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.

Association between pelvic floor muscle trauma and contraction in parous women from a general population.

OBJECTIVE: To study possible associations between pelvic floor muscle contraction, levator ani muscle (LAM) trauma and/or pelvic organ prolapse (POP) ≥ Stage 2 in parous women recruited from a general population. METHODS: This was a secondary analysis of data from a cross-sectional study of 608 parous women from a general population examined using the POP quantification system (POP-Q) and three-dimensional/four-dimensional transperineal ultrasound for identification of LAM macrotrauma (avulsion) and microtrauma (distension of levator hiatal area > 75th percentile on Valsalva maneuver). Muscle contraction was assessed using the modified Oxford scale (MOS), perineometry and ultrasound measurement of proportional change of anteroposterior hiatal diameter and levator hiatal area at rest and on pelvic floor muscle contraction. The Mann-Whitney U-test was used to study associations between pelvic floor muscle contraction, LAM trauma and POP. RESULTS: Women with macrotrauma (n = 113) had significantly weaker median pelvic floor muscle contraction, as measured using MOS and perineometry, than did women with an intact LAM (n = 493) (contraction strength was 1.5 (range, 0.0-5.0) vs 3.5 (range, 0.0-5.0) on MOS, and vaginal squeeze pressure was 15.0 (range, 0.0-78.0) cmH2 O vs 28.0 (range, 0.0-129.0) cmH2 O on perineometry; P < 0.001). This was also demonstrated by ultrasound measurement, with a proportional change in hiatal area of 19.9% (range, 4.1-48.0%) vs 34.0% (range, 0.0-64.0%) (P < 0.001) and proportional change in anteroposterior diameter of 16.2% (range, -5.7 to 42.6%) vs 26.0% (range, -3.4 to 49.4%) (P < 0.001). No statistically significant difference between women with (n = 65), and those without (n = 378), microtrauma was found after excluding women with macrotrauma. Women with POP had weaker muscle contraction than those without; in those with POP-Q ≥ 2 (n = 275) compared with those with POP-Q < 2 (n = 333), muscle contraction strength was 3.0 (range, 0.0-5.0) vs 3.5 (range, 0.0-5.0) on MOS, vaginal squeeze pressure was 21.0 (range, 0.0-98.0) cmH2 O vs 28.0 (range, 3.0-129.0) cmH2 O on perineometry, proportional change in hiatal area was 29.6% (range, 0.0-60.9%) vs 33.8% (range, 0.0-64.4%) and proportional change in anteroposterior diameter was 22.8% (range, -5.7 to 49.4%) vs 25.7% (range, -3.4 to 49.4%) (P < 0.001 for all). CONCLUSIONS: LAM macrotrauma was associated with weaker pelvic floor muscle contraction measured using palpation, perineometry and ultrasound. Women with POP had weaker contraction than did women without POP. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

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.

Anal sphincter defects and fecal incontinence 15-24 years after first delivery: a cross-sectional study.

OBJECTIVES: To establish the prevalence of external (EAS) and internal (IAS) anal sphincter defects present 15-24 years after childbirth according to mode of delivery, and their association with development of fecal incontinence (FI). The study additionally aimed to compare the proportion of women with obstetric anal sphincter injuries (OASIS) reported at delivery with the proportion of women with sphincter defect detected on ultrasound 15-24 years later. METHODS: This was a cross-sectional study including 563 women who delivered their first child between 1990 and 1997. Women responded to a validated questionnaire (Pelvic Floor Distress Inventory) in 2013-2014, from which the proportion of women with FI was recorded. Information about OASIS was obtained from the National Birth Registry. Study participants underwent four-dimensional transperineal ultrasound examination. Defect of EAS or IAS of ≥ 30° in at least four of six slices on tomographic ultrasound was considered a significant defect and was recorded. Four study groups were defined based on mode of delivery of the first child. Women who had delivered only by Cesarean section (CS) constituted the CS group. Women in the normal vaginal delivery (NVD) group had NVD of their first child and subsequent deliveries could be NVD or CS. The forceps delivery (FD) group included women who had FD, NVD or CS after FD of their first born. The vacuum delivery (VD) group included women who had VD, NVD or CS after VD of their first born. Multiple logistic regression was used to calculate adjusted odds ratios (aORs) for comparison of prevalence of an EAS defect following different modes of delivery and to test its association with FI. Fisher's exact test was used to calculate crude odds ratios (ORs) for IAS defects. RESULTS: Defects of EAS and IAS were found after NVD (n = 201) in 10% and 1% of cases, respectively, after FD (n = 144) in 32% and 7% of cases and after VD (n = 120) in 15% and 4% of cases. No defects were found after CS (n = 98). FD was associated with increased risk of EAS defect compared with NVD (aOR = 3.6; 95% CI, 2.0-6.6) and VD (aOR = 3.0; 95% CI, 1.6-5.6) and with increased risk of IAS defect compared with NVD (OR = 7.4; 95% CI, 1.5-70.5). The difference between VD and NVD was not significant for EAS or IAS. FI was reported in 18% of women with an EAS defect, in 29% with an IAS defect and in 8% without a sphincter defect. EAS and IAS defects were associated with increased risk of FI (aOR = 2.5 (95% CI, 1.3-4.9) and OR = 4.2 (95% CI, 1.1-13.5), respectively). Of the ultrasonographic sphincter defects, 80% were not reported as OASIS at first or subsequent deliveries. CONCLUSIONS: Anal sphincter defects visualized on transperineal ultrasound 15-24 years after first delivery were associated with FD and development of FI. Ultrasound revealed a high proportion of sphincter defects that were not recorded as OASIS at delivery. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Assessment of pelvic floor muscle contraction with palpation, perineometry and transperineal ultrasound: a cross-sectional study.

OBJECTIVE: To study the correlation between palpation, perineometry and transperineal ultrasound for assessment of pelvic floor muscle contraction and to define a contraction scale for ultrasound measurements. METHODS: This was a cross-sectional study of 608 women examined with palpation of pelvic floor muscle contraction, using the Modified Oxford Scale, and measurement of the vaginal squeeze pressure with a vaginal balloon connected to a fiber-optic microtip transducer (perineometry). Transperineal ultrasound was used for measurements of levator hiatal area and anteroposterior (AP) diameter in the plane of minimal hiatal dimensions, at rest and on contraction. The pelvic floor muscle contraction was expressed as the percentage difference between values at rest and on contraction. Spearman's rank was used to test for correlation between the different methods of assessment. RESULTS: Significant correlations were found between all assessment methods (P < 0.001). Palpation correlated with perineometry (rs = 0.74) and with proportional change in hiatal area (rs = 0.67) and AP diameter (rs = 0.69) on ultrasound. Perineometry correlated with proportional change in hiatal area (rs = 0.60) and AP diameter (rs = 0.66) on ultrasound. We defined a contraction scale based on the proportional change in AP diameter. In this population, a change in AP diameter of < 7% corresponded to absence of contractions, 7-18% corresponded to weak contractions, 18-35% corresponded to normal contractions and > 35% corresponded to strong contractions. CONCLUSIONS: We found moderate to strong correlation between ultrasound measurements, palpation and perineometry for assessing pelvic floor muscle contraction. The proportional change in levator hiatal AP diameter was the ultrasound measurement with strongest correlation to palpation and perineometry and formed the basis for the contraction scale for ultrasound measurements. Copyright © 2015 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.