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.

Pelvic floor muscle contraction automatic evaluation algorithm for pelvic floor muscle training biofeedback using self-performed ultrasound.

INTRODUCTION: Non-invasive biofeedback of pelvic floor muscle training (PFMT) is required for continuous training in home care. Therefore, we considered self-performed ultrasound (US) in adult women with a handheld US device applied to the bladder. However, US images are difficult to read and require assistance when using US at home. In this study, we aimed to develop an algorithm for the automatic evaluation of pelvic floor muscle (PFM) contraction using self-performed bladder US videos to verify whether it is possible to automatically determine PFM contraction from US videos. METHODS: Women aged ≥ 20 years were recruited from the outpatient Urology and Gynecology departments of a general hospital or through snowball sampling. The researcher supported the participants in their self-performed bladder US and videos were obtained several times during PFMT. The US videos obtained were used to develop an automatic evaluation algorithm. Supervised machine learning was then performed using expert PFM contraction classifications as ground truth data. Time-series features were generated from the x- and y-coordinate values of the bladder area including the bladder base. The final model was evaluated for accuracy, area under the curve (AUC), recall, precision, and F1. The contribution of each feature variable to the classification ability of the model was estimated. RESULTS: The 1144 videos obtained from 56 participants were analyzed. We split the data into training and test sets with 7894 time series features. A light gradient boosting machine model (Light GBM) was selected, and the final model resulted in an accuracy of 0.73, AUC = 0.91, recall = 0.66, precision = 0.73, and F1 = 0.73. Movement of the y-coordinate of the bladder base was shown as the most important. CONCLUSION: This study showed that automated classification of PFM contraction from self-performed US videos is possible with high accuracy.

Correlation between congenital pelvic floor muscle development assessed by magnetic resonance imaging and postoperative defecation.

OBJECTIVE: Children with congenital anorectal malformation (CAM) experience challenges with defecation. This study aims to assess defecation in preschool-age children with CAM and to evaluate the correlation between pelvic floor muscle developed assessed by magnetic resonance imaging (MRI) and postoperative defecation. METHODS: We collected clinical data and MRI results from 89 male children with CAM. The bowel function scores for children with Perineal (cutaneous) fistula, Rectourethral fistula(Prostatic or Bulbar), and Rectovesical fistula were computed. MRI scans were subjected to image analysis of the striated muscle complex (SMC). The association between pelvic floor muscle score and bowel function score was examined using the Cochran-Armitage Trend Test. RESULTS: We observed that 77.4% of the SMC scores by MRI for Perineal fistula were good. The Rectourethral fistula SMC score was 40.6% for moderate and 59.4% for poor. The SMC score for Rectovesical fistula was 100% for moderate. Furthermore, 77.4% of patients with Perineal fistula had bowel function scores (BFS) ≥ 17 points. Among those with Rectourethral fistula and Rectovesical fistula, 12.5% and 0 had BFS ≥ 17 points, respectively. An analysis of muscle development and bowel function in patients with Rectovesical fistula, Rectourethral fistula, and Perineal fistula revealed a correlation between SMC development and BFS. Subgroup analysis showed that the Perineal fistula had statistical significance; however, the Rectourethral fistula and Rectovesical fistula were not statistically significant. CONCLUSION: A correlation exists between pelvic floor muscle development and postoperative defecation in children with Perineal fistula.

Soft-tissue dystocia due to paradoxical contraction of the levator ani as a cause of prolonged second stage: concept, diagnosis, and potential treatment.

Smaller pelvic floor dimensions seem to have been an evolutionary need to provide adequate support for the pelvic organs and the fetal head. Pelvic floor dimension and shape contributed to the complexity of human birth. Maternal pushing associated with pelvic floor muscle relaxation is key to vaginal birth. Using transperineal ultrasound, pelvic floor dimensions can be objectively measured in both static and dynamic conditions, such as pelvic floor muscle contraction and pushing. Several studies have evaluated the role of the pelvic floor in labor outcomes. Smaller levator hiatal dimensions seem to be associated with a longer duration of the second stage of labor and a higher risk of cesarean and operative deliveries. Furthermore, smaller levator hiatal dimensions are associated with a higher fetal head station at term of pregnancy, as assessed by transperineal ultrasound. With maternal pushing, most women can relax their pelvic floor, thus increasing their pelvic floor dimensions. Some women contract rather than relax their pelvic floor muscles under pushing, which is associated with a reduction in the anteroposterior diameter of the levator hiatus. This phenomenon is called levator ani muscle coactivation. Coactivation in nulliparous women at term of pregnancy before the onset of labor is associated with a higher fetal head station at term of pregnancy and a longer duration of the second stage of labor. In addition, levator ani muscle coactivation in nulliparous women undergoing induction of labor is associated with a longer duration of the active second stage of labor. Whether we can improve maternal pelvic floor relaxation with consequent improvement in labor outcomes remains a matter of debate. Maternal education, physiotherapy, and visual feedback are promising interventions. In particular, ultrasound visual feedback before the onset of labor can help women increase their levator hiatal dimensions and correct levator ani muscle coactivation in some cases. Ultrasound visual feedback in the second stage of labor was found to help women push more efficiently, thus obtaining a lower fetal head station at ultrasound and a shorter duration of the second stage of labor. The available evidence on the role of any intervention aimed to aid women to better relax their pelvic floor remains limited, and more studies are needed before considering its routine clinical application.

Changes in Pelvic Floor Ultrasonographic Features after Flat Magnetic Stimulation in Women with Chronic Pelvic Pain and Levator Ani Muscle Hypertonicity.

Background and Objectives: Chronic pelvic pain (CPP) represents a major public health problem for women with a significant impact on their quality of life. In many cases of CPP, due to gynecological causes-such as endometriosis and vulvodynia-improper pelvic floor muscle relaxation can be identified. Treatment of CPP with pelvic floor hypertonicity (PFH) usually involves a multimodal approach. Traditional magnetic stimulation has been proposed as medical technology to manage muscle hypertonicity and pelvic pain conditions through nerve stimulation, neuromodulation, and muscle relaxation. New Flat Magnetic Stimulation (FMS)-which involves homogeneous rather than curved electromagnetic fields-has the potential to induce sacral S2-S4 roots neuromodulation, muscle decontraction, and blood circulation improvement. However, the benefits of this new technology on chronic pelvic pain symptoms and biometrical muscular parameters are poorly known. In this study, we want to evaluate the modification of the sonographic aspect of the levator ani muscle before and after treatment with Flat Magnetic Stimulation in women with chronic pelvic pain and levator ani hypertonicity, along with symptoms evolution. Materials and Methods: A prospective observational study was carried out in a tertiary-level Urogynaecology department and included women with CPP and PFH. Approval from the local Ethics Committee was obtained before the start of the study (protocol code: MAGCHAIR). At the baseline, the intensity of pelvic pain was measured using a 10 cm visual analog scale (VAS), and patients were asked to evaluate their pelvic floor symptoms severity by answering the question, "How much do your pelvic floor symptoms bother you?" on a 5-answer Likert scale. Transperineal ultrasound (TPU) was performed to assess anorectal angle (ARA) and levator ani muscle minimal plane distance (LAMD). Treatment involved Flat Magnetic Stimulation alone or with concomitant local or systemic pharmacological therapy, depending on the patient's preferences. FMS was delivered with the DR ARNOLD system (DEKA M.E.L.A. Calenzano, Italy). After the treatment, patients were asked again to score the intensity of pelvic pain using the 10 cm visual analog scale (VAS) and to evaluate the severity of their pelvic floor symptoms on the 5-answer Likert scale. Patients underwent TPU to assess anorectal angle (ARA) and levator ani muscle minimal plane distance (LAMD). Results: In total, 11 patients completed baseline evaluation, treatment, and postoperative evaluation in the period of interest. All patients underwent eight sessions of Flat Magnetic Stimulation according to the protocol. Adjuvant pharmacological treatment was used in five (45.5%) patients. Specifically, we observed a significant increase in both ARA and LAMD comparing baseline and post-treatment measurements (p < 0.001). Quality of life scale scores at baseline and after treatment demonstrated a significant improvement in both tools (p < 0.0001). Conclusions: Flat Magnetic Stimulation, with or without adjuvant pharmacological treatment, demonstrated safety and efficacy in reducing pelvic floor hypertonicity, resulting in improvement in symptoms' severity and sonographic parameters of muscular spasm.

MRI characterization of pelvic floor ligaments in nulliparous women: Technique development and morphometry within the 3D pelvic inclination correction system (3D-PICS).

PURPOSE: The aim of the MRI-study was to evaluate the visibility of the pelvic floor ligaments and to analyze the ligament morphometry in 3D space. METHODS: Twenty-two nulliparous women underwent MRI with a ligament specific protocol. MR datasets were evaluated using the 3D Pelvic Inclination Correction System (3D-PICS). The round ligament (RL), sacrospinous ligament (SSL), sacrotuberous ligament (STL), urogenital diaphragm (UGD) and uterosacral ligament (USL) were analyzed. Qualitative and quantitative analysis was performed. 3D coordinates for origin and insertion points were determined relative to the symphysis; subsequently lengths and angles were calculated. Interrater reliability was calculated to validate the point determination method. RESULTS: Moderate to good visibility was reported for the RL, the SSL, the STL and the UGD. Standard deviation of the points analyzed in the different dimensions vary from 1.5 mm to 21.3 mm. Origin and insertion points of the ligaments are found within a mean standard distance of 10.7 mm. The highest variability was seen in insertion points of RL, with a standard distance of 25.4 mm. The interrater reliability was good to very good (range of intraclass correlation coefficients (ICC) from 0.58 to 0.96), except for the UGD ventral points (ICC from 0.27 to 0.55). CONCLUSIONS: This in-vivo MRI technique development study offers first exact data describing the pelvic floor ligaments in nulliparous women in 3D-PICS. Visibility, exact 3D coordinates of the origin and insertion points, lengths, angles and interrater reliability assessed for all parameters were evaluated morphometrically.

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.

Obstetric risk factors for levator ani muscle avulsion: A systematic review and meta-analysis.

OBJECTIVES: Women have a 11% lifetime risk of undergoing surgery for vaginal prolapse. Levator ani muscle (LAM) avulsion is one etiological factor associated with primary and recurrent pelvic organ prolapse. Pelvic organ prolapse has been shown to greatly affect the quality of life and well-being of women. Conduct a meta-analysis identifying risk factors associated with LAM avulsion recognised on transperineal ultrasound (TPUS) or magnetic resonance imaging (MRI) in primiparous women after vaginal birth. STUDY DESIGN: OVID Medline, Embase and the Cochrane Library from inception to January 2021 were searched. Review Manager 5.3 (The Cochrane Collaboration) was used to analyse data. Odds ratios (OR) with 95% confidence intervals (95% CIs) were calculated. The heterogeneity among studies was calculated using the I2statistic. RESULTS: Twenty-five studies were eligible for inclusion (n = 9333 women). Major LAM avulsion was diagnosed in an average of 22 % (range 12.7-39.5 %) of cases. Twenty-two studies used TPUS and three used MRI to diagnose avulsion. Modifiable and non-modifiable risk factors were identified. Significant predictors identified were forceps (OR 6.25 [4.33 - 9.0]), obstetric anal sphincter injuries (OR 3.93 [2.85-5.42]), vacuum (OR 2.41 [1.40-4.16]), and maternal age (OR 1.06 [1.02-1.10]). CONCLUSIONS: This is the first meta-analysis of both modifiable and non-modifiable risk factors associated with LAM avulsion. This information could be used to develop a clinically applicable risk prediction model to target postnatal women at risk of LAM avulsion with a view to prevent the onset of pelvic floor organ prolapse.

Pelvic floor status in opera singers. a pilot study using transperineal ultrasound.

BACKGROUND: Control of pelvic floor muscles (PFM) is emphasized as important to obtain functional breath support in opera singing, but there is not much research that proves PFM function as part of breath support in classical singing. Transperineal ultrasound is a reliable method for quantification of PFM contraction in urogynecology. Our aim was to establish if transperineal ultrasound can be used for observation of movement of the PFM during singing and to quantify pelvic floor contraction. METHODS: Cross sectional study of 10 professional opera singers examined with transperineal ultrasound in the supine position at rest and contraction, and standing at rest and during singing. Levator hiatal area was measured in a 3D rendered volume. Levator hiatal anteroposterior (AP) diameter and bladder neck distance from symphysis were measured in 2D images. RESULTS: The AP diameter was shortened from supine rest to contraction (15 mm), standing (6 mm) and singing (9 mm), all p < 0.01. The bladder neck had a non-significant descent of 3 mm during singing. The mean proportional change in AP diameter from rest to contraction was 24.2% (moderate to strong contraction) and from rest to singing was 15% (weak to moderate contraction). CONCLUSIONS: Transperineal ultrasound can be used to examine the PFM during singing. The classically trained singers had good voluntary PFM contraction and moderate contraction during singing. AP diameter was significantly shortened from supine to upright position, with further shortening during singing, confirming that female opera singers contracted their pelvic floor during singing.

The Application of Shear Wave Elastography to Determine the Elasticity of the Levator Ani Muscle and Vaginal Tissue in Patients With Pelvic Organ Prolapse.

OBJECTIVES: The changes of the extracellular matrix of the connective tissue have significantly contributed to the incidence of pelvic organ prolapse (POP). It seems reasonable that sonoelastography could be a useful tool to evaluate the elasticity of pelvic floor tissue in patients with POP and compare it to those without POP. The main aim of this pilot study was to determine if there are differences in the elasticity of the levator ani muscle (LAM) and vaginal tissue between patients with and without POP. METHODS: Prospective observation study, including 60 patients (30 with POP and 30 without POP). Sonoelastography was performed to evaluate the elasticity (in kilopascals, kPa) of the following regions of interest: vagina at the level of middle third of the urethra; vagina at the level of the bladder trigone; vagina in the anterior and posterior fornix; vagina at the level of middle third of the anorectal canal; posterior third of the LAM. RESULTS: A total of 60 patients completed the study (30 with POP, 30 without POP). In the POP group, 18/30 (60%) had an anterior vaginal wall prolapse, 3/30 (10%) a uterine prolapse, 15/30 (50%) a rectocele, and 6/30 (20%) a enterocele. Patients with POP had higher elasticity in all anatomical study areas, with statistically significant differences in the anterior fornix (13.6 vs 11.2 kPa; P: .012). A multiple regression (controlling age, menopausal stage, and parity) allowed to detect statistically significant differences in the elasticity of the middle third of the urethra (P: .03) and the middle third of the anorectal canal (P: .019). CONCLUSION: It is possible to evaluate the elasticity of the LAM and vaginal tissue using sonoelastography, detecting a higher elasticity in patients with POP than in those without POP.

Evaluation of pelvic structural abnormalities in primiparous women with stress urinary incontinence.

INTRODUCTION AND HYPOTHESIS: The objective was to evaluate the morphological characteristics of pelvic floor structure specific to de novo stress urinary incontinence (SUI) in primiparous women using three-dimensional (3D) reconstruction fusion technology based on static MRI combined with dynamic MRI. METHODS: Eighty-one primiparous women after the first vaginal delivery were studied, 40 with SUI and 41 without SUI. 3D reconstruction models based on static MRI were used to describe the anatomical abnormalities of pelvic floor tissues. Dynamic MRI was used to describe segmental activities of the urethra and vagina. The relationship between the morphometry and postpartum SUI was evaluated by logistic regression analysis and receiver operator characteristic curve. RESULTS: The differences in the distance from the bladder neck to the pubic symphysis (BSD), the angle between the posterior wall of the urethra and the anterior wall of the vagina, the width of the distal region of the vagina, urethral length, urethral compression muscle volume (CUV), and pubovisceral muscle volume, puborectal muscle volume, were measured, and except for the extremity of the anterior urethral wall, the total displacements (TDs) of the other sites between the two groups were statistically significant (p < 0.05). Logistic regression analysis showed that the BSD decreased, the CUV decreased, the TDs of the first site and the eighth site increment correlated significantly with postpartum SUI occurrence (p < 0.05). CONCLUSIONS: 3D reconstruction fusion technology provides an important support for a precise assessment of the pelvic floor dysfunction. The BSD, CUV, and iliococcygeus muscle volume have certain values in predicting de novo SUI after first vaginal birth.

Validation of a built-in software in automatically reconstructing the tomographic images of the levator ani muscle.

INTRODUCTION AND HYPOTHESIS: Transperineal ultrasound (TPUS) is an effective tool for evaluating the integrity of the levator ani muscle (LAM). Several operating steps are required to obtain the standard multi-slice image of the LAM, which is experience dependent and time consuming. This study was aimed at evaluating the feasibility and reproducibility of the built-in software, Smart-pelvic™, in reconstructing standard tomographic images of LAM from 3D/4D TPUS volumes. METHODS: This study was conducted at a tertiary teaching hospital, enrolling women who underwent TPUS. Tomographic images of the LAM were automatically reconstructed by Smart-pelvicTM and rated by two experienced observers as standard or nonstandard. The anteroposterior diameter (APD) of the levator hiatus was also measured on the mid-sagittal plane of the automatically and manually reconstructed images. The APD measurements of each approach were compared using Bland-Altman plots, and interclass correlation coefficient (ICC) was used to evaluate intra- and inter-observer reproducibility. Meanwhile, the time taken for the reconstruction process of both methods was also recorded. RESULTS: The ultrasound volume of a total of 104 patients were included in this study. Using Smart-pelvicTM, the overall success rate of the tomographic image reconstruction was 98%. Regarding measurements of APD, the ICC between the automatic and manual reconstruction methods was 0.99 (0.98, 0.99). The average time taken for reconstruction per case was 2.65 ± 0.52 s and 22.08 ± 3.45 s, respectively. CONCLUSIONS: Using Smart-pelvicTM to reconstruct tomographic images of LAM is feasible, and it can promote TPUS by reducing operator dependence and improving examination efficiency in a clinical setting.

The acute effects of running on pelvic floor morphology and function in runners with and without running-induced stress urinary incontinence.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to examine the impact of a single running session on pelvic floor morphology and function in female runners, and to compare those with and without running-induced stress urinary incontinence (RI-SUI). METHODS: This cross-sectional, observational study involved two groups: female runners who regularly experienced RI-SUI (n = 19) and runners who did not (n = 20). Pelvic floor muscle (PFM) properties were assessed using intravaginal dynamometry during maximal voluntary contractions (MVC) and during passive tissue elongation. The morphology of the pelvic floor was assessed at rest, during MVC and during maximal Valsalva maneuver (MVM) using 2D and 3D transperineal ultrasound imaging before and after a running protocol. Mixed-effects ANOVA models were used to compare all outcomes between groups and within-groups, including the interaction between group and time. Effect sizes were calculated. RESULTS: No changes in PFM function assessed using intravaginal dynamometry were observed in either group after the run. Significant and large within-group differences were observed on ultrasound imaging. Specifically, the area and antero-posterior diameter of the levator hiatus were larger after the run, the bladder neck height was lower after the run, and the levator plate length was longer after the run (p ≤ 0.05). At the peak MVM and MVC, the bladder neck height was lower after the run than before the run (p ≤ 0.05). No between-group differences were observed for any outcomes. CONCLUSIONS: Running appears to cause transient strain of the passive tissues of the female pelvic floor in runners both with and without RI-SUI, whereas no concurrent changes are observed in PFM contractile function.

Is the Presence of Levator Ani Muscle Avulsion Relevant for the Diagnosis of Uterine Prolapse?

OBJECTIVE: To determine if the addition of the assessment of levator ani muscle (LAM) avulsion to the measurement of the difference in the pubis-uterine fundus distance between rest and with the Valsalva maneuver could increase the diagnostic capacity of ultrasound for uterine prolapse (UP). METHODS: This multicenter, observational and prospective study included 145 patients. Ultrasound assessment was performed, establishing the diagnosis of UP as a difference between the pubic-uterine fundus distance at rest and during the Valsalva maneuver ≥15 mm (standard technique), while LAM avulsion was defined as an abnormal LAM insertion in three central slices using multislice ultrasound. A binary multivariate logistic regression model was made using nonautomated methods to predict surgical UP (general population, premenopausal, and postmenopausal patients), including the difference between the pubis-uterine fundus distance at rest and with the Valsalva maneuver as well as LAM avulsion. RESULTS: A total of 143 patients completed the study. The addition of LAM avulsion criteria to the standard dynamic distance-based protocol for the diagnosis of UP resulted in a higher sensitivity for the general population (79.7 vs 68.1%) as well as for premenopausal (89.3 vs 79.9%) and postmenopausal patients (76 vs 66.1%). In contrast, the standard technique showed a higher specificity than the model based on the standard technique associated with LAM avulsion for the general population (89.2 vs 74.3%) and premenopausal women (91.7 vs 63.2%). For postmenopausal patients, the model based on the standard technique associated with LAM avulsion had a higher sensitivity (76 vs 66.1%) and specificity (91.7 vs 86.8%) than the ultrasound diagnosis of UP. CONCLUSION: The implementation of the assessment of LAM avulsion in the ultrasound diagnosis of UP is useful in postmenopausal patients, increasing sensitivity and specificity relative to the ultrasound assessment based only on the difference between the pubis-uterine fundus distance at rest and with the Valsalva maneuver.

Preventive effects of sodium hyaluronate combined with pelvic floor neuromuscular electrical stimulation on the intrauterine adhesions in women after abortion.

The aim of this study was to investigate the clinical efficacy of combining pelvic floor neuromuscular stimulation treatment (NMES) with sodium hyaluronate in preventing intrauterine adhesions (IUA) following abortion. A total of 140 women who underwent artificial abortion were enrolled. The control group received only an intrauterine injection of sodium hyaluronate post-surgery, while the observation group received both the injection and daily pelvic floor NMES treatments, beginning on the day after the abortion. Monthly follow-ups on menstrual conditions were conducted for six months post-surgery. Fasting venous blood samples from both groups were collected on the second day post-abortion and the day after treatment. Transvaginal color Doppler ultrasound was used on the second day post-abortion and the 15th day post the first menstrual cycle to measure endometrial thickness, and the pulsatility and resistance indices of the endometrial spiral arteries. Over the six-month follow-up, the combination therapy group exhibited a notably lower IUA incidence compared to the control group (2.8% vs. 15.7%). Furthermore, combined treatment significantly expedited post-abortion menstrual recovery, reduced vaginal bleeding volume and duration (P < 0.001). It also increased endometrial thickness and reduced the endometrial spiral artery's pulsatility and resistance indices (P < 0.05). In addition, lower serum tumor necrosis factor alpha (TNF-α) and higher interleukin-10 (IL-10) were found in the observation group compared to the control group (P < 0.05). The combination therapy offers significant advantages in preventing and reducing IUA after abortion, resulting in a substantial reduction in IUA occurrence.

Evaluation of levator ani muscle elasticity after vaginal delivery and cesarean section using shear wave elastography.

PURPOSE: The risk of pelvic floor muscle injury is commonly considered to be higher in vaginal than in cesarean delivery. This study aimed to compare levator ani muscle (LAM) elasticity after vaginal and cesarean delivery using shear wave elastography (SWE). METHODS: Postpartum women who underwent a single SWE evaluation 1 month after their first delivery were divided into vaginal and cesarean delivery groups. The elastic moduli of both sides of the LAM were measured in a horizontal section and compared between the groups. In addition, a subgroup analysis was performed to compare LAM elasticity according to the delivery method within the vaginal delivery group-normal vaginal delivery, episiotomy, and operative vaginal delivery. RESULTS: Sixty-two women were included (vaginal delivery, n = 47; elective cesarean section, n = 15). Multiple regression analysis revealed that the LAM elastic modulus was significantly lower in the vaginal delivery group than in the cesarean delivery group (right LAM: 44.2 vs. 72.7 kPa, p = 0.0036; left LAM 40.4 vs. 82.7 kPa, p < 0.0001). In the subgroup analysis, the right LAM elastic modulus was significantly lower in the operative vaginal delivery subgroup than in the normal vaginal delivery subgroup (p = 0.0131). However, there was no significant difference in the left LAM elastic modulus between the three subgroups. CONCLUSION: LAM elasticity was significantly lower after vaginal delivery than after cesarean delivery. Furthermore, the elasticity of the right LAM was lower after operative vaginal delivery than after normal vaginal delivery. SWE has the potential to provide an objective quantitative assessment of postpartum pelvic floor muscle recovery.

Comparative study of female pelvic floor among undeformed high-resolution thin-sectional anatomical (visible human) images and MRI and ultrasound images.

PURPOSE: Using visible human, MRI and ultrasound images, we aim to provide an anatomical basis for the identification and diagnosis of pelvic floor structure and disease by ultrasound imaging. METHODS: One Chinese visible human (CVH) image, one American visible human image, 9 MRI images of normal volunteers, and 40 ultrasound images of normal volunteers or pelvic organ prolapse patients were used. Pelvic organs, pelvic floor muscles, and the connective tissue in CVH, VHP, MRI, and ultrasound images were selected for comparative study. RESULTS: We successfully identified the boundary of the anal sphincter complex, including the subcutaneous, superficial, and deep parts of the external anal sphincter, conjoined longitudinal muscles and internal anal sphincter; the levator ani muscle (LAM), including the internal and external parts of the pubovisceral muscle and the superficial and deep parts of the puborectal muscle; the urethral sphincter complex, including the urethral sphincter proper and the urethral compressor; and the perineal body, the rectoperineal muscle and superficial transverse perineal muscle. CONCLUSIONS: We successfully recognized and studied the location, subdivisions, 2D morphology and spatial relationships of the LAM, anal sphincter complex, urethral sphincter complex and perineal body in ultrasound images, thereby helping sonologists or clinicians accurately identify pelvic floor muscles and supporting structures in ultrasound images.

Prevalence of diastasis m. rectus abdominis and pelvic floor muscle dysfunction in postpartum women.

OBJECTIVE: The aim of this study was to determine the prevalence of Diastasis of the rectus abdominis muscles (DRAM) and pelvic floor muscle dysfunction (PFMD) in postpartum women. Design: The observational prospective study. MATERIAL: 150 of 180 women (83.3 %) from 6 weeks to 6 months postpartum, with a mean age of 33.1 years. METHODS: For diastasis examination, inter recti distance (IRD) was measured by a linear 2D ultrasound probe, 4.5 cm above the navel, in its area and 4.5 cm below the navel when lying on the back at rest and under a load test. The degree of DRAM was classified into four grades. Urinary leakage symptoms were assessed by the International Incontinence Consultation Questionnaire (ICIQ - UI SF). RESULTS: The first degree of diastasis during the load test was 38.1 % above the navel, 36.4 % in the navel area, and 23.7 % below the navel. The second degree of diastasis with load was 28.8 % above the navel, 21.2 % in the navel area, and 10.2 % below the navel. PFMD showed 31.3 % of women with mild symptoms of SUI, 32.2 % of women with grade 1 cystocele. CONCLUSION: The average IRD distance at rest and during the load test confirmed the first grade of DRAM out of four degrees of severity. Moderate and medium DRAM occurred according to location in an average of one-third of the cases. The highest percentage of DRAM was above the navel, and the lowest percentage below the navel. PFMD was detected in an average of one-third of cases. It is important to monitor these parameters with a view to improving the quality of life index in the future (Tab. 5, Ref. 22).

Evaluation of anatomical factors affecting stress urinary incontinence in female patients via dynamic pelvic floor magnetic resonance imaging.

Objective: To evaluate the anatomical factors affecting stress urinary incontinence (SUI) in female patients via dynamic pelvic floor magnetic resonance imaging (DP-MRI). Methods: This prospective study was conducted on 43 female patients, including 22 patients with SUI (disease group) and 21 patients without SUI (control group). All patients underwent DP-MRI. The length, volume, transverse/anteroposterior diameter, and outer/inner layer thickness of the urethra were measured on static (T2W) pulse sequences. Urethral angle, posterior urethro-vesical angle (PUVA), bladder neck-pubococcygeal angle, and position of the bladder neck and cervix relative to the pubococcygeal line were measured on dynamic (Cine) pulse sequences at rest and during evacuation phase. These parameters were compared between the groups to evaluate which anatomical factors affected SUI. The area under the ROC curve (AUC) and threshold of the sensitivity and specificity of these parameters for the diagnosis of SUI were calculated. Results: The mean age of the patients was 57.3±13.8 years (disease group: 53.9±12.6 years; control group: 60.8±14.4 years). The mean number of childbirths was 2.2±0.65, and vaginal delivery accounted for 73% in each group. There was no significant difference between the two groups in terms of length, transverse diameter, outer layer thickness of the urethra, urethral angle, bladder neck-pubococcygeal angle, position of bladder neck relative to the pubococcygeal line in both resting and evacuation phases (p>0.05). There was a significant difference between the two groups regarding volume (p=0.014), anteroposterior diameter (p=0.01), inner layer thickness of the urethra (p=0.04), and PUVA (p<0.001) at rest and evacuation phases and cervix position at evacuation phase (p=0.001). The AUC of the PUVA for SUI diagnosis was 0.9 at rest and 0.98 during evacuation phases. For the threshold 133.5° at rest phase and 153.5° at evacuation phase, the sensitivity and specificity of PUVA were 0.86 and 0.86 at rest phase and 0.91 and 0.95 at evacuation phase, respectively. Conclusions: PUVA was the anatomical factor that had the greatest effect on SUI and provided high sensitivity and specificity for SUI diag-nosis.