Sonographic predictors of obstructive defecatory dysfunction.

INTRODUCTION AND HYPOTHESIS: We aimed to evaluate the association between obstructive defecatory symptoms in women with levator ani deficiency (LAD), worsened minimum levator hiatus measurements, widened anorectal angle (ARA), and increased levator-plate descent angle (LPDA). METHODS: Using a cross-sectional study design, patients who had undergone 3D endovaginal ultrasound (3D EVUS) imaging of the pelvic floor were sampled and categorized into two groups: those with and those without obstructive defecatory symptoms (ODS) based on their Colorectal and Anal Distress Index (CRADI-8) questionnaire. The levator ani (LA) muscle was scored based on severity of defect. ARA and LPDA were measured and dichotomized (ARA ± 170°; LPDA ± 9°. RESULTS: One hundred patients were analyzed: 52 asymptomatic and 48 with ODS. The mean (standard deviation ) age was 59 years (SD ±14.97). There was no difference in the distribution of LAD severity between groups (p = 0.1438) or mean minimal levator hiatus (MLH) (p = 0.3326). ARA and LPDA were significantly different in those with ODS compared with their asymptomatic counterparts (p < 0.0001 and 0.0004, respectively) (Table 1). On multivariable logistic regression, ARA and LPDA were included in the final model. Patients with an ARA >170° had seven times the odds of ODS than those with ARA ≤170° [odds ratio (OR) = 7.01, 95 % confidence interval (CI) 2.30-21.35; p = 0.0006). Patients with an LPDA <9° had 3 times the odds of ODS than those with an LPDA ≥9° (OR = 3.30, 95 % CI 1.22, 8.96, p = 0.0190). CONCLUSIONS: This study demonstrates that increased levator plate descent and widened ARA as measured on 3D endovaginal ultrasound imaging are associated with ODS.

How well can levator ani muscle morphology on 3D pelvic floor ultrasound predict the levator ani muscle function?

INTRODUCTION AND HYPOTHESIS: The aim of our study was to assess the performance of levator ani muscle deficiency (LAD) evaluated by 3D endovaginal ultrasound (EVUS) to detect pelvic floor muscle function as assessed by digital examination. METHODS: This cross-sectional study was conducted among 77 patients referred to our urogynecology clinic for pelvic floor dysfunction symptoms. Patients underwent physical examinations including digital pelvic muscle strength assessment using the Modified Oxford scale (MOS). EVUS volumes were evaluated and levator ani muscles were scored according to a validated LAD scoring system. MOS scores were categorized as nonfunctional (scores 0-1) and functional (scores 2-5). RESULTS: Mean age of participants was 56 (SD ± 12.5) and 71% were menopausal. Overall, 32.5% had nonfunctional muscle strength and 44.2% were classified as having significant LAD. LAD identified by ultrasound had a sensitivity of 60% (95% CI 41 -79%) for detecting nonfunctional muscle and a specificity of 63% (95% CI 50 -77%) for detecting functional muscle. Overall, LAD demonstrated fair ability to discriminate between patients with and those without poor muscle function (area under the ROC curve = 0.70 [95% CI 0.58-0.83]). Among patients with an LAD score of 16-18, representing almost total muscle avulsion, 70% had nonfunctional MOS scores, whereas in patients with normal/minimal LAD (scores of 0-4), 89.5% had functional MOS scores. CONCLUSIONS: Levator ani deficiency and MOS scales were moderately negatively correlated. Among patients with normal morphology or the most severe muscle deficiency, LAD scores can identify the majority of patients with functional or nonfunctional MOS scores respectively.

Interrater reliability of assessing levator ani deficiency with 360° 3D endovaginal ultrasound.

INTRODUCTION AND HYPOTHESIS: Three-dimensional endovaginal ultrasound has been used for evaluation of levator ani muscle deficiency. The aim of this study was to assess interrater agreement/reliability of 3D endovaginal ultrasound for scoring levator ani deficiency (LAD). METHODS: This was a cross-sectional study. Women referred to our urogynecology clinic for different pelvic floor dysfunction symptoms during November 2010-November 2012 were recruited. All patients underwent physical examination, including Pelvic Organ Prolapse Quantification (POP-Q) examination and high-resolution 3D endovaginal ultrasound. The levator muscle was divided into three subgroups based on our prior work: the puboperinealis/puboanalis (PA), puborectalis (PR), and iliococcygeus/pubococcygeus (PV). Subgroups were evaluated in their specific axial plane and were scored according to thickness and detachment from the pubic bone. Scoring was conducted by four raters blinded to case status and to one another's scores. RESULTS: Ninety patients were recruited. The median age was 52 (range 24-86). Median body mass index (BMI) was 28.08 (range 17.08-51.39). Fifty percent of patients were menopausal. The range of exact agreement for total LAD score was 77-90 %. All the correlation coefficients at the individual sites as well as the overall scores were positive at above 0.63 and significant at <0.0001 level. CONCLUSIONS: Our study demonstrates excellent agreement between raters assessing levator ani muscle deficiency using 3D endovaginal ultrasound. This level of concordance supports the reliability of the 3D endovaginal ultrasound technique and scoring method among raters [corrected].

3D pelvic floor ultrasound findings and severity of anal incontinence.

INTRODUCTION AND HYPOTHESIS: The aim of our study was to determine the association between the severity of anal incontinence and levator ani deficiency, anal sphincter defects, anorectal angle, and colonic motility abnormalities. METHODS: This was a retrospective study. Subjects were categorized into three groups: normal, minor anal incontinence, and major anal incontinence according to their answers to the PFDI-20 questionnaire. 3D endovaginal ultrasound was utilized to assess levator ani muscle and the anorectal angle. Levator ani muscle subdivisions were scored based on avulsion from the pubic bone and muscle thickness, based on our previous work. 3D endoanal ultrasound was utilized to assess anal sphincters. Colonic motility abnormalities were defined as diarrhea, constipation or both. RESULTS: Ninety-seven patients were included in the analysis: 45 with major anal incontinence, 29 with minor anal incontinence, and 23 continent women. On multivariate logistic regression, sphincter defect, anorectal angle, and colonic motility abnormalities were associated with anal incontinence severity. Women with an external anal sphincter defect had a 20.36-fold chance of having severe anal incontinence compared with patients with no defect (OR 20.36, 95% CI 5.4, 76.6); those with both defective sphincters had a 102.5-fold chance of having severe anal incontinence (OR 102.5, 95% CI 10.2, >999). Anorectal angle ≥170° was significantly associated with the severity of anal incontinence (OR = 4.07, 95% CI 1.53, 10.79), as was the presence of colonic mobility abnormality (OR 5.31, 95% CI 1.86, 15.19). CONCLUSIONS: 3D pelvic floor ultrasound can be an efficient tool for anal incontinence evaluation in women. Anal sphincter defects, colonic motility abnormalities, and anorectal angle were associated with the severity of anal incontinence. While there was a trend toward worsening levator ani deficiency among those with major anal incontinence, this did not reach statistical significance.

Visualization of periurethral structures by 3D endovaginal ultrasonography in midsagittal plane is not associated with stress urinary incontinence status.

INTRODUCTION AND HYPOTHESIS: Our aim was to determine the association between visualizing periurethral structures in the midsagittal plane with 3D endovaginal ultrasonography (EVUS) and stress urinary incontinence (SUI) status. METHODS: In a cross-sectional study, we measured urethral length and scored for presence or absence of the following in midsagittal plane in patients with and without stress SUI: striated urogenital sphincter, longitudinal/circular smooth muscle, vesical trigone, trigonal plate, trigonal ring, and compressor urethra. Summary statistics were calculated for the study population. Fisher's exact test was used to compare continuous data. Categorical data was compared with the chi-square. RESULTS: Data from 161 patients was available for review. Mean patient age was 54.4 [±15.6 standard deviation (SD)] years, and median parity was two (range 0-5). Among these women, 137/161(85%) did not have SUI and 24/(15%) did; 20/161 (12%) had anterior-compartment prolapse stage 2 or greater, and among them, only two had urinary incontinence (UI). No association was found between UI and visualization of the periurethral structures. Mean urethral lengths did not differ between groups (p = 0.37). CONCLUSIONS: Visualization of periurethral structures by 3D EVUS in the midsagittal plane is not associated with SUI status.

The determinants of minimal levator hiatus and their relationship to the puborectalis muscle and the levator plate.

OBJECTIVE: To determine the muscles comprising the minimal levator hiatus. DESIGN: Cross-sectional study. SETTING: The University of Oklahoma Health Sciences Center, USA. POPULATION: Eight female fresh frozen pelves and 80 nulliparouswomen. METHODS: Three-dimensional endovaginal ultrasound was performed in eight fresh frozen female pelves. The structures of the levator hiatus were tagged with needles and the cadavers were dissected to identify the tagged structures. A group of 80 nullipara underwent 3D endovaginal ultrasound, and the minimal levator hiatus area, puborectalis area, and anorectal angle were assessed, and normal values were obtained. MAIN OUTCOME MEASURES: Anatomic borders of minimal levator hiatus and normality in pelvic floor measurements. RESULTS: The pubococcygeus forms the inner lateral border and anterior attachment of the minimal levator hiatus to the pubic bone. The puboanalis fibres are immediately lateral to pubococcygeus attachments. There are variable contributions of the puborectalis fibres lateral to the puboanalis attachment. The posterior border of the minimal levator hiatus is formed by the levator plate. Eighty community-dwelling nulliparous women underwent 3D endovaginal ultrasound. The median age was 47 years (range 22-70 years). The mean of minimal levator hiatus and puborectalis hiatus areas were 13.4 cm(2) (±1.89 cm(2) SD) and 14.8 cm(2) (±2.16 cm(2) SD). The mean anorectal and levator plate descent angles were 156° (±10.04° SD) and 15.9° (±8.28° SD). CONCLUSION: Anterior and lateral borders of the minimal levator hiatus are formed mostly by pubococcygeus. The puborectalis, pubococcygeus, and iliococcygeus form the bulk of the levator plate.