Levator-urethra gap: is there a need for individualization of cut-offs?

OBJECTIVES: To determine whether height, weight and body mass index (BMI) are associated with the levator-urethra gap (LUG) measurement, and whether these factors confound the relationship between LUG and symptoms and signs of pelvic organ prolapse (POP). METHODS: This was a retrospective study of women seen at a tertiary urogynecology unit between January 2020 and December 2021. Postprocessing of saved ultrasound volume data was used to measure the LUG, blinded against all other data. This measurement was tested for its association with organ descent and hiatal area, and height, weight and BMI were investigated for any potential confounding effect. RESULTS: The 624 women seen during the inclusion period presented mostly with stress urinary incontinence (448/624 (72%)), urgency urinary incontinence (469/624 (75%)) and/or prolapse (338/624 (54%)). Mean age at assessment was 58 (range, 20-94) years, mean height was 163 (range, 142-182) cm, mean weight was 80 (range, 41-153) kg and mean BMI was 30 (range, 17-65) kg/m2. LUG measurements could be obtained in 613 women, resulting in 7356 (12 × 613) measurements. The average LUG in individual women measured 2.35 cm on the right and 2.32 cm on the left side (difference not significant), with a mean ± SD of 2.34 ± 0.63 cm overall. Mean LUG was associated with symptoms and signs of prolapse, both on clinical examination (POP quantification system) and on imaging, but not with height (P = 0.36), weight (P = 0.20) or BMI (P = 0.09). CONCLUSIONS: Levator-urethra gap measurements do not seem to be significantly associated with height, weight or BMI in our population, obviating the need for individualization of LUG. However, this does not exclude interethnic variability of this biometric measure. © 2024 International Society of Ultrasound in Obstetrics and Gynecology.

Do some levator avulsions improve over time?

OBJECTIVE: To determine whether the sonographic appearance of levator avulsion after vaginal childbirth can improve significantly over the first few years postpartum. METHODS: Retrospective study of women seen in the context of two prospective perinatal imaging studies. All subjects had undergone an interview, clinical examination and 4D translabial ultrasound (TLUS) on average 4.3 months and 3.1 years post-partum. Volume data sets were analysed at a later date blinded against all other data. The number of abnormal slices at both time points was compared using Mann- Whitney U Test. Patients in whom findings had changed over time were reviewed separately in parallel in order to reduce the impact of differences in slice location and imaging settings. The symmetry test was used to analyse changes between the two postnatal visits. RESULTS: Of 1148 women originally recruited, 315 had had at least two postnatal visits. 42 were excluded, leaving 273 women for analysis. They were first seen on average 4.3 (2.6-9.8) months after childbirth and the last time 3.1 (1.4-8) years postpartum. Cohen's kappa for the two assessments was 0.89, with agreement in 97% (264/273) of cases. At the first visit, complete avulsion was diagnosed in 20, partial avulsion in 32, and no avulsion in 221. While seven partial avulsions appeared sonographically normal at the second visit, there were no statistically significant changes in avulsion category between visits (P=0.4). CONCLUSION: Tomographic pelvic floor imaging obtained 2.5-10 months after childbirth may be used as a proxy for long- term outcomes. Findings at a mean of 3.1 years showed 97% agreement with imaging obtained at an average of 4.3 months. There was a non-significant reduction in abnormal slices affecting at most 3/12 slices. This may be explained by compensatory hypertrophy of remaining intact muscle. Sonographic normalisation of complete avulsion was not observed. This article is protected by copyright. All rights reserved.

Validation of new ultrasound algorithm for estimating prevalence of anal sphincter trauma in a urogynecological population.

OBJECTIVES: To estimate the prevalence of major perineal trauma in a urogynecological population, to test the predictive value of sonographic tear grading (Gillor algorithm) for anal incontinence (AI), AI bother score and St Mark's score, and to compare the predictive power of the Gillor algorithm with that of the residual-defect method. METHODS: This was a retrospective study of 721 women attending a tertiary urogynecology unit between February 2019 and May 2021. All women underwent a standardized interview, including determination of St Mark's score and visual analog scale (VAS) bother score for AI, as well as exoanal (translabial) ultrasound with later offline analysis. Results were reported as the presence of a residual defect of the external anal sphincter (EAS), i.e. a discontinuity of ≥ 30° in ≥ 4/6 tomographic slices, and according to the Gillor algorithm (normal, Grade 3a, Grade 3b or Grade 3c/4). RESULTS: Mean age at assessment was 57 (range, 19-93) years and mean body mass index was 30 (range, 17-57) kg/m2 . Six hundred and thirty-six (88.2%) women were vaginally parous and 161 (22.3%) had undergone at least one forceps delivery. AI was reported by 186/721 (25.8%) women, with a median St Mark's score of 10 (interquartile range (IQR), 6-14) and a median VAS score of 6.3 (IQR, 3.9-10). EAS defects were detected in 261 (36.2%) women, with a residual defect diagnosed in 88 (12.2%). On sonographic grading according to the Gillor algorithm, we identified 532 (73.8%) women with a normal sphincter, 66 (9.2%) with Grade-3a tear, 87 (12.1%) with Grade-3b tear and 36 (5.0%) with Grade-3c/4 tear. In total, the Gillor algorithm classified 189 (26.2%) women as having suffered a major perineal tear. The two grading systems were in moderate agreement (κ, 0.537 (95% CI, 0.49-0.56); P < 0.001). There were weak, albeit significant, associations between EAS defects and measures of AI (P = 0.009 to P = 0.047), both for residual defect as well as the Gillor algorithm. CONCLUSION: Neither the Gillor algorithm nor the residual-defect method of quantifying sphincter trauma on imaging is clearly superior in terms of predicting AI. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

All or nothing? A second look at partial levator avulsion.

OBJECTIVE: To define associations between partial levator trauma and symptoms and signs of pelvic organ prolapse (POP). METHODS: This was a retrospective study of 3484 women attending a tertiary urogynecology unit for symptoms of pelvic floor dysfunction between January 2012 and February 2020. All women underwent a standardized interview, clinical pelvic organ prolapse quantification (POP-Q) examination and tomographic ultrasound imaging of the pelvic floor. Women with full levator avulsion were excluded from analysis. Partial levator avulsion was quantified using the tomographic trauma score (TTS), in which slices 3-8 are scored bilaterally for abnormal insertions. Binomial multiple logistic regression was analyzed independently for the outcome variables prolapse symptoms, symptom bother and objective prolapse on clinical examination and imaging, with age and body mass index as covariates. Two continuous outcome variables, prolapse bother score and hiatal area on Valsalva, were analyzed using multiple linear regression. RESULTS: Of the 3484 women, ultrasound data were missing or incomplete in 164 due to lack of equipment, clerical error and/or inadequate image quality. Full levator avulsion was diagnosed in 807 women, leaving 2513 for analysis. TTS ranged from 0-10, with a median of 0. Partial trauma (TTS > 0) was observed in 667/2513 (26.5%) women. All subjective and objective measures of POP were associated significantly with TTS, most strongly for cystocele. Associations were broadly linear and similar for all slice locations but disappeared after accounting for hiatal area on Valsalva. CONCLUSION: Partial avulsion is associated with POP and prolapse symptoms. This association was strongest for cystocele, both on POP-Q and ultrasound imaging. The effect of partial avulsion on POP and prolapse symptoms is explained fully by its effect on hiatal area. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Is age at menarche a predictor of maternal birth trauma?

OBJECTIVE: Age at menarche and the interval between menarche and age at first vaginal birth have been shown to be associated with reproductive performance; however, their association with maternal birth trauma has not been studied. We aimed to determine whether age at menarche, age at first vaginal birth and their interval are associated independently with levator ani muscle (LAM) avulsion and external anal sphincter (EAS) defect. METHODS: This was a retrospective analysis of the ultrasound volume datasets of 466 vaginally parous patients attending one of two tertiary urogynecological units in Australia. All patients had undergone a standardized interview and clinical examination using the pelvic organ prolapse quantification staging system, followed by four-dimensional translabial ultrasound. Tomographic ultrasound imaging was used to evaluate the LAM for avulsion and the EAS for significant defect. RESULTS: Of the 466 women analyzed, LAM avulsion was diagnosed in 121 (26.0%) and significant EAS defect in 55 (11.8%). Logistic regression analysis showed no association between age at menarche and LAM avulsion (P = 0.67). Weak but significant associations were noted between LAM avulsion and age at first vaginal birth (odds ratio (OR), 1.070 (95% CI, 1.03-1.11); P = 0.0007) and between LAM avulsion and menarche-to-first-vaginal-birth interval (OR, 1.064 (95% CI, 1.02-1.11); P = 0.0018). No significant associations were noted between significant EAS defect and any of the evaluated variables (all P ≥ 0.49). CONCLUSIONS: Age at menarche is not predictive of maternal birth trauma i.e. LAM avulsion and EAS residual defect. There was a statistically significant association between LAM avulsion and menarche-to-first-vaginal-birth interval; however, this was not stronger than the previously established association between LAM avulsion and age at first vaginal birth, arguing against any distinct effect of prolonged prepregnancy hormonal stimulation on the biomechanical properties of the pelvic floor. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Has the prevalence of levator avulsion after forceps delivery changed over the last six decades? A retrospective study in a urogynaecological population.

OBJECTIVE: Forceps delivery is associated with a higher risk of maternal birth trauma. It is speculated that it is due to sub-optimal use of forceps in inexperienced hands. The aim of this study was to determine the association between time of forceps birth and prevalence of levator avulsion over the last six decades. STUDY DESIGN: This was a retrospective analysis of datasets of women with a history of forceps delivery, seen at a tertiary urogynaecological centre between January 2014 and August 2018. They had undergone a standardized interview, clinical examination and four-dimensional translabial ultrasound. Archived imaging data was reviewed for levator avulsion offline at a later date, blinded against all clinical data. Associations between levator avulsion, maternal age at first vaginal birth, the weight of the first vaginally born baby, and time since forceps delivery categorised by decade were tested by univariable analysis. Factors found to be significant on univariable analysis were included in a multivariable logistic regression model to test the association between prevalence of levator avulsion and time of forceps delivery while controlling for confounders. RESULTS: In total, 2026 patients were seen during the study period. Among them 511 (25.2%) had a history of forceps delivery. Fourteen volume datasets were incomplete or missing, leaving 497 complete datasets for analysis. Mean age at presentation was 58 ± 12 years (23-91). Mean body mass index was 29 ± 6 kg/m2. Mean age at first delivery was 25 ± 5 years. Mean birth weight of the first vaginal birth was 3454 ± 557 g. 457 women (92%) had had one forceps delivery, 31 had two forceps deliveries (6%) and 9 had three forceps deliveries (2%). Mean time interval between forceps delivery and assessment was 32 ± 13 years (0.3-64.8). 229 women (46%) were diagnosed with levator avulsion. The prevalence of avulsion after forceps increased significantly from 34% to 56% between 1950 and 2017 (P = 0.04). However this difference became insignificant when controlling for maternal age at 1st vaginal delivery and birth weight. CONCLUSIONS: We found no evidence of a changed prevalence of levator avulsion at forceps delivery over the last 67 years.

Is location of urethral kinking a confounder of association between urethral closure pressure and stress urinary incontinence?

OBJECTIVES: Intact urethral support and normal sphincter function are deemed important for urinary continence. We aimed to test whether the location of urethral kinking (as the probable anatomical correlate of maximal pressure transmission) is associated with stress urinary incontinence and/or urodynamic stress incontinence. METHODS: This was a retrospective study of women seen at a tertiary urogynecological center in 2017. Patients had undergone an interview, multichannel urodynamic testing and four-dimensional translabial ultrasound examination. Those with a history of anti-incontinence surgery, absence of urethral kinking on ultrasound and/or missing or inadequate ultrasound volume data were excluded. Volume data were used to assess urethral mobility using a semi-automated Excel® urethral motion profile program. Mobility vectors were calculated using the formula √((x valsalva - x rest )2 + (y valsalva - y rest )2 ), where x and y are the coordinates of six equidistant points along the length of the urethra from the bladder neck to the external urethral meatus. The location of urethral kinking was identified as a concave contour of the urethra on the vaginal side in the midsagittal plane on maximum Valsalva maneuver. The distance between the center of the kink and the bladder neck was measured and expressed as a centile in relation to the total length of the urethra, using the formula: (distance from bladder neck/total length of urethra) × 100. Univariate and multivariate analyses were performed to test the associations of stress urinary incontinence and urodynamic stress incontinence with age, maximum urethral pressure, urethral mobility vectors and location of urethral kinking. RESULTS: Of 450 women seen during the study period, 61 were excluded owing to previous incontinence surgery and 82 owing to absence of urethral kinking, inadequate volume data or missing data, leaving 307 women included, of whom 227 (74%) complained of stress urinary incontinence and 211 (69%) complained of urgency urinary incontinence. 190 (62%) of the women were diagnosed with urodynamic stress incontinence. On multivariate analysis, maximum urethral pressure (36 vs 50 cmH2 O; P < 0.001), mid-urethral mobility (2.27 vs 2.03 cm; P = 0.003) and location of urethral kinking (63.1st vs 59.7th centile; P = 0.002) were associated significantly with urodynamic stress incontinence. The location of urethral kinking was associated with stress urinary incontinence on univariate analysis (P = 0.026) but not on multivariate analysis (P = 0.21). CONCLUSIONS: The location of urethral kinking is associated with urodynamic stress incontinence. The further urethral kinking is from the mid urethra, the more likely is urodynamic stress incontinence. This provides circumstantial evidence for the pressure-transmission theory of stress urinary continence. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Ultrasound imaging of slings and meshes in urogynecology.

Imaging is used increasingly in urogynecology. One of the main applications is in the assessment of synthetic implants. Ultrasound is particularly useful for this purpose as most such implants appear highly echogenic on ultrasound but are not visible using other imaging techniques. The worldwide success of synthetic mid-urethral slings, introduced in the late 90s, led to the subsequent introduction of transvaginal mesh in 2003-2004. Widespread use of synthetic implants for both urinary incontinence and prolapse has caused a rise in implant-related complications and increasing negative publicity and litigation, with many products removed from the market. It is not surprising that there is increasing demand for the assessment and evaluation of sling and mesh implants using imaging. This review article discusses the role of translabial/transperineal ultrasound in the evaluation of synthetic implants used in the treatment of urinary incontinence and pelvic organ prolapse. The discussion focuses on those applications of the technique that are useful for surgeons dealing with patients after mesh and/or sling placement. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

How comparable is clinical grading of obstetric anal sphincter injury with that determined by four-dimensional translabial ultrasound?

OBJECTIVES: To evaluate the agreement between grading of obstetric anal sphincter injuries (OASI) on translabial ultrasound (TLUS), using a newly developed algorithm, and grading on postpartum examination. A secondary aim was to assess the correlation between tear severity, as defined on ultrasound, and symptoms of anal incontinence and/or fecal urgency. METHODS: This was a retrospective study of patients seen at a perineal clinic between 2012 and 2018, after recent primary repair of OASI. All patients underwent a standardized interview including the St Mark's anal incontinence test and four-dimensional TLUS. Post-processing of ultrasound volume data was performed blinded to all other data. Using tomographic ultrasound imaging, a set of eight slices was obtained, and the central six slices were evaluated for sphincter abnormalities. Slices with distortion, thinning or defects were rated as abnormal. The following algorithm was used to grade OASI: a Grade-3a tear was diagnosed if the external anal sphincter (EAS) was abnormal in < 4/6 slices; a Grade-3b tear was diagnosed if the EAS was abnormal in ≥ 4/6 slices; and a Grade-3c/4 tear was diagnosed if both the EAS and internal anal sphincter were abnormal in ≥ 4/6 slices. Clinical grading of OASI was determined according to the Royal College of Obstetricians and Gynaecologists guidelines. Agreement between clinical and TLUS diagnosis of OASI was evaluated using weighted κ. RESULTS: Of the 260 women seen during the study period, 45 (17%) were excluded owing to missing data or a repeat OASI, leaving 215 complete datasets for analysis. The average follow-up interval was 2.4 months (range, 1-11 months) after OASI and the mean age of the women was 29 years (range, 17-42 years). One hundred and seventy-five (81%) women were vaginally primiparous. OASI was graded clinically as Grade 3a in 87 women, Grade 3b in 80, Grade 3c in 29 and Grade 4 in 19. On imaging, full agreement between clinical and TLUS grading was noted in 107 (50%) women, with a weighted κ of 0.398. In 96 (45%) women, there was disagreement by one category, with a weighted κ of 0.74 and in 12 (6%) there was disagreement by two categories. Twenty-four (11%) women were found to have a normal anal sphincter on imaging. Overall, potential clinical over-diagnosis was noted in 72 (33%) women and potential under-diagnosis in 36 (17%). The seniority of the diagnosing obstetrician did not significantly alter agreement between clinical and sonographic OASI grading (κ 0.44, 0.43, and 0.34, for specialists and senior and junior residents, respectively). The association between symptoms of anal incontinence and/or fecal urgency and TLUS grading did not reach significance (P = 0.052). CONCLUSIONS: Clinical and TLUS-based grading of OASI showed fair agreement. Clinical over-diagnosis may be increasingly common in our population, although under-diagnosis may still occur in a significant minority. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

Changes in urethral mobility and configuration after prolapse repair.

OBJECTIVE: To evaluate changes in urethral mobility and configuration after prolapse repair. METHODS: This was a retrospective study of 92 patients who were examined between 2005 and 2016 before and after surgery for pelvic organ prolapse (POP) without concomitant anti-incontinence surgery. All patients were assessed with an interview, POP quantification and translabial four-dimensional ultrasound. Urethral mobility was evaluated using semi-automated urethral motion profile software in which x- and y-coordinates of six equidistant points along the length of the urethra were determined both at rest and on Valsalva, relative to the posteroinferior margin of the pubic symphysis. Urethral kinking was measured by placing tangents distal and proximal to any visually identified change in the urethral axis. Imaging data obtained before and after prolapse surgery were compared. RESULTS: Mean age was 58 years and mean follow-up was 5.8 months. Prolapse symptoms had resolved in 85% of patients. Highly significant reductions in urethral mobility and urethral kinking were seen after surgery (all P ≤ 0.001). Similar changes were observed after anterior vaginal repair with or without apical repair, without concomitant posterior repair (n = 23; all P < 0.05). CONCLUSIONS: POP surgery was associated significantly with 'straightening' of the urethra and reduction in urethral mobility. The effect seems to be due largely to cystocele repair. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Pelvic organ prolapse in Caucasian and East Asian women: a comparative study.

OBJECTIVE: Ethnicity has been suggested to be a significant risk factor for pelvic organ prolapse (POP); yet, pelvic organ descent in different ethnic groups, especially in Asian populations, is not well studied. The aim of this study was to compare prolapse stages, pelvic organ descent and hiatal dimensions between East Asian and Caucasian women presenting with symptoms of POP. METHODS: This was a prospective observational study of East Asian and Caucasian women presenting with symptoms of POP to a tertiary urogynecology clinic in, respectively, Hong Kong and Sydney. Demographic data, prolapse symptoms and prolapse stage were assessed. Physical examination was performed using the pelvic organ prolapse quantification (POP-Q) system. All women underwent transperineal ultrasound using Voluson systems. Offline analysis of four-dimensional ultrasound volume data was performed at a later date, by one operator blinded to all clinical data, to ascertain pelvic organ descent and hiatal dimensions on Valsalva maneuver. Levator muscle avulsion was assessed in volumes obtained on pelvic floor muscle contraction. Multiple logistic regression analysis was performed to assess factors associated with prolapse on clinical and ultrasound examinations. RESULTS: A total of 225 East Asian women were included between July 2012 and February 2014 from the Hong Kong clinic and 206 Caucasian women between January 2015 and July 2016 from the Sydney clinic. There was no significant difference in the overall staging of prolapse. However, in East Asian women, compared with Caucasians, apical compartment prolapse was more common (99.6% vs 71.8%, P < 0.001) and posterior compartment prolapse less common (16.9% vs 48.5%, P < 0.001) on POP-Q examination. On Valsalva maneuver, the position of the uterus was lower in East Asian than in Caucasian women (-11.3 vs 1.35 mm, P < 0.001), while the rectal ampulla position was lower in Caucasians than in East Asians (-10.6 vs - 4.1 mm, P < 0.001). On multiple regression analysis, Caucasian ethnicity was a significant factor for lower risk of apical compartment prolapse on clinical assessment (odds ratio (OR), 0.01; P < 0.001) and on ultrasound (OR, 0.13; P < 0.001), and for a higher risk of posterior compartment prolapse on clinical assessment (OR, 4.36; P < 0.001) and of true rectocele on ultrasound (OR, 8.14; P < 0.001). CONCLUSIONS: East Asian women present more commonly with uterine prolapse while Caucasians show more often posterior compartment prolapse. Ethnicity was a significant predictor of type of prolapse on multivariate analysis. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Laparoscopic sacrocolpopexy: how low does the mesh go?

OBJECTIVE: Laparoscopic sacrocolpopexy is becoming an increasingly popular surgical approach for repair of apical vaginal prolapse. The aim of this study was to document the postoperative anterior mesh position after laparoscopic sacrocolpopexy and to investigate the relationship between mesh location and anterior compartment support. METHODS: This was an external audit of patients who underwent laparoscopic sacrocolpopexy for apical prolapse ≥ Stage 2 or advanced prolapse ≥ Stage 3, between January 2005 and June 2012. All patients were assessed with a standardized interview, clinical assessment using the International Continence Society Pelvic Organ Prolapse quantification and four-dimensional transperineal ultrasound to evaluate pelvic organ support and mesh location. Mesh position was assessed with respect to the symphysis pubis whilst distal mesh mobility was assessed using the formula √[(XValsalva - Xrest )2 + (YValsalva - Yrest )2 ], where X is the horizontal distance and Y is the vertical distance between the mesh and the inferior symphyseal margin, measured at rest and on Valsalva. RESULTS: Ninety-seven women were assessed at a mean follow-up of 3.01 (range, 0.13-6.87) years after laparoscopic sacrocolpopexy, 88% (85/97) of whom considered themselves to be cured or improved, and none had required reoperation. On clinical examination, prolapse recurrence in the apical compartment was not diagnosed in any patient; however, 60 (62%) had recurrence in the anterior compartment and 43 (44%) in the posterior compartment. On ultrasound examination, mesh was visualized in the anterior compartment in 60 patients. Both mesh position and mobility on Valsalva were significantly associated with recurrent cystocele on clinical and on ultrasound assessment (all P < 0.01). For every mm that the mesh was located further from the bladder neck on Valsalva, the likelihood of cystocele recurrence increased by 6-7%. CONCLUSION: At an average follow-up of 3 years, laparoscopic sacrocolpopexy was highly effective for apical support; however, cystocele recurrence was common despite an emphasis on anterior mesh extension. Prolapse recurrence seemed to be related to mesh position and mobility, suggesting that the lower the mesh is from the bladder neck, the lower the likelihood of anterior compartment prolapse recurrence. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Does the Epi-No(®) birth trainer prevent vaginal birth-related pelvic floor trauma? A multicentre prospective randomised controlled trial.

OBJECTIVE: Vaginal childbirth may result in levator ani injury secondary to overdistension during the second stage of labour. Other injuries include perineal and anal sphincter tears. Antepartum use of a birth trainer may prevent such injuries by altering the biomechanical properties of the pelvic floor. This study evaluates the effects of Epi-No(®) use on intrapartum pelvic floor trauma. DESIGN: Multicentre prospective randomised controlled trial. SETTING: Two tertiary obstetric units in Australia. POPULATION: Nulliparous women carrying an uncomplicated singleton term pregnancy. METHODS: Participants were assessed clinically and with 4D translabial ultrasound in the late third trimester, and again at 3-6 months postpartum. Women randomised to the intervention group were asked to use the Epi-No(®) device from 37 weeks of gestation until delivery. MAIN OUTCOME MEASURES: Levator ani, anal sphincter, and perineal trauma diagnosed clinically and/or with translabial ultrasound imaging. RESULTS: Of 660 women randomised, 504 (76.4%) returned for assessment at a mean of 5 months postpartum. There was no significant difference in the incidence of levator avulsion [12 versus 15%; relative risk (RR) 0.82, 95% confidence interval (95% CI) 0.51-1.32; absolute risk reduction (ARR) 0.03, 95% CI -0.04 to 0.09; P = 0.39], irreversible hiatal overdistension (13 versus 15%; RR 0.86, 95% CI 0.52-1.42; ARR 0.02, 95% CI -0.05 to 0.09; P = 0.51), clinical anal sphincter trauma (7 versus 6%; RR 1.12, 95% CI 0.49-2.60; ARR -0.01, 95% CI -0.05 to 0.06; P = 0.77), and perineal tears (51 versus 53%; RR 0.96, 95% CI 0.78-1.17; ARR 0.02, 95% CI -0.08 to 0.13; P = 0.65). A marginally higher rate of significant defects of the external anal sphincter on ultrasound was observed in the intervention group (21 versus 14%; RR 1.44, 95% CI 0.97-2.20; ARR -0.06, 95% CI -0.13 to 0.05; P = 0.07). CONCLUSION: Antenatal use of the Epi-No(®) device is unlikely to be clinically beneficial in the prevention of intrapartum levator ani damage, or anal sphincter and perineal trauma. TWEETABLE ABSTRACT: No evidence of a protective effect of the Epi-No(®) device on intrapartum pelvic floor rauma.

Warping of the levator hiatus: how significant is it?

OBJECTIVES: The levator hiatus is the largest potential hernial portal in the human body. Excessive distensibility is associated with female pelvic organ prolapse (POP). Distension occurs not just laterally but also caudally, resulting in perineal descent and hiatal deformation or 'warping'. The aim of this study was to quantify the warping effect in symptomatic women, to validate the depth of the rendered volume used for the 'simplified method' of measuring hiatal dimensions and to determine predictors for the degree of warping. METHODS: This was a retrospective study utilizing records of patients referred to a tertiary urogynecological service between November 2012 and March 2013. Patients underwent a standardized interview, clinical assessment using the POP quantification system of the International Continence Society and four-dimensional translabial ultrasound. The craniocaudal difference in the location of minimal distances in mid-sagittal and coronal planes was determined by offline analysis of ultrasound volumes, and provided a numerical measure of warping. We tested potential predictors, such as demographic factors, signs and symptoms of prolapse, levator avulsion and levator distensibility, for an association with warping. RESULTS: Full datasets were available for 190 women. The mean craniocaudal difference in location of minimal distances in mid-sagittal and coronal planes was -1.26 mm (range, -6.7 to 4.6 mm; P < 0.001). This measure of warping was associated with hiatal area on Valsalva maneuver (r = - 0.284; P < 0.0001) and signs of significant prolapse on clinical and ultrasound examination (both P < 0.0001). CONCLUSIONS: The plane of minimal dimensions of the levator ani hiatus is non-Euclidean, i.e. warped, and the degree of warping is associated with hiatal distension, or 'ballooning', and with POP. However, the degree of warping is minor, the largest difference we found in the location of the plane of minimal dimensions being 6.7 mm. Hence, our results support the determination of hiatal area in a rendered volume of 1-2 cm in depth. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Is pelvic organ support different between young nulliparous African and Caucasian women?

OBJECTIVE: There seems to be substantial variation in the prevalence of pelvic floor disorders between different ethnic groups. This may be due partially to differences in pelvic floor structure and functional anatomy. To date, data on this issue are sparse. The aim of this study was to compare hiatal dimensions, pelvic organ descent and levator biometry in young, healthy nulliparous Caucasian and African women. METHODS: Healthy nulliparous non-pregnant volunteers attending a local nursing school in Uganda were invited to participate in this study during two fistula camps. All volunteers underwent a simple physician-administered questionnaire and a four-dimensional translabial ultrasound examination. Offline analysis was performed to assess hiatal dimensions, pelvic organ descent, levator muscle thickness and area. To compare findings with those obtained in nulliparous non-pregnant Caucasians, we retrieved the three-dimensional/four-dimensional ultrasound volume datasets of a previously published study. RESULTS: The dataset of 76 Ugandan and 49 Caucasian women was analyzed. The two groups were not matched but they were comparable in age and body mass index. All measurements of hiatal dimensions and pelvic organ descent were significantly higher among the Ugandans (all P ≤ 0.01); however, muscle thickness and area were not significantly different between the two groups. CONCLUSIONS: Substantial differences between Caucasian and Ugandan non-pregnant nulliparae were identified in this study comparing functional pelvic floor anatomy. It appears likely that these differences in functional anatomy are at least partly genetic in nature. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Perineal and vaginal tears are clinical markers for occult levator ani trauma: a retrospective observational study.

OBJECTIVES: Levator avulsion has been shown to be associated with anterior and central compartment prolapse and is a risk factor for prolapse recurrence. Diagnosis in the delivery room is usually impossible, as levator avulsion is commonly occult. The objective of this study was to determine if vaginal and major perineal tears are clinical markers of levator trauma as diagnosed by four-dimensional (4D) translabial ultrasound 3-6 months postpartum. METHODS: This was a retrospective observational study using data obtained in two perinatal trials. A total of 774 women seen, on average, 5 (range, 2.3-22.4) months after their first delivery of a term singleton cephalic baby underwent a standardized interview, clinical assessment and 4D translabial ultrasound examination. Clinical data were obtained from the institutional obstetric database, including information on vaginal and perineal tears. Levator avulsion was diagnosed using tomographic ultrasound, with operators blinded to the clinical data. RESULTS: Both third- and fourth-degree perineal tears and vaginal sidewall tears were independently associated with levator avulsion (P = 0.004 and P = 0.012, respectively). The odds ratio for avulsion in women suffering from such overt trauma was 3.44 (95% CI, 1.47-8.03) for third-/fourth-degree perineal tears and 3.35 (95% CI, 1.30-8.61) for vaginal sidewall tears. CONCLUSIONS: Vaginal sidewall and third-/fourth-degree perineal tears were found to be independent clinical indicators of an increased risk of levator trauma, as diagnosed by 4D translabial ultrasound 3-6 months postpartum. Such clinical markers may become useful in the identification of women at high risk of levator trauma and future pelvic floor disorders.

Association of urinary and anal incontinence with measures of pelvic floor muscle contractility.

OBJECTIVE: To assess the association between clinical and sonographic measures of pelvic floor muscle (PFM) function and symptoms of urinary and anal incontinence (AI). METHODS: This was a retrospective study of women seen at a tertiary urogynecological unit. All women had undergone a standardized interview, clinical examination including Modified Oxford Scale (MOS) grading, urodynamic testing and four-dimensional translabial ultrasound (TLUS). Cranioventral shift of the bladder neck (BN) and reduction in the hiatal anteroposterior (AP) diameter were measured using ultrasound volumes acquired on maximal PFM contraction, blinded against all clinical data. RESULTS: Data from 726 women with a mean age of 56 ± 13.7 (range, 18-88) years and a mean body mass index of 29 ± 6.1 (range, 17-55) kg/m(2) were analyzed. Stress (SI) and urge (UI) urinary incontinence were reported by 73% and 72%, respectively, and 13% had AI. Mean MOS grade was 2.4 ± 1.1 (range, 0-5). Mean cranioventral BN shift on TLUS was 7.1 ± 4.4 (range, 0.3-25.3) mm; mean reduction in AP hiatal diameter was 8.6 ± 4.8 (range, 0.3-31.3) mm. On univariate analysis, neither MOS nor TLUS measures were strongly associated with symptoms of urinary incontinence or AI; associations were non-significant except for BN displacement/SI (7.3 mm vs 6.5 mm; P = 0.028), BN displacement/UI (6.85 vs 7.75; P = 0.019), hiatal AP diameter/AI (9.6 mm vs 8.5 mm; P = 0.047) and MOS/SI (2.42 vs 2.19; P = 0.013). CONCLUSIONS: In this large retrospective study we did not find any strong associations between sonographic or palpatory measures of PFM function and symptoms of urinary incontinence or AI. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

How large does a rectocele have to be to cause symptoms? A 3D/4D ultrasound study.

INTRODUCTION: Rectocele is a common condition, which on imaging is defined by a pocket identified on Valsalva or defecation. Cut-offs of 10 and 20 mm for pocket depth have been described. This study analyses the correlation between rectocele depth and symptoms of bowel dysfunction to define a cut-off for the diagnosis of "significant rectocele" on ultrasound. METHODS: A retrospective study using 564 archived data sets of patients seen at tertiary urogynaecological clinics. Patients underwent a standardised interview including a set of questions regarding bowel function, and translabial 3D/4D ultrasound. Assessments were undertaken supine and after voiding. Rectocele depth was measured on Valsalva. RESULTS: Out of 564, data on symptoms was missing in 18 and ultrasound volumes in 25, leaving 521. Mean age was 56 years (range 18-86), mean BMI 29 (17-56). Presenting symptoms were prolapse (51 %), constipation (21 %), vaginal digitation (17 %), straining at stool (46 %), incomplete bowel emptying (41 %) and faecal incontinence (10 %). A clinically significant rectocele (ICS POPQ stage ≥2) was found in 48 % (n=250). In 261 women a rectal diverticulum was identified, of an average depth of 17 (SD, 7) mm. On ROC statistics a cut- off of 15 mm in depth provided optimal sensitivities of 66 % for vaginal digitation and 63 % for incomplete emptying, and specificities of 52 and 57 % respectively. CONCLUSIONS: Rectocele depth is associated with symptoms of obstructed defecation. A "clinically significant" rectocele may be defined as a diverticulum of the rectal ampulla of ≥15 mm in depth, although poor test characteristics limit clinical utility of this cut-off.