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.

Is Vaginal Laxity Associated with Vaginal Parity and Mode of Delivery?

INTRODUCTION AND HYPOTHESIS: Vaginal laxity (VL) is a common symptom of pelvic floor dysfunction. Although VL has become a frequent topic for research in the last decade, its pathogenesis is still not well understood. The objective was to determine whether vaginal parity or mode of delivery is associated with vaginal laxity. METHODS: This was a retrospective observational study involving women seen in a tertiary urogynecology clinic between May 2016 and November 2018 with symptoms of pelvic floor dysfunction. Patients underwent a standardized interview, clinical examination (POP-Q), and four-dimensional (4D) pelvic floor ultrasound (PFUS). Data regarding vaginal parity and the mode of delivery were based on patient-reported information. Archived 4D-PFUS volumes were analyzed offline to evaluate levator hiatal area on Valsalva. RESULTS: Data from 1,051 patients were analyzed. VL was reported by 236 women (23%) who were younger on average (mean age 54 vs 59 years, p < 0.001) and less likely to be menopausal (530 out of 815 [65.0%] vs.129 out of 236 [54.7%]), p = 0.004]. Symptoms of prolapse were much more common in the VL group (214 out of 236 [91%] vs 316 out of 815 [39%], p = < 0.001) and on imaging mean levator hiatal area (HA) on Valsalva was larger (31 vs 26 cm2, p = 0.01). Vaginal parity was associated with VL symptoms (235 out of 236 [99%] vs 767 out of 815 [94%], p = 0.008), but neither VL prevalence nor bother increased with higher parity. Women who delivered vaginally were three times more likely to complain of VL than those who delivered only by cesarean section. CONCLUSIONS: Vaginal laxity was found to be more prevalent in vaginally parous women. This effect seems to be largely attributable to the first delivery. Instrumental delivery was not shown to increase association with VL compared with normal vaginal delivery.

Diagnostic utility of translabial ultrasound in pelvic organ prolapse: a prospective observational study.

BACKGROUND: The increasing awareness of women's health issues, specifically pelvic organ prolapse (POP) and urinary incontinence (UI), has spurred a surge in patients seeking specialised advice for these conditions, necessitating modern diagnostic approaches for such issues. This study explored the diagnostic utility of translabial ultrasound for POP, emphasising its correlation with clinical assessments based on International Continence Society (ICS) criteria. METHODS: Seventy-one patients with POP Quantification System (POP-Q) stage 0-IV with or without UI were prospectively enrolled at Jagiellonian University Medical College between 2014 and 2016. The study objectives included evaluating diagnostic accuracy and concordance across pelvic compartments, correlating the diagnoses with patient-reported symptoms, and identifying variables contributing to diagnostic discrepancies. RESULTS: Translabial ultrasound identified POP in 74.5% of the patients, aligning closely with clinical evaluations. Concordance was the highest in assessments performed in the medial compartment (85.8%), while assessments performed in the anterior (29.6%) and posterior (29.6%) compartments showed higher rates of discrepancies. Correlation analyses showed varying associations, with the posterior compartment exhibiting the least pronounced correlation (R = 0.72, p < 0.0001). Self-perceive POP showed no discernible differences in relation to ultrasonographic and clinical assessments. Among the respondents, 55.9% reported experiencing the sensation of POP. Mean POP levels determined using the two approaches precisely matched in 46.5% of these cases. Discrepancies involved variables such as self-perceived POP, number of deliveries, child weight at birth, UI, and sexual activity. CONCLUSIONS: Translabial ultrasound showed robust correlation with clinical assessments for evaluating POP, especially for defining defects and facilitating treatment-related decision-making. Our findings highlight the reliability of this method, particularly for assessments in the medial compartment. The evidence did not indicate the superiority of either method in detecting POP disorders for symptomatic versus asymptomatic patients. Significantly, a higher POP-Q measurement in clinical examination was correlated with greater sexual activity.

Pelvic organ prolapse can affect up to 50% of women after delivery. This study examined the usefulness of transperineal ultrasound in evaluating the presence and degree of pelvic organ prolapse. Our findings demonstrated a robust correlation between the results of clinical and translabial ultrasound examinations in assessing the degree of pelvic organ prolapse. Translabial ultrasound is an inexpensive and accessible method that can confirm the clinical manifestations of pelvic organ prolapse and serve as an alternative to clinical examination, thereby supporting the decision-making process regarding surgical treatment.

Does Cystocele Type Vary Between Vaginally Parous and Nulliparous Women?

OBJECTIVES: To evaluate whether cystocele type varies with vaginal parity. METHODS: Retrospective analysis of 464 vaginally nulliparous women seen at 2 urogynecology units between November 2006 and November 2019. A control group consisted of 871 vaginally parous women seen between July 2017 and November 2019. Patients underwent a standardized interview, POPQ, urodynamic testing, and translabial ultrasound. On imaging, significant cystocele was defined as bladder descent to ≥10 mm below symphysis pubis. Volume datasets were analyzed offline and blinded against clinical data. RESULTS: Of 5266 women seen during the inclusion period, 464 were vaginally nulliparous. Three were excluded due to missing data, leaving 461. A control group of 871 parous women was generated from patients seen during the last 2.5 years of the inclusion period. Vaginally nulliparous women were presented at a younger age compared to vaginally parous women (P < .001). Symptoms of prolapse were reported in 104 (22%) nulliparae and 489 (56%) parous women (P < .0001). Vaginally parous women demonstrated more bladder descent (P < .0001) and more cystocele (418/871 versus 43/461, P < .0001), with a higher proportion of type III cystocele (cystocele with intact retrovesical angle) (20/43 versus 273/ 418, P < .0001). Cystourethrocele (Green type II) was more common in nulliparae and cystocele type III in parous women (P = .015). On multivariate analysis, these differences in proportions remained significant (P = .049). CONCLUSIONS: Nulliparity was associated with a higher proportion of Green type II cystoceles. Green type III cystocele was more common in vaginally parous women, suggesting that the latter may be more likely to be due to childbirth-related pelvic floor trauma.

Assessment of Perineal Scars on Translabial Pelvic Floor Ultrasound: A Pilot Study.

OBJECTIVE: We aimed to describe a method for identifying and evaluating perineal scars using translabial pelvic floor ultrasound. We hypothesized that translabial ultrasound can identify a perineal scar and can differentiate episiotomies from spontaneous tears. METHODS: This pilot study is a secondary analysis of data obtained in the Epi-No® trial. Perineal integrity was assessed using volumes acquired on pelvic floor muscle contraction according to the method previously described for anal sphincter imaging. A scar was diagnosed if a hypoechoic distortion in the perineum was noted. We postulated that an episiotomy would result in a linear scar visible on four dimensional translabial ultrasound whereas nonlinear scars were considered the result of spontaneous perineal tear of grade 2 or higher. The results of this assessment were compared with data retrieved from electronic medical records. RESULTS: A scar was identified in 79/120 women (66%): 42 (35%) linear and 37 (31%) nonlinear. Sonographic and clinical diagnosis agreed on the presence or absence of perineal trauma in 66%. Agreement for the type of laceration was 50%. CONCLUSION: In this retrospective pilot study, a blinded assessment of translabial ultrasound volume data showed agreement between clinical data and sonographic assessment of perineal integrity in 66% and of type of laceration in 50%. More work is needed to optimize the method in assessment of perineal scars to improve its performance before it can be used in clinical audit and research.

Relationship between urethral motion profile and parity assessed by translabial ultrasound imaging.

PURPOSE: This study aims to describe the differences in the urethral motion profile (UMP) of primiparous and multiparous women immediately postpartum. METHODS: This prospective study recruited 65 women (29 primiparous, 36 multiparous) one-seven days postpartum. The patients underwent a standardised interview and two-dimensional translabial ultrasound (TLUS). To evaluate the UMP, the urethra was manually traced and divided into five segments with six equidistant points. The mobility vector (MV) for each point was calculated as [Formula: see text]. A Shapiro-Wilk test was conducted to test normality. An independent t-test and a Mann-Whitney test were conducted to express differences between the groups. The Pearson correlation coefficient was used to determine the relationships among MVs, parity and confounders. Finally, a univariate generalised linear regression analysis was performed. RESULTS: MV1-MV4 were found to be normally distributed. A significant difference for all MVs, except for MV5, was demonstrated between parity groups (MV1: t = 3.88 (p < .001), MV2: t = 3.82 (p < .001), MV3: t = 2.65 (p = .012), MV4: t = 2.54 (p = .015), MV6: U = 150.00 (exact sig. two tailed = .012)). A strong-to-very strong mutual correlation was observed between MV1 to MV4. The univariate generalised linear regression showed that parity can predict up to 26% of urethral mobility. CONCLUSION: This study shows that multiparous women have significantly higher urethral mobility compared to primiparous women in the first week postpartum, with the most significant effect observed in the proximal urethra.

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.

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.

Ultrasound assessment of bladder descent and its correlation with prolapse severity in Chinese women: a prospective multicenter study.

INTRODUCTION AND HYPOTHESIS: Translabial ultrasound is currently regarded as one of the most promising modalities in the evaluation of female pelvic organ prolapse. However, abnormal bladder descent on pelvic floor ultrasound has not been established among Chinese women. This study aimed to establish optimal cutoffs for defining bladder prolapse among Chinese women using translabial ultrasound. METHODS: In this prospective multicenter study, 674 women with symptoms of lower urinary tract dysfunction and/or pelvic floor dysfunction were finally included and underwent interview, Pelvic Organ Prolapse Quantification (POP-Q) examinations and 4D translabial ultrasound. The receiver-operating characteristic (ROC) statistic was used to assess accuracy and define the optimal cutoffs. RESULTS: The mean patient age was 42.6 (range, 19-82) years. Multivariable analysis showed that both POP-Q assessment and translabial ultrasound findings for anterior compartment were significantly associated with prolapse symptoms. The ROC statistics suggested an optimal cutoff value of 10 mm below the symphysis pubis of bladder position on Valsalva for predicting prolapse symptoms, with an area under the curve (AUC) of 0.73. Compared to translabial ultrasound, POP-Q stage showed similar accuracy for predicting prolapse symptoms (AUC: 0.74; P = 0.79), with an optimal cutoff of POP-Q stage ≥ 2. CONCLUSIONS: This study proposed that the descent of the bladder to ≥ 10 mm below the symphysis pubis on Valsalva should be proposed as an optimal cutoff value for defining abnormal bladder prolapse on translabial ultrasound among the Chinese population. These cutoff values are nearly identical to those previously established in mainly Caucasian women.

Is vaginal laxity an early symptom of pelvic organ prolapse?

INTRODUCTION AND HYPOTHESIS: We aimed to determine whether vaginal laxity (VL) may be an early symptom of pelvic organ prolapse (POP). METHODS: This was a retrospective observational study including patients referred to a urogynecological clinic owing to symptoms of pelvic floor dysfunction. The interview included inquiry about VL and POP symptoms. Clinical examination and translabial ultrasound (TLUS) were performed to assess for POP and levator hiatal ballooning. Analysis of ultrasound datasets was performed with the reviewer blinded against all other data. Linear regression models were used to evaluate associations between age categories and symptoms. RESULTS: The analysis included 531 patients. Mean age was 59.7 years (range 17.6-92.0), mean body mass index (BMI) was 29.5 kg/m2 (14.7-53.5) and 458 (86%) were vaginally parous. Overall, POP symptoms were reported by 258 patients (49%) and VL by 118 (22%). Significant clinical POP was diagnosed in 384 patients (72%). Levator hiatal ballooning on TLUS was noticed in 56%. VL and POP symptoms showed a divergent association with age (p = 0.02). This trend remained significant after controlling for clinically significant POP (p = 0.01) and levator hiatal ballooning (p = 0.002). Of 384 women with significant objective POP, 231 (60%) reported symptoms of POP. Of 153 women with asymptomatic POP, 7 (5%) reported symptoms of VL. CONCLUSIONS: With increasing age the prevalence of VL decreases, whereas symptoms of POP increase. However, only very few women with objective POP perceive VL as their only symptom, independent of age at presentation. Therefore, vaginal laxity does not seem to be an early symptom of prolapse.

Translabial ultrasound: a non-invasive technique for assessing "technical errors" after TOT failure.

INTRODUCTION AND HYPOTHESIS: The aims of this study were to evaluate by transperineal ultrasound if there were ultrasound-detectable changes over time in the dynamic behavior of the sling in patients who underwent transobturator tape (TOT), and to evaluate if dynamic translabial ultrasonography recognized factors that may be associated with failed surgery. METHODS: This was a single-center prospective study. We included women who underwent "out-in" TOT for stress urinary incontinence (SUI). A dynamic translabial ultrasound was performed 6 months post-surgery and again at the last visit. The objective cure for SUI was defined as the absence of urine leakage during the stress test. We evaluated the bladder neck mobility at rest and during Valsalva; the position of the mesh along the urethra; the concordance of urethral movement with the sling during Valsalva; the symmetry of the lateral arms of the sling during straining; and the presence or absence of bladder neck funneling. RESULTS: From December 2012 to February 2016, 80 consecutive patients were included. Six months after surgery, incontinent women compared with continent women had the sling in a proximal or distal position, that moved discordantly with the urethra (p < 0.0001), with asymmetry arm and bladder neck funneling (p < 0.0001). Continent patients had a significant improvement of urethrocele grade both at rest (p = 0.036) and during Valsalva (p = 0.045). CONCLUSIONS: Technical and positioning errors can lead to the failure of anti-incontinence surgical treatment. Translabial ultrasound allows the correct positioning of the sling to be evaluated and any errors that need to be analyzed in order to then solve the failure.

The evolution of levator ani muscle trauma over the first 9 months after vaginal birth.

INTRODUCTION AND HYPOTHESIS: The objective was to investigate the evolution of levator ani muscle (LAM) trauma over the first 9 months after birth and to evaluate their agreement between different assessment periods. METHODS: From March 2017 to April 2019 we prospectively evaluated LAM states (intact, hematoma, partial or complete avulsion) of primiparous women after vaginal birth by using 4D translabial ultrasound (TLUS) at three different assessment periods. All women were examined 1-4 days (A1) and 6-10 weeks (A2) postpartum, and women with a trauma additionally 6-9 months postpartum (A3). Cohen's Kappa analysis was performed to evaluate the test agreement between the assessment periods. RESULTS: Thirty-two percent of the women at A1 had a LAM trauma and 24% at A2. The higher number of LAM injuries at A1 can be explained by hematomas (14%), of which 51% spontaneously resolved at A2, 35% revealed themselves as partial, and 12% as complete avulsions. At A3, we observed anatomical improvement from complete to partial avulsions (23%) and few partial avulsions changed into an intact LAM (3%); none of the complete avulsions changed into an intact LAM. The agreement of 4D TLUS between A1 and A2 was moderate to good (0.64 for the right-sided LAM/0.60 for the left-sided LAM) and between A2 and A3 good to very good (0.76 right-sided/0.84 left-sided). CONCLUSIONS: Levator ani muscle trauma can reliably be diagnosed during all assessment periods. However, the agreement between A1 and A2 was only moderate to good. This can be explained by hematomas inside the LAM that were only observed early postpartum. We observed some anatomical improvement at A3, but no complete avulsion improved to an intact LAM.

2D pelvic floor ultrasound imaging in identifying levator ani muscle trauma agrees highly with 4D ultrasound imaging.

INTRODUCTION AND HYPOTHESIS: The objective was to evaluate the agreement between 2D and 4D translabial ultrasound (TLUS) technique in showing levator ani muscle (LAM) states after vaginal birth. METHODS: In a prospective observational cohort study between March 2017 and April 2019 we evaluated LAM states (intact, hematoma, partial, complete avulsion) of primiparous women having given birth vaginally with singletons in vertex presentation ≥ 36+0 gestational weeks by using 2D and 4D TLUS within 1-4 days postpartum (assessment A1) and again 6-10 weeks postpartum (assessment A2). Cohen's Kappa analysis was performed for each side separately to evaluate the test agreement between the two ultrasound techniques at every assessment period. RESULTS: A total of 224 women participated at A1 and 213 at A2. The agreement between the two ultrasound techniques was good to very good at A1 (Cohen`s kappa right-sided 0.78, left-sided 0.82) and very good at A2 (Cohen`s kappa both sides 0.88). The agreement was best when assessing an intact LAM or a complete avulsion (Cohen`s kappa between 0.78-0.92 for complete avulsions). CONCLUSIONS: The comparison between 2D and 4D TLUS showed a good to very good agreement in LAM trauma immediately after birth as well as 6-10 weeks postpartum. Therefore, 2D ultrasound could also be a valuable method for demonstrating a LAM abnormality and could be used in settings where 3D/4D ultrasound equipment is not available.

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.

Ultrasound Evaluation of Mid-Urethral Sling Position: A Potential Predictor of Outcomes and Adverse Effects.

OBJECTIVE: The aim of this study was to evaluate mid-urethral sling (MUS) position and its association with postoperative outcomes and complications. DESIGN: This was a prospective cohort study. Ninety-two women who underwent MUS procedure with a median follow-up period of 11 months (interquartile range 5-24 months) were recruited. PARTICIPANTS/MATERIALS, SETTING, METHODS: Two-dimensional trans-labial ultrasound with an endovaginal probe was used to visualize the urethral length (UL), sling distance to the bladder neck (BN) and to the urethra longitudinal smooth muscle (LSM). RESULTS: Mean sling-LSM, UL, and sling-BN distances were 5.97 ± 2.04 mm, 28.66 ± 3.19 mm, and 18.85 ± 4.46 mm, respectively. Sling position relative to BN (proximal vs. middle vs. distal) was not associated with surgery outcomes and complications; however, mean sling-LSM in patients with exposure (4.3%) was significantly higher compared to those who did not experience exposure (8.80 ± 1.9 mm vs. 5.8 ± 2.0 mm, p = 0.048). Moreover, the mean sling-LSM distance was associated with patient satisfaction (5.87 ± 2.0 mm in satisfied patients with VAS > 6 vs. 6.29 ± 2.1 mm in unsatisfied patients, p value = 0.043). Likewise, patients who had worsened or showed de novo overactive bladder (OAB) symptoms (8.8%) had significantly higher mean sling-LSM distance compared to patients with improved OAB symptoms (6.52 ± 2.0 mm vs. 5.37 ± 1.9 mm, p = 0.007). Mean sling-LSM distance was lower in patients with recurrent urinary tract infection (UTI), voiding dysfunction, and improved stress urinary incontinence, whereas patients with dyspareunia after surgery had higher mean sling-LSM distance; however, these differences were not statistically significant. LIMITATIONS: Both trans-obturator and retropubic procedures with or without concomitant prolapse surgery were assessed. Heterogeneity of the study population and pelvic floor ultrasound being performed by a single urogynecologist were the limitations of the current study. CONCLUSIONS: Ultrasound visualization of MUS is feasible and has the potential to predict outcomes and complications. High sling-LSM distance was associated with exposure, and low sling-LSM distance with increased satisfaction rate, probability of voiding dysfunction, and recurrent UTI.

Does obesity change the perception of pelvic organ prolapse?

INTRODUCTION AND HYPOTHESIS: There is a complex relationship between obesity and pelvic organ prolapse. The objective of our study was to evaluate whether body mass index (BMI) changes the relationship between signs and symptoms of prolapse. METHODS: This was a retrospective observational study based on datasets of women seen in a tertiary urogynecological center with symptoms of pelvic floor and lower urinary tract dysfunction between April 2012 and October 2015. Patients underwent a structured interview, clinical examination (based on the POP-Q) and 4D transperineal ultrasound (TPUS). Offline assessment of sonographic organ descent was undertaken later, blinded to all patient data. RESULTS: Weight and BMI affect the relationship between symptoms and signs of prolapse. This effect is statistically highly significant. The more obese a patient is, the less likely she is to notice a given degree of objective prolapse, regardless of whether it is diagnosed clinically or on imaging. CONCLUSIONS: In this retrospective study, we found a highly significant effect of weight and BMI on prolapse perception in the sense that obesity seems to mask prolapse while a low BMI increases the likelihood of a given degree of prolapse being noticed by the patient.

The role of the angle of progression in the prediction of the outcome of occiput posterior position in the second stage of labor.

BACKGROUND: Occiput posterior position is the most frequent cephalic malposition, and its persistence at delivery is associated with a higher risk of maternal and perinatal morbidity. Diagnosis and management of occiput posterior position remain a clinical challenge. This is partly caused by our inability to predict fetuses who will spontaneously rotate into occiput anterior from those who will have persistent occiput posterior position. The angle of progression, measured with transperineal ultrasound, represents a reliable tool for the evaluation of fetal head station during labor. The relationship between the persistence of occiput posterior position and fetal head station in the second stage of labor has not been previously assessed. OBJECTIVE: This study aimed to evaluate the role of fetal head station, as measured by the angle of progression, in the prediction of persistent occiput posterior position and the mode of delivery in the second stage of labor. STUDY DESIGN: We recruited a nonconsecutive series of women with posterior occiput position diagnosed by transabdominal ultrasound in the second stage of labor. For each woman, a transperineal ultrasound was performed to measure the angle of progression at rest. We compared the angle of progression between women who delivered fetuses in occiput anterior position and those with persistent occiput posterior position at delivery. Receiver operating characteristics curves were performed to evaluate the accuracy of the angle of progression in the prediction of persistent occiput posterior position. Finally, we performed a multivariate logistic regression to determine independent predictors of persistent occiput posterior position. RESULTS: Overall, 63 women were included in the analysis. Among these, 39 women (62%) delivered in occiput anterior position, whereas 24 (38%) delivered in occiput posterior position (persistent occiput posterior position). The angle of progression was significantly narrower in the persistent occiput posterior position group than in women who delivered fetuses in occiput anterior position (118.3°±12.2° vs 127.5°±10.5°; P=.003). The area under the receiver operating characteristics curve was 0.731 (95% confidence interval, 0.594-0.869) with an estimated best cutoff range of 121.5° (sensitivity of 72% and specificity of 67%). On logistic regression analysis, the angle of progression was found to be independently associated with persistence of occiput posterior position (odds ratio, 0.942; 95% confidence interval, 0.889-0.998; P=.04). Finally, women who underwent cesarean delivery had significantly narrower angle of progression than women who had a vaginal delivery (113.5°±8.1 vs 128.0°±10.7; P<.001). The area under the receiver operating characteristics curve for the prediction of cesarean delivery was 0.866 (95% confidence interval, 0.761-0.972). At multivariable logistic regression analysis including the angle of progression, parity, and gestational age at delivery, the angle of progression was found to be the only independent predictor associated with cesarean delivery (odds ratio, 0.849; 95% confidence interval, 0.775-0.0930; P<.001). CONCLUSION: In fetuses with occiput posterior at the beginning of the second stage of labor, narrower values of the angle of progression are associated with higher rates of persistent occiput posterior position at delivery and a higher risk of cesarean delivery.

Correlation between translabial ultrasound parameters and outcomes in retropubic mid-urethral slings: can we predict success?

PURPOSE: The aim of this study was to assess the association between four-dimensional translabial ultrasound (4D-TLUS) features of the retropubic mid-urethral sling (MUS) and post-operative pelvic floor symptoms. METHODS: A prospective cohort study was performed involving 100 women who had a solitary retropubic MUS (TVT Exact™) between Jan 2013 and Dec 2017 for urodynamic stress incontinence (SI) at a tertiary urogynaecological centre. All patients completed a standardised interview and had free flowmetry, prolapse evaluation and assessment for mesh exposure and tenderness. 4D-TLUS parameters measured included pelvic organ descent, levator ani status, sling-symphysis pubis (SP) gap at rest and Valsalva, angle formed by cranial and caudal ends of the sling, cranio-caudal and dorso-ventral sling-symphysis pubis distance at Valsalva. The primary outcome was treatment success as defined by patient report of cure or improvement and no objective demonstrable SI. RESULTS: Eighty-nine (89%) patients reported treatment success. Two patients (2%) had mesh exposure; one was symptomatic with pain, requiring complete sling removal. There was a significant association between treatment success and a SP gap at Valsalva of 10-12 mm (p = 0.001); and independently with a SP angle at Valsalva of 45°-80° (p = 0.007). A narrower SP gap at Valsalva closer to 10 mm was associated with voiding symptoms (p = 0.036). CONCLUSION: Sling-pubis gap and sling-pubis angle at Valsalva appear to be significantly associated with treatment success in retropubic MUS. There is a significant association between a narrower sling-pubis gap at Valsalva and voiding symptoms.

Fetal head progression and regression on maternal pushing at term and labor outcome.

OBJECTIVES: The aim of our study was two-fold. First, to evaluate the association between the change in the angle of progression (AoP) on maternal pushing and labor outcome. Second, to assess the incidence and clinical significance of the reduction of AoP on maternal pushing. METHODS: This was a prospective cohort study of nulliparous women with singleton pregnancy at term. AoP was measured at rest and on maximum Valsalva maneuver before the onset of labor, and the difference between AoP on maximum Valsalva and that at rest (ΔAoP) was calculated for each woman. Following delivery and data collection, we assessed the association between ΔAoP and various labor outcomes, including Cesarean section (CS), duration of the first, second and active second stages of labor, Apgar score and admission to the neonatal intensive care unit (NICU). The prevalence of women with reduction of AoP on maximum Valsalva maneuver (AoP-regression group) was calculated and its association with the mode of delivery and duration of different stages of labor was assessed. RESULTS: Overall, 469 women were included in the analysis. Among these, 273 (58.2%) had spontaneous vaginal birth, 65 (13.9%) had instrumental delivery and 131 (27.9%) underwent CS. Women in the CS group were older, had narrower AoP at rest and on maximum Valsalva, higher rate of epidural administration and lower 1-min and 5-min Apgar scores in comparison with the vaginal-delivery group. ΔAoP was comparable between the two groups. On Pearson's correlation analysis, AoP at rest and on maximum Valsalva maneuver had a significant negative correlation with the duration of the first stage of labor. ΔAoP showed a significant negative correlation with the duration of the active second stage of labor (Pearson's r, -0.125; P = 0.02). Cox regression model analysis showed that ΔAoP was associated independently with the duration of the active second stage (hazard ratio, 1.014 (95% CI, 1.003-1.025); P = 0.012) after adjusting for maternal age and body mass index. AoP reduction on maximum Valsalva was found in 73 (15.6%) women. In comparison with women who showed no change or an increase in AoP on maximum Valsalva, the AoP-regression group did not demonstrate significant difference in maternal characteristics, mode of delivery, rate of epidural analgesia, duration of the different stages of labor or rate of NICU admission. CONCLUSIONS: In nulliparous women at term before the onset of labor, narrower AoP at rest and on maximum Valsalva, reflecting fetal head engagement, is associated with a higher risk of Cesarean delivery. The increase in AoP from rest to Valsalva, reflecting more efficient maternal pushing, is associated with a shorter active second stage of labor. Fetal head regression on maternal pushing is present in about 16% of women and does not appear to have clinical significance. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.