Morphometry of the nulliparous pelvic floor.

OBJECTIVES: To describe morphometry of the pelvic floor in a large population of nulliparous women, comparing those with and those without pelvic pain. We also aimed to assess its association with characteristics such as age and body mass index (BMI). METHODS: This was a prospective study performed between January 2013 and November 2015 in non-pregnant nulliparous women attending a general gynecology clinic. Following collection of demographic data, women were examined using translabial four-dimensional (4D) ultrasound. Dynamic volumes of pelvic floor muscle were obtained at rest, on maximal contraction and on Valsalva maneuver, and analyzed at a later date by an assessor blinded to demographic details. Standard measurements for each volume included levator hiatal area and anteroposterior and transverse diameters, and pubovisceral muscle length and width. Subanalysis was performed comparing women with and those without pelvic pain. Linear regression analysis was performed to assess the association between characteristics, including age and BMI, and levator hiatal area at rest. RESULTS: Three hundred and sixty eight nulliparous women were examined using translabial 4D ultrasound. Median levator hiatal area was 10.62 cm2 at rest, 11.95 cm2 on Valsalva maneuver and 8.18 cm2 on maximal contraction. There was no difference between women with and those without pelvic pain when comparing biometric measurements of the pelvic floor musculature, except for in pubovisceral muscle width during the contraction phase. Regression analysis demonstrated that higher age and BMI were associated with increased levator hiatal area measurement. CONCLUSIONS: Pelvic floor morphometry in nulliparous women is unchanged by pelvic pain, but levator hiatal area is increased in women with higher BMI and age. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Four-dimensional ultrasound guidance for pelvic floor Botulinum toxin-A injection in chronic pelvic pain: a novel technique.

OBJECTIVE: Botulinum toxin-A (BoNT-A) is used in the treatment of pelvic floor muscle overactivity associated with chronic pelvic pain (CPP) when conservative methods such as physiotherapy are not effective or appropriate. Traditional injection techniques require finger-guided palpation of pelvic floor muscles with concurrent insertion of the needle. The aim of this study was to describe a novel technique for the injection of BoNT-A into the pelvic floor musculature using four-dimensional ultrasound (4D-US) guidance. METHODS: Thirty-one BoNT-A injections were performed using the new technique between October 2013 and January 2016, on women scheduled to have BoNT-A injection for pelvic floor muscle overactivity and CPP. The pelvic floor was assessed by 4D-US. A test injection of saline was performed to confirm location of the needle, then BoNT-A was injected into the muscle under ultrasound guidance, using 4D-US to confirm that the fluid expanded and tracked along muscle fibers. RESULTS: The saline test confirmed correct location of the needle following a median of 1 (range, 1-3) attempt at needle placement. In all 31 instances, satisfactory injection of BoNT-A, with 4D-US confirmation of fluid expansion within the muscle body, was performed. CONCLUSIONS: Injection of BoNT-A under 4D-US guidance is feasible and allows accurate placement into the target muscle in women with pelvic floor muscle overactivity associated with CPP. This technique may provide a safer alternative to finger-guided methods, owing to a lower likelihood of operator needle-stick injury. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Improvement in pelvic pain with botulinum toxin type A - Single vs. repeat injections.

The aim of this prospective study was to report the outcomes of pain and vaginal pressures of successive botulinum toxin type A injections for women with objective pelvic floor muscle overactivity and a two-year history of pelvic pain. Between 2005 and 2008, 37 women underwent injection of 100 IU of botulinum toxin type A into the puborectalis and pubococcygeous muscles with dysmenorrhoea, dyspareunia, dyschesia, and non-menstrual pelvic pain assessed using a visual analogue scale (VAS), and vaginal pressure measured by vaginal manometry, at 0, 4, 12 and 26 weeks from each injection. 26 women (70%) had one injection of botulinum toxin type A and 11 (30%) had 2 or more injections. The second injection was performed at the earliest at 26 weeks after the first, with subsequent injections having a median time to re-injection of 33.4 weeks (range 9.4-122.7 weeks). Single and repeated injections both demonstrated a statistically significant reduction in dyspareunia by VAS scores from 54 to 30 in the single injection group and from 51 to 23 in the multiple injection group (p = .001), non-menstrual pelvic pain VAS from 37 to 25 (p = .04), as well as vaginal pressures; 40 versus 34 cm H(2)O (p = .02). No statistically significant difference in dysmenorrhoea or dyschesia was observed for either group from their baseline scores. Multiple injections of botulinum toxin type A in women with pelvic floor muscle overactivity provide significant relief from dyspareunia and non-menstrual pelvic pain. The upper limit between re-injection is not yet determined, nor is the maximum number of treatments. Clinical outcomes for single and subsequent injection of botulinum toxin type A for recurrent pelvic pain are equivalent. Women who have had benefit from a single injection of botulinum toxin type A can be reassured that if symptoms reoccur, repeated injections can be expected to be equally efficacious.