Does parity impact obstructed defecation in women with normal anorectal anatomy?

INTRODUCTION AND HYPOTHESIS: Obstructed defecation (OD) is often associated with trauma to pelvic connective tissue and nerves sustained during pregnancy and childbirth. Although there are multiple potential etiologies of defecatory dysfunction, the pathophysiology of this symptom complex is not well understood. The purpose of this study is to determine the role of parity in the development of obstructed defecatory symptoms in women with normal anorectal anatomy in a search for evidence of a presumptive neuropathic effect of pregnancy and childbirth. METHODS: This study retrospectively evaluated the records of 754 women presenting at a tertiary urogynecology unit for pelvic floor dysfunction with no anatomical abnormalities of the anorectum on imaging. They were stratified according to parity. The authors determined the prevalence of obstructed defecation symptoms in these groups. Chi-squared test was performed for statistical analysis. RESULTS: Median age was 51 (range 16-88) years, and median vaginal parity was 2 (0-8); 399 (53%) women reported symptoms of OD. When anatomical abnormalities of the anorectum were excluded, parity did not seem to have a major effect on the prevalence of symptoms of OD. CONCLUSIONS: In this cohort, parity is unlikely to be a cause of OD in women with normal anorectal anatomy.

Is coital incontinence a manifestation of urodynamic stress incontinence or detrusor overactivity?

INTRODUCTION AND HYPOTHESIS: Coital incontinence (CI) is an underreported symptom among sexually active women. It has been assumed that incontinence at penetration (CIAP) is due to urodynamic stress incontinence (USI), while coital incontinence at orgasm (CIAO) is thought to be due to detrusor overactivity (DO). METHODS: To evaluate demographic and urodynamic findings associated with coital incontinence (CI) and to confirm the hypotheses 'CIAP is associated with USI' and 'CIAO is associated with DO we performed a retrospective study of 661 sexually active women attending a tertiary clinic between January 2017 and December 2019 for pelvic floor dysfunction. All patients filled in a standardized questionnaire and had a clinical examination and multichannel urodynamic testing. Women were asked if they experienced urine leakage during intercourse and the timing of such leakage. RESULTS: Of 661 sexually active women, one third (n = 220) reported coital incontinence. While 121 (18%) women experienced CIAP, 172 (26%) had CIAO and 76 (11.5%) suffered both. For women with pure USI, the prevalence of CIAP (61.7%) and CIAO (69.5%) was significantly higher than for women with pure DO, where only 12.3% had CIAP and 8.6% had CIAO. Factors significantly associated with CI were body mass index, mid-urethral closure pressure (MUCP) and abdominal leak point pressure (ALPP). When only women with pure USI or DO were included, USI remained associated with CI while DO was not. CONCLUSIONS: CI is clearly associated with SUI and USI and is likely to share etio-pathogenetic mechanisms. CI seems to be a manifestation of USI, even when it occurs during orgasm.

Imaging Characteristics of Episiotomy Scars on Translabial Ultrasound: An Observational Study.

INTRODUCTION: Episiotomy has been purported to protect the anal sphincter from injury; efficacy is, however, disputed. Correct execution of episiotomy may have substantial implications. We aimed to describe the characteristics of episiotomy scars on translabial ultrasound (TLUS). METHODS: In this retrospective observational study involving women after repair of obstetric anal sphincter injuries, 76 women with a history of episiotomy were analyzed. Episiotomy scars were assessed on tomographic ultrasound in the transverse plane using volumes acquired on pelvic floor muscle contraction. We measured scar length, depth, and angle relative to a vertical reference line. Episiotomy scars were described as 1) ipsilateral if they started on the same side as the direction of the episiotomy, 2) contralateral if on the opposite side, and 3) mediolateral if the scar began in the midline. RESULTS: The mean scar angle was 50.5° (SD 14°; range 14.4°-79.3°) while mean scar length was 14.2 mm (SD 4.5; range 5.7-27.5 mm) and depth was 8.4 mm (SD 2.8, range 3.1-18.2 mm). Sixteen (21%) scars were located mediolateral while 32 (42%) were ipsilateral. In 28 (37%) women, the starting point of the episiotomy was located contralateral to the direction of the episiotomy. CONCLUSION: In this pilot series, the mean angle of episiotomy scars was within the safe zone of 40° to 60°, however, in one-third of cases the cut may have been initially directed toward the sphincter, not away from it. This observation suggests that not all episiotomies are performed optimally.

Is perineal hypermobility an independent predictor of obstructive defecation?

INTRODUCTION AND HYPOTHESIS: Symptoms of obstructed defecation (OD) and anatomical abnormalities of the posterior compartment are prevalent in urogynecological patients. The aim of this study was to determine whether perineal hypermobility is an independent predictor of OD, as is the case for rectocele, enterocele and rectal intussusception. METHODS: This is a retrospective study of 2447 women attending a tertiary urodynamic center between September 2011 and December 2016. The assessment included a structured interview, urodynamic testing, a clinical examination and 4D transperineal ultrasound. After exclusion of previous pelvic floor surgery and defined anatomical abnormalities of the anorectum, 796 patients were left for analysis. Perineal hypermobility was defined as rectal descent ≥ 15 mm below the symphysis pubis, determined in stored ultrasound volume datasets offline, using proprietary software, blinded to all other data. Any association between perineal hypermobility and symptoms of obstructed defecation was tested for by chi-square (X2) test. RESULTS: For the 796 patients analyzed, median age was 52 (range, 16-88) years with a mean BMI of 27 (range, 15-64) kg/m2. Average vaginal parity was two (range, 0-8). Reported OD symptoms in this group included sensation of incomplete emptying in 335 (42%), straining at stool in 300 (37%) and digitation in 83 (10%). At least one of those symptoms was reported by 424 (53%) women; 153 showed perineal hypermobility. There was no significant association between perineal hypermobility and OD symptoms on univariate testing. CONCLUSIONS: We found no evidence of an independent association between perineal hypermobility and obstructed defecation.

Does Vaginal Parity Alter the Association Between Symptoms and Signs of Pelvic Organ Prolapse?

OBJECTIVES: This study aimed to investigate whether the number of vaginal births a woman has alters the association between symptoms and signs of pelvic organ prolapse. METHODS: In this retrospective study, we investigated data on 1748 women seen between April 2012 and January 2016. To elucidate whether the number of vaginal births is a confounder of this relationship, we used receiver operating characteristic statistics to investigate the association between symptoms and signs of prolapse in women of different vaginal parity. RESULTS: A higher number of vaginal births was associated with a higher likelihood of symptoms of prolapse for any given degree of prolapse. Multivariate modeling, however, showed this confounding effect to be due to higher vaginal parity in older women (P < .001). Receiver operating characteristic curves obtained for the association between symptoms and signs of prolapse were near identical regardless of whether vaginal parity was included in the modeling. This was true for both clinical and imaging assessments of prolapse. CONCLUSIONS: Although vaginal childbirth is associated with symptoms of prolapse, the number of vaginal births does not alter the relationship between symptoms and signs of prolapse among individuals presenting to a tertiary care center for evaluation. Previously published limits for "normal" pelvic organ mobility can be used irrespective of vaginal parity.

Parity and anal sphincter trauma.

INTRODUCTION AND HYPOTHESIS: Obstetric anal sphincter injury (OASI) is a form of maternal trauma secondary to vaginal birth. Women with a history of OASI are deemed to be at a higher risk of recurrence. However, it is unclear if multiparity is associated with higher prevalence. The aim of the study was to test the following hypothesis: the prevalence of external anal sphincter (EAS) tears diagnosed on transperineal ultrasound (TPUS) is related to vaginal parity. METHODS: A retrospective observational study on 1,273 women who attended a tertiary urogynecology service between January 2014 and December 2016. Patients had undergone a standardized interview, clinical examination and 4D TPUS. Tomographic ultrasound imaging was used to evaluate the EAS, blinded to all clinical data. RESULTS: Of 1,273 women, 1,143 (90%) were vaginally parous, with a mean vaginal parity of 2 (range 1-8). Mean age was 54 (range 17-89) years. Anal incontinence was reported in 186 women (15%) with an average St Mark's incontinence score of 12 (range 1-23). EAS defects on ultrasound were identified in 148 (12%). On univariate analysis, there was no significant difference in the prevalence of EAS defects in vaginally primiparous and multiparous women (p = 0.460). CONCLUSIONS: There is no significant difference in the prevalence of EAS tears between vaginally primiparous and multiparous women. This argues against additional traumatic effects of subsequent vaginal births.

Anal sphincter imaging: better done at rest or on pelvic floor muscle contraction?

INTRODUCTION AND HYPOTHESIS: Exo-anal ultrasound imaging of the anal sphincter is usually undertaken on pelvic floor muscle contraction (PFMC) as this seems to enhance tissue discrimination. Some women are unable to achieve a satisfactory PFMC, and in this situation, the sphincter is assessed at rest. We aimed to determine whether sphincter imaging at rest is inferior to imaging on PFMC. METHODS: We analysed 441 women in this retrospective study. All underwent a standardised interview, including St Mark's incontinence score, clinical examination and 4D trans-labial ultrasound (TLUS). On analysing volume data, tomographic imaging was used to obtain a standardised set of slices at rest and on PFMC to evaluate external anal sphincter (EAS) and internal anal sphincter (IAS) trauma as described previously. RESULTS: When assessments obtained from volumes acquired at rest and on PFMC were tested against measures of anal incontinence (AI), all associations between the diagnosis of significant anal sphincter defects and AI were no stronger when imaging was performed on PFMC. On cross-tabulation, the percentage agreement for significant defects of the EAS and IAS at rest and on PFMC was 96.5% and 98.9% respectively, if discrepancy by one slice was allowed. CONCLUSIONS: Exo-anal tomographic imaging of sphincter defects at rest seems sufficiently valid for clinical use and may not be inferior to sphincter assessment on pelvic floor muscle contraction.

Should Genital Hiatus/Perineal Body Be Measured at Rest or on Valsalva?

OBJECTIVE: Genital hiatus (Gh) and perineal body (Pb) are part of the Pelvic Organ Prolapse Quantification assessment system, but it is unclear whether measurements should be taken at rest or on Valsalva. This study was designed to assess the predictive value of Gh and Pb measurements obtained at rest and on Valsalva for signs and symptoms of pelvic organ prolapse (POP). METHODS: This is a retrospective study involving 416 women who presented to a tertiary urogynecology unit with symptoms of pelvic floor dysfunction. Genital hiatus and Pb were measured at rest and on maximal Valsalva. The strength of association between binary markers of POP and measurements of Gh/Pb was estimated using logistic regression analysis. Receiver operator characteristic statistics were used to compare predictive values of Gh and Pb measurements obtained at rest and on Valsalva. RESULTS: A total of 451 women were seen during the study period. Thirty-five were excluded owing to missing data, leaving 416. Fifty-four percent (n = 223) complained of POP symptoms. On examination, 80% (n = 332) had significant POP (stage 2+ in anterior or posterior compartments or stage 1+ in the central compartment). On imaging, significant POP was diagnosed in 66% (n = 275). Mean hiatal area was 22 cm (SD, 7; range, 5-49 cm) at rest and 30 cm (SD, 10; range, 11-69 cm) on Valsalva. Genital hiatus and Pb measured on Valsalva were consistently stronger predictors of prolapse symptoms and objective prolapse (by clinician examination and by ultrasound) than at Gh and Pb measured at rest. The corresponding area under the curve values were significantly larger for Gh/Pb measures on Valsalva after adjusting for multiple confounders. CONCLUSIONS: Genital hiatus/Pb measured on maximal Valsalva is a superior predictor of symptoms and signs of POP compared with Gh/Pb at rest.

Impact of subsequent pregnancies on pelvic floor functional anatomy.

INTRODUCTION AND HYPOTHESIS: Vaginal childbirth clearly has an effect on pelvic floor anatomy, and pregnancy itself also likely plays a role. This study investigated the effects of consecutive pregnancies by comparing pelvic organ support and function in urogynecological patients delivered by cesarean section (CS) only. METHODS: This was a retrospective study using 161 archived data sets of urogynecological patients delivered exclusively by CS presenting with symptoms of pelvic floor dysfunction between 2007 and 2015. Patients had undergone an interview, clinical examination using the Pelvic Organ Prolapse Quantification (POP-Q) system, and 3D/4D translabial ultrasound (TLUS) using Voluson systems. Measures of functional pelvic floor anatomy were obtained from stored ultrasound (US) volumes at a later date, using proprietary software, and blinded against all other data. RESULTS: One hundred and sixty-one women delivered exclusively by CS were seen in a urogynecological clinic. Volume data analysis was possible in 151 patients. Mean age was 52 (26-82) years, with a mean body mass index (BMI) of 29.5 (18.4-48.7) kg/m2. Forty-three (28.5%) women had one CS, 67 (44.4%) had two, and 41 (27.1%) had three or more. On multivariate analysis, adjusting for age, BMI, history of hysterectomy, and incontinence or prolapse surgery, there were no significant differences between groups. CONCLUSIONS: On comparing women with one, two, or three or more CS, we found no significant differences in any measured sonographic parameters of pelvic organ descent and pelvic floor muscle function. This implies that subsequent pregnancies after the first are unlikely to exert significant additional effects on pelvic floor functional anatomy.

Digitation to Void: What Is the Significance of This Symptom?

OBJECTIVE: Digitation to void is defined as the need to apply manual pressure on the perineum or the vagina to assist with voiding. It has been associated with prolapse; however, there is little objective data concerning this symptom. Our aim was to determine the correlation between digitation to void, symptoms and signs of pelvic organ prolapse (POP), and urodynamic data. METHODS: This was a retrospective study that included a total of 1174 patients seen at a tertiary urogynecological unit. A standardized history was obtained from all patients followed by multichannel urodynamic testing, Pelvic Organ Prolapse Quantification scoring and 3-D/4-D translabial ultrasound. Stored 4-D translabial ultrasound volumes were obtained and analyzed at a later date. RESULTS: Digitation to void was present in 7% (n = 83) of our population. It is associated with primary symptoms of POP (odds ratio [OR], 25.75; confidence interval [CI], 8.08-82.05), clinically significant POP (OR, 5.62; CI, 2.25-14.02), and POP on ultrasound (OR, 5.39; CI, 2.67-10.88). Cystocele presented the strongest association, clinically (OR, 3.45; CI, 1.98-6.03) and on ultrasound (OR, 4.04; CI, 2.46-6.64). Digitation to void was also associated with symptoms of voiding dysfunction (OR, 6.38 [3.83-10.64]) and slower maximum urine flow rate centile (18.4 vs 24.9, P = 0.017). CONCLUSIONS: Digitation to void is strongly associated with primary symptoms of prolapse and of voiding dysfunction, clinically significant POP, and pelvic organ descent on ultrasound. It is also associated with objective voiding dysfunction. The strongest associations were found with cystocele, both clinically and on imaging.

Prolapse assessment supine and standing: do we need different cutoffs for "significant prolapse"?

INTRODUCTION AND HYPOTHESIS: Translabial ultrasound (TLUS) has shown good correlations between clinical examination and imaging findings in the supine position, and limits of normality have been described. This is not the case for imaging in the standing position. This study was designed to test the hypothesis that different cutoff values are required for imaging in the standing position. METHODS: This was a retrospective study carried out in a tertiary urogynecological unit in women presenting with symptoms of lower urinary tract and pelvic floor dysfunction between August 2013 and December 2015. All women underwent a standardized interview, 4D TLUS and a POP-Q assessment. Organ descent on ultrasound was measured relative to the postero-inferior margin of the symphysis pubis (SP) on maximal Valsalva in the supine and standing positions. Receiver operator characteristic (ROC) statistics were used to determine optimal cutoffs for "normal" pelvic organ support. RESULTS: We assessed 243 data sets. Mean patient age was 57 years. Prolapse symptoms were reported by 59.2%, and POP of stage ≥ 2 was found in 82.3%. On analysing imaging data sets obtained in the standing position, we obtained similar cutoff values to those established previously for supine imaging, using ROC statistics. The levator hiatus distended significantly more on Valsalva in the standing position compared with supine, and on ROC analysis we identified a new optimal cutoff of 29 cm2. CONCLUSIONS: Established cutoffs for supine imaging of organ descent are suitable for imaging in the standing position. Hiatal distensibility may require a higher cutoff of 29 cm2.

Correlations between Sonographic and Urodynamic Findings after Mid Urethral Sling Surgery.

PURPOSE: We studied correlations between sonographic and urodynamic findings after suburethral sling surgery. MATERIALS AND METHODS: This retrospective study was done in 141 women who underwent multichannel urodynamic testing and translabial 4-dimensional ultrasound after suburethral sling surgery between 2006 and 2016. We determined the sling-pubis gap, ie the distance between the sling and the inferior posterior margin of the pubic symphysis, during the Valsalva maneuver and the urethral motion profile. The latter was assessed by calculating the mobility vectors of 6 equidistant points along the length of the urethra from the bladder neck to the external urethral meatus against the dorsocaudal margin of the pubic symphysis during the Valsalva maneuver. Correlations were determined between the sling-pubis gap and the mobility vectors, and between these measures and urodynamic data. RESULTS: Median followup in the 126 women with complete data was 36 months. Significant correlations were found between the sling-pubis gap and the mid urethral mobility vectors (all p <0.02). The sling-pubis gap and the mid urethral mobility vectors negatively correlated with detrusor pressure at maximum flow (p = 0.037 and 0.004, respectively). Urodynamic stress incontinence was more likely in women with a greater sling-pubis gap (p = 0.003). CONCLUSIONS: The tighter the sling on ultrasound, the less likely is urodynamic stress incontinence and the higher the detrusor pressure during voiding.

Pelvic organ prolapse: does hormone therapy use matter?

OBJECTIVE: To determine the effect of hormone therapy (HT) use on pelvic organ support. METHODS: A retrospective observational study involving postmenopausal women with pelvic floor dysfunction attending a tertiary urogynecology center between January 2012 and March 2015. All underwent a clinical examination including International Continence Society Pelvic Organ Prolapse Quantification and 4D translabial ultrasound imaging. Information on current or former use of systemic HT and current local estrogen use was collected. Main outcome measure was pelvic organ support. RESULTS: One thousand four hundred forty-three women were seen during the study period. On univariate analysis, current HT was significantly associated with sonographically determined descent of the rectal ampulla (ß [95% confidence interval] 3.4 mm [0.4-6.5], P = 0.03) and Gh + Pb (-0.45 mm [-0.8 to -0.1], P = 0.005). Past HT use, duration of HT use, or current vaginal estrogen use was not associated with pelvic organ support. On multivariate analysis controlling for age, parity, body mass index, history of forceps delivery, and avulsion, the association between current HT on the one hand and Gh + Pb as well as increased descent of the rectal ampulla on ultrasound, remained significant (P = 0.008 and P = 0.012, respectively). CONCLUSION: HT may have a minor negative effect on pelvic organ support; however, the effect is likely too small to be clinically relevant.