex, perineal body, and anococcygeal raphe. The pubovisceral muscle contributes primarily to urogenital hiatus closure, whereas the puborectal muscle is mainly related to levator hiatus closure, although each muscle contributes to the other. Dorsally and laterally, the iliococcygeal muscle forms a shelflike structure in women with normal support that spans the remaining area between these medial muscles and attachments to the pelvic sidewall. Other features include the levator plate, bowl volume, and anorectal angle. The pelvic floor conceptual model integrates existing observations and points out evident knowledge gaps in how parturition, injury, disease, and aging can contribute to changes associated with pelvic floor function caused by the detachment of one or more important connection points or pubovisceral muscle failure.

Factors involved in changes in the levator ani during pregnancy.

INTRODUCTION AND HYPOTHESIS: Levator ani muscle (LAM) dimensions increase during pregnancy to allow the delivery of the fetus. The objective was to investigate which factors are involved in LAM modifications during pregnancy. METHODS: A prospective longitudinal observational study was conducted between July 2015 and March 2018. Ninety-nine nulliparous pregnant women were included. Data on the physical examination, 4D transperineal ultrasound and hormonal concentrations (progesterone, oestradiol and relaxin) were collected during the first and third trimesters. RESULTS: We found higher hiatal dimensions at the beginning of pregnancy than in other studies with nonpregnant women. Increases in the levator ani hiatal (LH) dimensions were observed at contraction (1.01 ±1.96 cm2), rest (0.82 ± 2.51 cm2) and on Valsalva (2.36 ± 3.64 cm2) throughout pregnancy. The distensibility in the third trimester was higher than in the first trimester (5.79 vs 4.24 cm2; p=0); however, the contractility was lower (-3.32 vs -3.5 cm2; p=0.04). Women with lower scores on the Modified Oxford Grading Scale in the third trimester presented with lower contractility in the LAM. A larger LH at the end of pregnancy was associated with age and body mass index. Eleven women developed ballooning during pregnancy; in these women, relaxin was higher in both trimesters than in women without ballooning, but these results were not statistically significant. The linear models to predict third-trimester Valsalva LH, distensibility and contractility were not conclusive and did not show any factors to predict LAM modifications during pregnancy. CONCLUSIONS: Hormones could play a role in modifying the muscle properties of LAM from the beginning of pregnancy, but we did not find an association between LAM measurements and hormone concentration in this study.

Comparison of the anterior pelvis and levator ani muscle on MRI in women with and without anterior pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: The objective was to compare the differences in pelvic and levator ani muscle diameters in women with and without anterior pelvic organ prolapse. METHODS: Three groups were included, including 50 nulliparous women (nulliparous group), 50 women with stage III-IV anterior vaginal prolapse (prolapse group), and 50 women of the same age as the prolapse group but without prolapse (nonprolapse control group). The ischial interspinous diameter (ISD), anterior pelvic area (APA), levator defect score (LDS), levator ani hiatus width (LH-W), H-line, M-line, levator ani plate length, levator ani plate angle, and cervix length (CL) were measured. RESULTS: There were no significant differences in ISD (10.6±0.8 vs 10.6±0.9 cm), LH-W (3.0±0.4 vs 3.3±0.4 cm), or CL (2.9±0.6 vs 3.0±0.5 cm) between the nulliparous group and the nonprolapse control group (p>0.05). However, there were significant differences between them and the prolapsed group (11.2±0.6 cm, 3.6±0.4 cm, 4.2±1.5 cm; p<0.05). There were no significant differences in LDS (0.70±0.61 vs 0.70±0.65) or APA (58.4±8.4 vs 60.1±7.4 cm2) between the nonprolapse control group and the prolapse group (p>0.05), but they were significantly different from those of the nulliparous group (0.08±0.34, 55.1±6.0 cm2) (p<0.05). The area under the receiver-operating characteristic curve for the ISD of nonprolapse control and prolapse groups was 0.713, and the cutoff value was 10.95 cm. CONCLUSIONS: The levator ani hiatus width and cervix length were larger in patients with anterior vaginal prolapse than in those without prolapse. An ischial ISD greater than 10.95 cm was associated with prolapse.

Appearance of levator ani muscle subdivision defects on level III vaginal support structures in women with and without pelvic organ prolapse: an MRI study.

INTRODUCTION AND HYPOTHESIS: Injury of the levator ani muscle (LAM) is a significant risk factor for pelvic organ prolapse (POP). The puborectalis (PRM) and pubovisceral (PVM) subdivisions are level III vaginal support structures. The null hypothesis was that there is no significant difference in patterns of LAM subdivisions in healthy nulliparous women. Secondarily, we evaluated the presence of different LAM injury in a POP-symptomatic cohort. METHODS: This retrospective magnetic resonance imaging study included: 64 nulligravidae without any pelvic floor dysfunction (PFD) and 526 women of various parity with symptomatic POP. Primary outcome was PVM and PRM morphology on the axial planes: the attachment site on the pubic bone, and the visible separation/border between the PVM and PRM. The attachment was scored as "normal" or "abnormal". The "abnormal" attachment was divided in two types: "type I"-loss of the muscle substance, but preservation of the overall muscle architecture-and "type II"-muscle detachment from the pubic bone. RESULTS: The puboanal muscle (PAM) subdivision was evaluated as a representative part of the PVM. The PAM and PRM attachments and separation were distinguished in all asymptomatic nulliparae. PAM and PRM attachments did not significantly differ. POP group characteristics were parity 1.9 ± 0.8, instrumental delivery 5.6%, hysterectomy or POP surgery 60%, all Pelvic Organ Prolapse Quantification (POP-Q) stages, LAM defect 77.6% (PRM: 77.1%; PAM: 51.3%). Type I injuries were more frequent (PRM 54.7%; PAM 53.9%) compared with type II (PRM 29.4%; PAM 42.1%). CONCLUSIONS: A LAM defect was present in 77.6% of women with symptomatic POP. In PRM and PAM subdivisions type I injury was more frequent than type II.

Multimodal measurements of levator bowl volume in nulligravid asymptomatic women: endovaginal ultrasound versus MRI.

INTRODUCTION AND HYPOTHESIS: Measurements of levator bowl volume using advanced imaging, may be predictive of pelvic floor muscle function. The aim of this study was to compare the volume of the levator bowl using both magnetic resonance imaging (MRI) and endovaginal ultrasound (EVU) of healthy asymptomatic women. METHODS: All participants underwent a comprehensive interview including completion of the Pelvic Floor Distress Inventory Questionnaire-20 questionnaire, pelvic examination with a pelvic organ prolapse quantification evaluation, MRI, and EVU. The pelvic floor was segmented using Slicer and the MRI segmentations were trimmed using two methods: soft-tissue landmarks and the field of view (FOV) of the ultrasound volume. The levator bowl volume of the 3D segmented shapes was measured using Blender's 3D printing toolkit. Normality was tested using the Shapiro-Wilks test and comparisons were made using self-paired t tests. RESULTS: The final analysis included 19 patients. Levator bowl volume measured via MRI was larger than that measured in EVU (46.1 ± 7.9 cm3 vs 27.4 ± 5.9 cm3, p<0.001). Reducing the FOV of the MRI to that of EVU caused the MRI volume to be much closer to the EVU volume (35.5 ± 3.3 cm3 vs 27.4 ± 5.9 cm3, p<0.001); however, it remained significantly larger. CONCLUSION: Levator bowl volume measured using MRI was larger than that measured using EVU no matter the method of delineation of the levator muscles. Although EVU is safe, cheap, and easy to perform, it captures a smaller volume of levator bowel than MRI.

Postpartum pelvic floor muscle training, levator ani avulsion and levator hiatus area: a randomized trial.

INTRODUCTION AND HYPOTHESIS: Vaginal delivery may lead to tearing of the levator ani (LA) muscle from its bony insertions (complete LA avulsion) and increased levator hiatus (LH) area, both risk factors for pelvic floor dysfunctions. Early active rehabilitation is standard treatment after musculo-skeletal injury. We hypothesized that pelvic floor muscle training (PFMT) early postpartum would reduce the presence of LA avulsions and reduce LH area. METHODS: We carried out a planned secondary analysis from a randomized controlled study. Primiparous women (n=175) giving birth vaginally were included 6 weeks postpartum, stratified on complete LA avulsion, and thereafter randomized to PFMT or control. The training participants (n=87) attended a supervised PFMT class once a week and performed home-based PFMT daily for 16 weeks. The control participants (n=88) received no intervention. Presence of complete LA avulsion, LH area at rest, maximal contraction, and maximal Valsalva maneuver were assessed by transperineal ultrasound. Between-group comparisons were analyzed by analysis of covariance for continuous data, and relative risk (RR) for categorical data. RESULTS: Six months postpartum, the number of women who had complete LA avulsion was reduced from 27 to 14 within the PFMT group (44% reduction) and from 28 to 17 within the control group (39% reduction). The between-group difference was not significant, RR 0.85 (95% CI 0.53 to 1.37). Further, no significant between-group differences were found for LH area at rest, during contraction, or Valsalva. CONCLUSIONS: Supervised PFMT class combined with home exercise early postpartum did not reduce the presence of complete LA avulsion or LH area more than natural remission.

Three-dimensional endovaginal ultrasound assessment using the levator ani deficiency score in primiparas: A replication study.

INTRODUCTION: It is essential to assess the levator ani properly as part of clinical care in patients presenting with pelvic floor dysfunction. The levator ani deficiency scoring system is a previously published method to assess levator ani defects with three-dimensional endovaginal ultrasound. The primary aim of this study was to determine the intra- and interrater reliability of the levator ani deficiency score in a cohort of non-instrumentally delivered primiparas. MATERIAL AND METHODS: Primiparas (n = 141) were examined at least 1 year after vaginal birth. Three-dimensional endovaginal ultrasound volumes were acquired by a single examiner using two different automated ultrasound probes. The volumes were analyzed by two separate raters who were blinded to each other's assessments. Descriptive statistics were calculated for levator ani deficiency score and categorized into three levels (mild, moderate, severe). Kendall's tau-b was calculated for intra- and interrater comparisons. RESULTS: Intrarater comparisons of levator ani deficiency score and levator ani deficiency category were high (Kendall's tau-b ≥0.80 for Rater 1; >0.79 for Rater 2). Interrater comparisons of levator ani deficiency score and levator ani deficiency category were also high (Kendall's tau-b >0.9 for assessment 1 and >0.78 for assessment 2). Varying by rater, probe and assessment, 75.9%-80.1% of the study population had no/mild deficiency, 6.4%-9.2% had moderate deficiency, and 4.3%-6.4% had severe levator ani deficiency. CONCLUSIONS: The levator ani deficiency scoring system is a feasible method to assess defects of the levator ani muscle and can be reproduced with high intra- and interrater correlations. Using the scoring system in clinical practice may facilitate concordant assessment between different examiners. However, the system should be used to support clinical findings and symptomatology and not as a screening tool, as the score is lacking the category of no levator ani deficiency.

One-year follow-up after standardized perineal reconstruction in women with deficient perineum after vaginal delivery.

INTRODUCTION: Perineal tears are common after childbirth and, if not surgically repaired, they may result in a deficient perineum that can cause symptoms of pelvic floor dysfunction. Perineal reconstruction aims to restore the perineal body and increase the support of the pelvic floor. The objective of the present study was to estimate symptom reduction after perineal reconstruction in patients with deficient perineum after vaginal delivery and to compare outcomes between participants with or without concomitant levator ani muscle deficiency. MATERIAL AND METHODS: Participants presenting at the Karolinska Pelvic Floor Center with symptoms of deficient perineum at least 1 year after vaginal birth were invited to the study. Inclusion criteria were a visible perineal scar and confirmed anatomic defect. Levator ani defects were assessed using the Levator Ani Deficiency score. A perineal reconstruction was performed in a standardized way. Subjective symptoms were evaluated using the validated "Karolinska Symptoms After Perineal Tear Inventory" at baseline and 1-year follow-up. A score difference in the symptom of an acquired sensation of a wide vagina was the primary outcome. Results were stratified by the presence or absence of a levator ani deficiency. RESULTS: A perineal reconstruction was performed in 131 patients and 128 patients completed the Karolinska Symptoms After Perineal Tear Inventory at baseline and 119 at follow-up. Median age was 36.1 (interquartile range [IQR] 7.9), median body mass index 22.3 (IQR 5.1) and a median of two vaginal deliveries. Fifty-four women (41.2%) had a levator ani deficiency. The mean score reduction for the item "Do you feel that your vagina is too wide/loose?" was -1.56 (SD 0.96; P < 0.001) from a mean score of 2.75 (maximum 3) at baseline. The mean total score reduction was -9.1 points (SD 5.3; P < 0.001) from a mean score of 18.4 (maximum 33) points at baseline. There were no significant differences between groups when stratifying by levator ani deficiency. CONCLUSIONS: Our results show that perineal reconstructive surgery significantly decreases symptoms of deficient perineum after vaginal delivery. A concomitant levator ani defect does not affect the symptom reduction of an acquired sensation of a wide vagina or the total score reduction after surgery.

Transvaginal Two-Dimensional Ultrasound Evaluation as a Screening Tool for Levator ani Muscle Avulsion in Postpartum Women.

OBJECTIVES: To evaluate the agreement between two-dimensional transvaginal ultrasound (2D-TVUS) and transperineal tomographic ultrasound imaging on three-dimensional (3D) volume in diagnosing levator ani muscle (LAM) avulsion of postpartum women. Furthermore, we tested the repeatability of the 2D-TVUS in measuring the LAM thickness. METHODS: A retrospective study was performed using the data sets from postpartum women. One doctor measured the thickness of the LAM on the images at the attachment to the arcus tendinous levator ani and the middle part using the 2D-TVUS ultrasound data sets of postpartum women. These women were examined twice, at 42-56 days and 3-6 months postpartum. Intra-observer repeatability was expressed using intraclass correlation coefficients (ICCs). The other doctor judged whether there was avulsion in the LAM on the 2D-TVUS and transperineal tomography imaging on the 3D volume. The inter-method agreement was determined using Cohen's kappa coefficient (k). RESULTS: Thickness measurements of the middle part and attachment of the LAM by 2D-TVUS showed excellent and good intra-observer repeatability (ICC 0.84; 95% CI, 0.76-0.88, and ICC 0.74; 95% CI, 0.67-0.84, respectively). The overall agreement was 92% (Cohen's kappa was 0.79) between 2D-TVUS and transperineal tomographic imaging. Compared to transperineal tomographic imaging in the diagnosis of LAM avulsion, the diagnostic sensitivity of 2D-TVUS was 91.7%, the specificity was 92.1%. CONCLUSIONS: The 2D-TVUS technique, a simple and reproducible method for assessing LAM avulsion, may be helpful as a screening tool for LAM avulsion of postpartum women.

Effect of pelvic floor status on the outcome of pelvic organ prolapse surgery.

Pelvic organ prolapse (POP) is a common diagnosis with an incidence in the population of up to 50%. POP causes restrictions in everyday life and reduces patients' quality of life. Therapy is either conservative in the form of physiotherapy or the use of different types of pessaries, possibly. in case of inappropriateness or failure of conservative treatment, an operative solution is chosen. Avulsion injury of the levator ani muscle (MLA) is a strong factor in the development of POP. Some patients undergo repeated surgeries for POP, negatively impacting their quality of life. Studies show that the stage of POP and avulsion injury is associated with an increased risk of recurrence after index prolapse surgery. Ultrasound diagnosis of MLA injuries might help in predicting the risk of recurrence. Assessment of pelvic floor function is crucial for the success of surgical management of POP.

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Pelvic floor ultrasound can clearly visualize the position and morphology of pelvic floor organs, observe the pelvic organ prolapse in real-time, and quantify and analyze the degree of the levator ani muscle injury, which is the most common imaging method to assess the morphology and function of the levator ani muscle to date. The different ultrasound imaging techniques provide a variety of indicators, each with its own advantages and limitations.Furthermore, two-dimensional ultrasound is the basis of imaging, but it fails to detect cross-sectional images of the pelvic floor; three-dimensional ultrasound can acquire the axial plane of the levator hiatus; tomographic ultrasound imaging allows real-time observation of the levator ani muscle injury; shear wave elastography can provide a quantitative assessment of the contractility and elastic characteristics of the levator ani muscle in real-time. It is of great significance to summarize the basic principles of various ultrasound imaging techniques, summarize the ultrasound image characteristics of levator ani muscle and its hiatus in different populations and different states, and explore the cut-off values and diagnostic criteria-related ultrasound parameters for improving the diagnostic efficiency of pelvic floor ultrasound for levator ani muscle injury, leading to reducing missed diagnosis and misdiagnosis of lesions.

Development and validation of a composite AI model for the diagnosis of levator ani muscle avulsion.

OBJECTIVE: To assess the feasibility and reliability of a composite AI model for the diagnosis of levator ani muscle (LAM) avulsion of tomographic ultrasound imaging (TUI). METHODS: Ultrasonic images of the pelvic floor from a total of 304 patients taken from January 2018 to October 2020 were included. All patients included underwent standardized interviews and transperineal ultrasound (TPUS). Transfer-learning and ensemble-learning methods were adopted to develop the proposed model on the basis of three classic convolutional neural networks (CNN). Confusion matrix (CM) and the ROC statistic were used to assess the effectiveness of the proposed model. Gradient-weighted class activation mappings (Grad-CAMs) were used to help enhance the interpretability of the proposed model. RESULTS: Of the 304 patients included, 208 were in the derivation cohort (108 LAM avulsion and 100 normal) and 96 (39 LAM avulsion and 57 normal) were in the validation cohort. The proposed model in LAM avulsion diagnosis outperformed other models and a junior clinician in both the test set of derivation cohort and the validation cohort, with accuracies of 0.95 and 0.81, and AUCs of 0.98 and 0.86, respectively. According to the heatmap of Grad-CAMs, the proposed model mainly localizes areas between the pubic symphysis and the bilateral insertion point of LAM when making a diagnosis, which is exactly the region of interest in clinical practice. CONCLUSION: The proposed model using ultrasonic images of the pelvic floor may be a promising tool in assisting the diagnosis of LAM avulsion in clinical practice. KEY POINTS: • First AI-assisted model for levator ani muscle avulsion diagnosis • Diagnosis accuracy of less-experienced clinicians could be improved using the proposed model.