Exploring transvaginal sonographic characteristics of the levator ani muscle in women with postpartum pelvic floor myofascial pain.

BACKGROUND: Pelvic floor myofascial pain is one of the pelvic floor dysfunction diseases disturbing women after delivery. There is a lack of objective standardization for the diagnosis of pelvic floor myofascial pain due to the various symptoms and the dependence on the palpating evaluation. Ultrasound imaging has the advantages of safety, simplicity, economy and high resolution, which makes it an ideal tool for the assistant diagnosis of pelvic floor myofascial pain and evaluation after treatment. METHODS: This is a retrospective case-control study including women accepting evaluation of pelvic floor function at 6 weeks to 1 year postpartum. They were divided into pelvic floor myofascial pain group and normal control group. A BCL 10-5 biplane transducer was applied to observed their puborectalis. The length, minimum width, area, deficiency, deficiency length, deficiency width, deficiency area, rate of deficiency area, local thickening,angle between the tendinous arch of levator ani muscle and puborectalis of corresponding puborectalis in different groups were observed and measured. RESULTS: A total of 220 postpartum women participated in the study, with 77 in the pelvic floor myofascial pain group and 143 in the normal control group. The Intraclass correlation coefficient value was over 0.750, and Kappa ranged from 0.600 to 0.800. puborectalis deficiency (adjusted odds ratio = 11.625, 95% confidence interval = 4.557-29.658) and focal thickening (adjusted odds ratio = 16.891, 95% confidence interval = 1.819-156.805) were significantly associated with higher odds of having postpartum pelvic floor myofascial pain. Grayscale or the angle between the arch tendineus levator ani and puborectalis measurements on the pain side tended to be smaller than on the non-pain side in patients with unilateral puborectalis or iliococcygeus pain (P < 0.05). CONCLUSIONS: This study demonstrated that transvaginal ultrasound was a potentially efficient technique for evaluating postpartum pelvic floor myofascial pain due to its ability to assess various sonographic characteristics of the levator ani muscles.

Comparison of Cross-Sectional Area of Pubovisceral Muscle in Nulliparous and Primiparous Women.

INTRODUCTION AND HYPOTHESIS: The main risk factor for pelvic floor disorders is vaginal delivery, which may cause levator ani muscle (LAM) injury and denervation. LAM includes pubovisceral muscle (PVM, pubococcygeus), puborectalis muscle (PRM), and iliococcygeus muscle. We hypothesize that primiparous women with low pelvic floor muscle contraction have a reduced PVM cross-sectional area (CSA) compared to nulliparous women. METHODS (SAMPLE SIZE AND STATISTICAL APPROACHES): This single-centre prospective observational study compared healthy nulliparous (n = 40) to primiparous (n = 40) women after vaginal delivery without LAM avulsion and Oxford score ≤ 3. Demographics, questionnaires (ICIQ-UI-SF, OAB-Q-SF, PISQ-12), POP-Q, Oxford score, ultrasound measurements (minimal anteroposterior and lateral diameters, hiatal area, PRM thickness, levator-urethra gap) and magnetic resonance imaging (MRI)-PVM CSA were evaluated. Normality was tested, and an appropriate test was used to compare the groups. Power calculation suggested 40 participants per group. RESULTS: The primiparous group was older, had a higher BMI, and their hiatal area on ultrasound at contraction was larger compared to the nulliparous group. The CSA of the left-sided PVM (1.15 ± 0.50 cm2) was larger compared to the right side (1.03 ± 0.50 cm2), p = 0.02 in nulliparous women. The PVM CSA of primiparous women with low Oxford score was reduced compared to nulliparous (0.87 ± 0.30 versus 1.09 ± 0.50 cm2, p = 0.006). The intra-rater reliability for PVM CSA had an ICC of 0.90 and inter-rater ICC of 0.77. CONCLUSIONS: Primiparous women after vaginal delivery with low pelvic floor contraction force had reduced PVM CSA on MRI images compared to nulliparous women.

[Imaging of the pelvic floor : The gynaecological perspective]. / Bildgebung des Beckenbodens : Die Sicht der Gynäkologie.

BACKGROUND: Pelvic floor dysfunction is common in women. OBJECTIVES: To describe the role of ultrasound in the urogynecological examination and imaging of the pelvic floor. MATERIALS AND METHODS: Analysis and summary of current recommendations and literature on the role of pelvic floor ultrasound. RESULTS: Pelvic floor ultrasound is a dynamic and real-time imaging modality. It is readily available, allows for a realistic assessment of anatomy and morphology, and poses minimal patient burden. CONCLUSIONS: Pelvic floor ultrasound is of great value in preoperative diagnostics as well as in the postoperative management of complications.

[Imaging of the pelvic floor : The urological perspective]. / Bildgebung des Beckenbodens : Die Sicht der Urologie.

BACKGROUND: Physiological pelvic floor function is essential for maintaining the appropriate storage and voiding function of the lower urinary tract. Disorders of pelvic floor function can consist of both hypofunction and hyperfunction and can result in urge symptoms, urinary incontinence, disorders of the micturition process, urinary retention, and chronic pelvic floor pain, as well as endangering the upper urinary tract. Thus, these disorders can be complex in their cause and effect. An exact diagnosis and initiation of a target-specific therapy of the respective functional disorder can only be achieved by the interaction of functional and imaging diagnostics. OBJECTIVES: The aim of this article is therefore to present these special imaging techniques from the perspective of functional urology and neuro-urology. METHODS: This paper presents the available imaging techniques in the diagnosis of pelvic floor dysfunction and places them in the diagnostic context of lower urinary tract dysfunction.

[Imaging of the pelvic floor (MR defecography) : The surgeon's perspective]. / Bildgebung des Beckenbodens (MR-Defäkographie) : Die Sicht der Chirurgie.

BACKGROUND: Magnetic resonance defecography (MRD) plays a central role in diagnosing pelvic floor functional disorders by visualizing the entire pelvic floor along with pelvic organs and providing functional assessment of the defecation process. A shared understanding between radiology and surgery regarding indications and interpretation of findings is crucial for optimal utilization of MRD. OBJECTIVES: This review aims to explain the indications for MRD from a surgical perspective and elucidate the significance of radiological findings for treatment. It intends to clarify for which symptoms MRD is appropriate and which criteria should be followed for standardized results. This is prerequisite to develop interdisciplinary therapeutic approaches. MATERIALS AND METHODS: A comprehensive literature search was conducted, including current consensus guidelines. RESULTS: MRD can provide relevant findings in the diagnosis of fecal incontinence and obstructed defecation syndrome, particularly in cases of pelvic floor descent, enterocele, intussusception, and pelvic floor dyssynergia. However, rectocele findings in MRD should be interpreted with caution in order to avoid overdiagnosis. CONCLUSION: MRD findings should never be considered in isolation but rather in conjunction with patient history, clinical examination, and symptomatology since morphology and functional complaints may not always correlate, and there is wide variance of normal values. Interdisciplinary interpretation of MRD results involving radiology, surgery, gynecology, and urology, preferably in the context of pelvic floor conferences, is recommended.

Pelvic floor imaging in asymptomatic subjects.

AIM: The aim of this work was to determine the range of normal imaging features during total pelvic floor ultrasound (TPFUS) (transperineal, transvaginal, endovaginal and endoanal) and defaecation MRI (dMRI). METHOD: Twenty asymptomatic female volunteers (mean age 36.5 years) were prospectively investigated with dMRI and TPFUS. Subjects were screened with symptom questionnaires (ICIQ-B, St Mark's faecal incontinence score, obstructed defaecation syndrome score, ICIQ-V, BSAQ). dMRI and TPFUS were performed and interpreted by blinded clinicians according to previously published methods. RESULTS: The subjects comprised six parous and 14 nulliparous women, of whom three were postmenopausal. There were three with a rectocoele on both modalities and one with a rectocoele on dMRI only. There was one with intussusception on TPFUS. Two had an enterocoele on both modalities and one on TPFUS only. There were six with a cystocoele on both modalities, one on dMRI only and one on TPFUS only. On dMRI, there were 12 with functional features. Four also displayed functional features on TPFUS. Two displayed functional features on TPFUS only. CONCLUSION: This study demonstrates the presence of abnormal findings on dMRI and TPFUS without symptoms. There was a high rate of functional features on dMRI. This series is not large enough to redefine normal parameters but is helpful for appreciating the wide range of findings seen in health.

The influence of defaecating proctograms on clinical decision-making in pelvic floor disorders.

AIM: Defaecating proctogram (DP) studies have become an integral part of the evaluation of patients with pelvic floor disorders. However, their impact on treatment decision-making remains unclear. The aim of this study was to assess the concordance of decision-making by colorectal surgeons and the role of the DP in this process. METHOD: Four colorectal surgeons were presented with online surveys containing the complete history, examination and investigations of 106 de-identified pelvic floor patients who had received one of three treatment options: physiotherapy only, anterior Delorme's procedure or anterior mesh rectopexy. The survey assessed the management decisions made by each of the surgeons for the three treatments both before and after the addition of the DP to the diagnostic work-up. RESULTS: After the addition of the DP results; treatment choice changed in 219 (52%) of 424 surgical decisions and interrater agreement improved significantly from κ = 0.26 to κ = 0.39. Three of the four surgeons reported a significant increase in confidence. Agreement with the actual treatments patients received increased from κ = 0.21 to κ = 0.28. Intra-anal rectal prolapse on DP was a significant predictor of a decision to perform anterior mesh rectopexy. CONCLUSION: The DP improves interclinician agreement in the management of pelvic floor disorders and enhances the confidence in treatment decisions. Intra-anal rectal prolapse was the most influential DP parameter in treatment decision-making.

Knowledge, attitudes, and practice of pelvic floor dysfunction and pelvic floor ultrasound among women of childbearing age in Sichuan, China.

Objective: Pelvic floor dysfunction (PFD) is highly prevalent among women. Pelvic floor ultrasound (PFU) is a critical method for assessing PFD. This study examined the knowledge, attitudes, and practice (KAP) of women of childbearing age regarding PFD and PFU. Methods: This cross-sectional study was conducted between August 18, 2022, and September 20, 2022, in Sichuan, China. A total of 504 women of childbearing age participated in this study. A self-administered questionnaire was developed to assess KAP regarding PFD and PFU. Univariable and multivariable logistic regression analyses were conducted to assess the association between demographic characteristics and KAP. Results: The average scores for knowledge, attitudes, and practice were 12.53, 39.98, and 16.51 out of 17, 45, and 20, respectively. Despite adequate knowledge of PFD symptoms, aging-related risks, and PFD harms (correct rates > 80%), participants showed poor knowledge about the benefits of PFU, PFU types, and Kegel exercise (correct rates < 70%). High scores in knowledge and attitude (odds ratio = 1.23 and 1.11, P < 0.001 and P = 0.005, respectively) were independent predictors of good practice, while never having been pregnant (odds ratio = 0.10, P < 0.001), alcohol consumption (odds ratio = 0.09, P = 0.027), and not being diagnosed with PFD or an unclear diagnosis independently predicted poor practice (both odds ratio = 0.03, both P < 0.001). Conclusion: Women of childbearing age in Sichuan, China, showed moderate knowledge, positive attitude, and good practice regarding PFD and PFU. Knowledge, attitude, pregnancy history, alcohol consumption, and PFD diagnosis are associated with practice.

Application of transperineal ultrasound combined with shear wave elastography in pelvic floor function assessment after hysterectomy.

This study explored the application of transperineal ultrasound (TPUS) combined with shear wave elastography (SWE) in evaluating the pelvic structure function of women after total hysterectomy. Seventy healthy women and 76 women who underwent total hysterectomy were selected for ultrasound examination. They were divided into normal (nulliparous) group, (parous) group without hysterectomy, and (parous) group with hysterectomy. TPUS combined with SWE was used to evaluate the pelvic floor structure and function in the 3 groups of women. Posterior urethrovesical angle in resting and maximal Valsalva state, anteroposterior diameter of hiatus in the 3 states, the bladder neck descent, the urethral rotation angle, the Young modulus of left and right puborectalisis muscle in resting state, and the incidence of pelvic floor dysfunction diseases were all higher in the group with hysterectomy than in the group without hysterectomy (P < .05). Bladder neck-symphyseal distance and anorectal junction-symphyseal distance in the maximum Valsalva state, and the difference in Young modulus between the left and right PR before and after anus contraction were all lower in the group with hysterectomy than the group without hysterectomy (P < .05). The incidence of pelvic floor dysfunction in postmenopausal patients in the group with hysterectomy was higher than that in premenopausal patients (P < .05). Total hysterectomy had negative effects on female pelvic floor structure and function. TPUS combined with SWE can be used to evaluate pelvic floor function in multiple dimensions.

Total pelvic floor ultrasound can reliably predict long-term treatment outcomes for patients with pelvic floor defaecatory dysfunction.

AIM: Integrated total pelvic floor ultrasound (TPFUS) may provide an alternative to defaecation proctography (DP) in decision making and treatment planning for patients with pelvic floor defaecatory dysfunction (PFDD). This study evaluates the use of TPUS as a screening tool, and its likelihood to predict long-term treatment outcomes. METHODS: Two blinded clinicians reviewed 100 women who had historically presented to a tertiary referral colorectal unit with PFDD from October 2014 to April 2015. The clinical history of the patients together with TPFUS or DP results were used to decide on main impression, treatment plan, likelihood of surgery and certainty of plan. These were compared to the actual treatment received six months later and again after a median follow-up of 68 months (range 48-84). RESULTS: A total of 82 patients were treated with biofeedback only and 18 also underwent surgery. There were no complications in any of the patients who had surgery. When compared with the actual treatment received, 99 of the 100 of the TPFUS group would have been treated appropriately. The number of false positives for surgical treatment was lower with TPFUS compared to DP. Clinician confidence in the overall decision was significantly higher after review with DP. CONCLUSIONS: TPFUS is a reliable assessment tool for PFDD. It can identify patients who can go straight to biofeedback and is just as good as DP at predicting likelihood of surgery. We might be able to rely on TPFUS more significantly in the future, even for surgical planning.

Three-dimensional high-resolution anorectal manometry: A comparative pilot study with X-ray defaecography.

Three-dimensional high-resolution anorectal manometry (3DHRAM) is a new technique that can explore anorectal disorders and provide interesting topographic data for the diagnosis of pelvic floor disorders such as paradoxical puborectalis syndrome (PPS). Our object was to evaluate whether 3DHRAM can reliably diagnose PPS already diagnosed with X-ray defaecography, which is considered to be the gold standard. All patients being tested in our department for dyschezia by 3D-HRAM and X-ray defecography were eligible for the study. The 3DHRAM results were compared with X-ray defecography. The sensitivity, specificity, and positive and negative predictive values were calculated for various 3DHRAM criteria to propose a diagnostic strategy for PPS. Twenty-three patients presented with PPS on X-ray defaecography. On 3DHRAM, according to our diagnostic strategy, the kappa value was 0.706, with a positive predictive value of 71.88% [95% CI, 53.02-85.60], a specificity of 80.43% [95% CI, 65.62-90.13], a sensibility of 95.83% [95% CI, 76.98-99.78], and area under curve value was 0.922. In this study, 3DHRAM was used to diagnose PPS with the same degree of reliability as X-ray defaecography, and we confirmed its use in the diagnosis of pelvic floor disorders. Further studies will be necessary to define classifications for these new anatomic data from 3DHRAM.

Levator ani muscle avulsion in patients with pelvic floor dysfunction - Does it help in understanding pelvic organ prolapse?

INTRODUCTION: Levator ani muscle (LAM) lesions are an important factor in the development of female pelvic organ prolapse (POP). OBJECTIVE: To determine the prevalence of LAM avulsion by transperineal ultrasound. The second outcome is to evaluate the association between complete avulsion and the type, degree, and number of POP compartments involved. MATERIALS AND METHODS: This was a retrospective cohort study performed in a tertiary hospital that included patients with pelvic floor dysfunction evaluated from January 2016 to March 2020. The presence of LAM avulsion was diagnosed by 3D/4D pelvic floor transperineal ultrasound. We identified women with POP, and they were classified according to the POP-Q system. The association between complete avulsion and the type, degree and number of compartments were calculated using generalized logit models. RESULTS: 848 women were included in the analysis. A complete LAM avulsion was found in 195 patients (23 %). Patients with complete avulsion were 4.7 (CI: 1.98-11.5) times more likely to have POP than patients with partial avulsion. The anterior compartment was the most frequently affected (n = 605, 25.8 %). Women with severe stage POP were 3.13 times (CI: 1.90-5.16) more likely to have bilateral complete LAM avulsion than women with mild prolapse. Patients with three-compartment POP were 2.75 times (CI: 1.53-4.94) more likely to have unilateral complete LAM avulsion than women with POP in one compartment. CONCLUSION: The prevalence of LAM avulsion is high in patients with urogynecological symptoms. Patients with complete LAM avulsion are at greater risk of developing POP and have a more advanced stage of prolapse and involvement of multiple compartments.

3D Ultrasound in Pelvic Floor: Is It Useful as a Prognostic Tool in Type of Labor Development and Subsequent Pelvic Floor Diseases?

The objective of our study is to determine the thickness of the pubovisceral fasciculus of the levator ani muscle and the area of the genital hiatus by means of three-dimensional perineal ultrasound, in pregnant women in the 2nd trimester, and to analyze the related maternal, perinatal and postpartum clinical variables. Furthermore, to compare the results of our study with two similar series previously published. An observational, prospective study of pelvic floor ultrasound was carried out, performed at week 20, whose delivery was attended in the obstetrics service of the Hospital General Universitario Gregorio Marañón de Madrid (HGUGM), during the period of August from 2021 to June 2022. Maternal, ultrasound, perinatal and postpartum clinical variables were collected from each participant. During the study period, a total of 54 patients were included in it. The mean gestational age at which the ultrasound was performed was 19.81 ± 0.91 weeks. In relation to the ultrasound variables, the mean thickness of the pubovisceral muscle was 0.87 ± 0.13 cm (95% CI, 0.64-1.38 cm), while, in the plane of minimum dimension of the genital hiatus, the hiatal area at rest was 13.41 ± 3.22 (95% CI, 4.60-18.78) cm2. There is a significant correlation between the age of pregnant women (over 35 years of age) and the increase in the area of the genital hiatus (r = 0.295, p = 0.031). 3D ultrasound of the pelvic floor performed at week 20 of gestation can to be an effective, non-invasive, reproducible and cheap tool in the prognosis of the development of labor and of possible subsequent perineal dysfunctions.

[Functional MRI of the pelvic floor]. / Funktionelle MRT des Beckenbodens.

Due to the complexity of pelvic floor dysfunctions and the frequent interdisciplinary findings, dynamic magnetic resonance imaging (MRI) can provide valuable (additional) information for the clinical examination in other disciplines through a comprehensive morphological and functional representation of the pelvic floor. It has therefore largely replaced conventional defecography under fluoroscopy in clinical practice. In order to increase the effectiveness and communication between radiology and the other specialist disciplines, recommendations for the standardized implementation and results of dynamic MRI were published by the European Society for Urogenital radiology (ESUR) in 2016 and based on these the Society for Abdominal Radiology (SAR) published simplified recommendations in 2019 for routine clinical use.

Validation of shear wave elastography as a noninvasive measure of pelvic floor muscle stiffness.

OBJECTIVES: To investigate the validity of shear wave elastography (SWE) as a measure of stiffness of the puborectalis muscle by examining: (1) the relationship between puborectalis muscle stiffness and pelvic floor muscle (PFM) activation at different intensities; and (2) the relationship between puborectalis stiffness and pelvic floor morphometry during contractions at different intensities. METHODS: Fifteen healthy asymptomatic women performed 6-s isometric PFM contractions at different intensities (0, 10%, 20%, 30%, 50%, 75%, and 100% of maximal voluntary contraction) guided by intravaginal electromyography (EMG). Stiffness of the puborectalis muscle was measured using SWE by calculating the average shear modulus in regions of interest that contained puborectalis muscle fibers parallel to the transducer. Pelvic floor morphometry was assessed in the mid-sagittal plane using transperineal B-mode ultrasound imaging. Shear modulus, EMG (root mean square amplitude) and pelvic floor morphometry parameters were normalized to the value recorded during maximal voluntary contraction. To assess the relationship between stiffness and pelvic floor activation/morphometry, coefficient of determination (r2 ) was calculated for each participant and a group average was computed. RESULTS: Shear modulus and EMG were highly correlated (average r2 ; left 0.90 ± 0.08, right 0.87 ± 0.15). Shear modulus also strongly correlated with bladder neck position (x-axis horizontal coordinates relative to the pubic symphysis), anorectal rectal angle and position, levator plate angle, and antero-posterior diameter of the levator hiatus (average r2 : range 0.62-0.78). CONCLUSIONS: These findings support the validity of SWE to assess puborectalis muscle stiffness in females. Stiffness measures were strongly associated with PFM EMG and pelvic floor morphometry and may be used to indirectly assess the level of activation of the puborectalis muscle without the use of more invasive techniques. By overcoming limitations of current assessment tools, this promising noninvasive and real-time technique could enable important breakthrough in the pathophysiology and management of pelvic floor disorders.