Association between 3D endovaginal and 2D perineal pelvic floor ultrasound findings and symptoms in women presenting with mid-urethral sling complications.

OBJECTIVES: To present the characteristics of women attending a tertiary urogynecology pelvic floor scan clinic with mid-urethral sling (MUS) complications and examine the association between patient symptoms and findings on two-dimensional (2D) perineal and three-dimensional (3D) endovaginal ultrasound. METHODS: This was a cross-sectional study of all women with MUS complications referred to a specialist pelvic floor ultrasound clinic between October 2016 and October 2018. Detailed history was obtained regarding their symptoms and time of onset. All patients underwent 2D perineal and 3D endovaginal ultrasound assessment. The association between patient symptoms and ultrasound findings was evaluated using logistic regression analysis. Only symptomatic women with a single MUS, without other pelvic floor mesh, prior mesh excision or bulking agents, were included in the regression analysis. RESULTS: A total of 311 women with a history of MUS surgery were seen during the study period. Vaginal and/or non-vaginal pain was reported by 80% of patients and this was the primary presenting complaint in 59% of the patients. One-third of the patients reported symptoms starting within 4 weeks after surgery. The data of 172 patients were included in the regression analysis. MUS position within the rhabdosphincter was significantly associated with voiding dysfunction (odds ratio (OR), 10.6 (95% CI, 2.2-50.9); P = 0.003). Voiding dysfunction was highest in those with C-shaped MUS both at rest and on Valsalva maneuver (OR, 3.2 (95% CI, 1.3-7.6); P < 0.001). MUS position in the distal third of the urethra was significantly associated with a higher rate of recurrent urinary tract infection (OR, 2.9 (95% CI, 1.3-6.3); P = 0.01). CONCLUSIONS: Pelvic floor ultrasound can provide insight into the position and shape of the MUS, which could explain some patient symptoms and guide management or surgical planning. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Transperineal and endovaginal ultrasound for evaluating suburethral masses: comparison with magnetic resonance imaging.

OBJECTIVE: To evaluate the utility of pelvic floor ultrasound (US) in the detection and evaluation of suburethral masses, using magnetic resonance imaging (MRI) as the reference standard. METHODS: This was a retrospective analysis of US and MRI scans of all women with a suburethral mass on clinical examination at a single urogynecology clinic over a 13-year period (February 2007 to March 2020). All women were examined using two-dimensional transperineal US (2D-TPUS) with or without three-dimensional endovaginal US (3D-EVUS). All patients underwent unenhanced T1-weighted and T2-weighted MRI, which was considered the reference standard in this study. Presence of a suburethral mass and its size, location, connection with the urethral lumen and characteristics were evaluated on both pelvic floor US and MRI. Agreement between pelvic floor US and MRI was assessed using intraclass correlation coefficients (ICC; 3,1). RESULTS: Forty women suspected of having a suburethral mass on clinical examination underwent both MRI and US (2D-TPUS with or without 3D-EVUS). MRI detected a suburethral mass in 34 women, which was also detected by US. However, US also identified a suburethral mass in the remaining six women. Thus, the agreement between US and MRI for detecting a suburethral mass was 85% (95% CI, 70.2-94.3%). The ICC analysis showed good agreement between MRI and 2D-TPUS for the measured distance between the suburethral mass and the bladder neck (ICC, 0.89; standard error of measurement (SEM), 3.64 mm) and excellent agreement for measurement of the largest diameter of the mass (ICC, 0.93; SEM, 4.31 mm). Good agreement was observed between MRI and 3D-EVUS for the measured distance from the suburethral mass to the bladder neck (ICC, 0.88; SEM, 3.48 mm) and excellent agreement for the largest diameter of the suburethral mass (ICC, 0.94; SEM, 4.68 mm). CONCLUSIONS: 2D-TPUS and 3D-EVUS are useful in the imaging of suburethral masses. US shows good-to-excellent agreement with MRI in identifying and measuring suburethral masses; therefore, the two modalities can be used interchangeably depending on availability of equipment and expertise. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology. - Legal Statement: This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

Early re-suturing of dehisced obstetric perineal wounds: A 13-year experience.

OBJECTIVES: To describe post-operative outcomes following early re-suturing of obstetric perineal wound dehiscence. STUDY DESIGN: This was a retrospective series of 72 women who underwent re- suturing of a dehisced perineal wound at a tertiary urogynaecology department during a 13-year period (December 2006 - December 2019). RESULTS: Seventy-two women with complete perineal wound dehiscence opted for secondary re-suturing. Other accompanying symptoms included purulent discharge from the wound (22.2 %), perineal pain (23.6 %) and both purulent discharge and pain (26.4 %). The median time taken for the wound to heal completely following re-suturing was 28 days (IQR 14.0-52.0); 49.2 % had healed completely by four weeks, 63.5 % by six weeks and 76.2 % by eight weeks. The median number of out-patient follow-up appointments required was 2 (IQR 1.0-3.0). No post-operative complications were experienced in 63.6 % of women, one complication occurred in 25.8 % and two complications in 10.6 %. Complications included skin dehiscence (33.3 %), granuloma (33.3 %), scar tissue (17.6 %), perineal pain (5.9 %) and sinus formation (5.9 %). Of the women who developed two complications, four developed skin dehiscence with granulation tissue and one had skin sinus formation. One developed granulation tissue with perineal pain. All complications were managed conservatively in an outpatient setting or surgically under local anaesthetic, without further complication. There was no significant difference (p = 0.443) in complication rates between the group (n = 10) with dehisced wounds with signs of wound infection (purulent discharge or the presence of both purulent discharge and pain) pre-operatively versus the group (n = 14) without signs of infection. CONCLUSIONS: This study demonstrates the positive outcomes of early re-suturing of perineal wound dehiscence with faster healing, reduced follow-up requirements and few major complications. It provides information to clinicians who are uncertain about the effects of early re-suturing of perineal wounds which can be used to help counsel mothers with wound dehiscence on their management options.

Levator ani muscle morphology and function in women with obstetric anal sphincter injury.

OBJECTIVES: To estimate the prevalence of, and explore the risk factors for, levator ani muscle (LAM) injury in women with clinically diagnosed obstetric anal sphincter injury (OASI). The secondary aim was to assess the association between LAM injury and pelvic floor muscle contraction, anal incontinence (AI) and urinary incontinence (UI) in women with OASI. METHODS: This was a cross-sectional study of 250 women with OASI, recruited between 2013 and 2015 from a tertiary referral center at Croydon University Hospital, UK. AI symptoms were assessed using the modified St Mark's incontinence score and UI was assessed using the International Consultation on Incontinence modular Questionnaire for Urinary Incontinence - Short Form. All participants underwent three/four-dimensional transperineal ultrasound at rest and on maximum pelvic floor muscle contraction. Major LAM injury was defined as a unilateral or bilateral defect in all three central slices on tomographic ultrasound imaging. Muscle contraction was assessed using the modified Oxford scale (MOS) and measured on ultrasound as the proportional change in the anteroposterior (AP) levator hiatal diameter between rest and contraction. Multivariable logistic regression analysis was used to study risk factors for LAM injury. Differences in contraction and AI and UI symptoms between women with intact and those with injured LAM were studied using multivariable ANCOVA and the Mann-Whitney U-test. RESULTS: Of the 248 women with OASI for whom ultrasound volumes of adequate quality were available, 29.4% were found to have major LAM injury. The prevalence of LAM injury was 23.6% after normal vaginal delivery and 40.2% after operative vaginal delivery (adjusted odds ratio, 4.1 (95% CI, 1.4-11.9); P = 0.01). LAM injury was associated with weaker pelvic floor muscle contraction, with an adjusted mean difference for proportional change in AP diameter of 5.0 (95% CI, 3.0-6.9) and MOS of 0.6 (95% CI, 0.3-0.9) (P < 0.001 for both). AI and UI symptom scores were similar between women with intact and those with injured LAM. CONCLUSIONS: Operative vaginal delivery was a risk factor for LAM injury in women with OASI. LAM injury was associated with weaker pelvic floor muscle contraction. Special attention is recommended for women with OASI and LAM injury, as they are at high risk for future pelvic floor disorders. The benefits of implementation of an intensive, focused and structured pelvic floor rehabilitation program need to be evaluated in these women. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Morfología y función del músculo elevador del ano en mujeres con lesión obstétrica del esfínter anal OBJETIVOS: Estimar la prevalencia y explorar los factores de riesgo de lesión del músculo elevador del ano (MEA) en mujeres con lesión obstétrica del esfínter anal (LOEA) diagnosticada clínicamente. El objetivo secundario fue evaluar la asociación entre la lesión del MEA y la contracción muscular del suelo pélvico, la incontinencia anal (IA) y la incontinencia urinaria (IU) en mujeres con LOEA. MÉTODOS: Este fue un estudio transversal de 250 mujeres con LOEA, reclutadas entre 2013 y 2015 en un centro de referencia terciario del Hospital Universitario de Croydon en el Reino Unido. Los síntomas de IA se evaluaron mediante una modificación de la puntuación de incontinencia de San Marcos y los de la IU mediante el Formulario resumido del Cuestionario Modular de la Consulta Internacional sobre Incontinencia para la Incontinencia Urinaria. Todas las participantes se sometieron a una ecografía transperineal tridimensional en reposo y en máxima contracción de los músculos del suelo pélvico. Las lesiones importantes del MEA se definieron como un defecto unilateral o bilateral en los tres cortes centrales de la ecografía tomográfica. La contracción muscular se evaluó mediante la escala de Oxford modificada (EOM) y se midió en la ecografía como el cambio proporcional en el diámetro hiatal del elevador anteroposterior (AP) entre el reposo y la contracción. Se utilizó un análisis de regresión logística multivariable para estudiar los factores de riesgo de lesión del MEA. Se estudiaron las diferencias en la contracción y los síntomas de IA e IU entre las mujeres con el MEA intacto y las lesionadas, mediante un ANCOVA multivariable y la prueba U de Mann-Whitney. RESULTADOS: De las 248 mujeres con LOEA para las que se disponía de una cantidad de ecografías de calidad adecuada, se encontró que el 29,4% tenía una lesión importante del MEA. La prevalencia de lesiones del MEA fue del 23,6% después de un parto vaginal normal y del 40,2% después de un parto vaginal quirúrgico (razones de momios ajustadas, 4,1 (IC 95%: 1,4-11,9); P=0,01). Las lesiones del MEA se asociaron con una contracción muscular más débil del suelo pélvico, con una diferencia de medias ajustada para el cambio proporcional en el diámetro del AP de 5,0 (IC 95%: 3,0-6,9) y para la EOM de 0,6 (IC 95%: 0,3-0,9) (P<0,001 para ambos). Las puntuaciones de los síntomas de la IA y la IU fueron similares entre mujeres con el MEA intacto y mujeres con lesiones. CONCLUSIONES: El parto vaginal quirúrgico fue un factor de riesgo de lesión del MEA en mujeres con LOEA. La lesión del MEA se asoció con una contracción muscular más débil del suelo pélvico. Se recomienda prestar una atención especial a las mujeres con LOEA y con lesiones del MEA, ya que tienen un alto riesgo de futuros trastornos del suelo pélvico. Es necesario evaluar en estas mujeres los beneficios de la implementación de un programa intensivo, focalizado y estructurado de rehabilitación del suelo pélvico.