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OBJECTIVES: To evaluate whether peri-operative changes in voiding function, pelvic organ descent and urethral mobility predict improvement in urgency urinary incontinence (UUI) following prolapse surgery. METHODS: A retrospective study of women undergoing prolapse surgery without a history of or without a concomitant anti-incontinence surgery at a tertiary unit between 2005 and 2019. All patients underwent a pre- and post-operative standardised interview, POP-Q examination, uroflowmetry and 4D translabial ultrasound. Post processing of ultrasound volume data was performed to assess pelvic organ descent and functional urethral anatomy. RESULTS: The datasets of 123 women were analysed. Mean follow-up was 5.5 months (SD 3.2). Mean age was 61 years (SD 11.7). UUI was reported by 68 before and 44 after operation (p = 0.001 for the reduction). Among those with pre-operative UUI, 34 reported cure of UUI, 20 improvement, 9 no change and 5 worsened UUI after their operation. De novo UUI was reported in 11. Fifty-seven women reported voiding dysfunction before and 32 after operation (p = 0.09 for the reduction). Abnormal uroflowmetry was noted in 63 women before and 37 after operation (p = 0.003 for change). On binary logistic regression, improved/cured UUI was associated with improved subjective voiding function (p = 0.003) and reduced residual urine volume (p = 0.02), but not with peri-operative changes in pelvic organ descent or functional urethral anatomy. CONCLUSION: Prolapse surgery resulted in short- to medium- term improvement in UUI. This was associated with subjective improvement in voiding function and with a reduction in post-void residual urine volume. SUMMARY: Prolapse surgery was associated with improvement in UUI which in turn was associated with subjectively improved voiding and reduced residual urine volume.
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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.
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OBJECTIVE: Levator avulsion is a major etiological factor of pelvic organ prolapse (POP) and is primarily diagnosed on tomographic axial plane imaging. Two-dimensional imaging can also image the levator. The objective was to test reproducibility and validity of coronal plane assessment for diagnosis of levator trauma by assessing the coronal plane obtained on tomographic ultrasound imaging. METHODS: A retrospective study of women who had undergone an interview, POPQ and four-dimensional translabial ultrasound at a tertiary urogynecological unit. Post-processing of archived volume data was performed for assessment; and levator muscle area and estimate of remnant muscle mass in the coronal plane. Interobserver reproducibility of the latter two measures and associations between various measures of levator trauma and POP were tested. RESULTS: Interobserver agreement was good for percentage estimates (ICC 0.743), but fair for area measurements (ICC 0.482). Six hundred and twenty four women were seen, 468 (75%) had significant clinical prolapse. Full levator avulsions were diagnosed in 137 (22%). Mean TTS was 2.7 (range 0-12). On coronal plane assessment average muscle area was 1.47 (SD 0.76) cm2 and 1.55 (SD 0.74) cm2 on the right and left, respectively (P = .005). It was 76% and 79% for average estimates of muscle mass (P = .021). Both measures were strongly associated with POP; however, they were not superior to TTS in predicting POP. CONCLUSION: Coronal plane assessment in volume data is reproducible and valid for evaluation of levator trauma. Muscle mass estimate may be a better measure than muscle area.
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Diafragma da Pelve , Prolapso de Órgão Pélvico , Ultrassonografia , Humanos , Feminino , Reprodutibilidade dos Testes , Estudos Retrospectivos , Ultrassonografia/métodos , Pessoa de Meia-Idade , Prolapso de Órgão Pélvico/diagnóstico por imagem , Diafragma da Pelve/diagnóstico por imagem , Diafragma da Pelve/lesões , Idoso , Adulto , Idoso de 80 Anos ou mais , Variações Dependentes do ObservadorRESUMO
INTRODUCTION AND HYPOTHESIS: Of women with symptomatic prolapse, 13-39% experience voiding dysfunction (VD). The aim of our observational cohort study was to determine the effect of prolapse surgery on voiding function. METHODS: Retrospective analysis of 392 women who underwent surgery between May 2005 and August 2020. All had a standardized interview, POP-Q, uroflowmetry and 3D/4D transperineal ultrasound (TPUS) pre-and postoperatively. Primary outcome was change in VD symptoms. Secondary outcomes were changes in maximum urinary flow rate (MFR) centile and post-void residual urine (PVR). Explanatory measures were change in pelvic organ descent as seen on POP-Q and TPUS. RESULTS: Of 392 women, 81 were excluded due to missing data, leaving 311. Mean age and BMI were 58 years and 30 kg/m2, respectively. Procedures performed included anterior repair (n = 187, 60.1%), posterior repair (n = 245, 78.8%), vaginal hysterectomy (n = 85, 27.3%), sacrospinous colpopexy (n = 170, 54.7%) and mid-urethral sling (MUS) (n = 192, 61.7%). Mean follow-up was 7 (1-61) months. Pre-operatively, 135 (43.3%) women reported symptoms of VD. Postoperatively, this decreased to 69 (22.2%) (p < 0.001), and of those, 32 (10.3%) reported de novo VD. The difference remained significant after excluding concomitant MUS surgery (n = 119, p < 0.001). Postoperatively, there was a significant decrease in mean PVR (n = 311, p < 0.001). After excluding concomitant MUS surgery, there was a significant increase in mean MFR centile (p = 0.046). CONCLUSIONS: Prolapse repair significantly reduces symptoms of VD and improves PVR and flowmetry.
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Prolapso de Órgão Pélvico , Retenção Urinária , Transtornos Urinários , Feminino , Humanos , Gravidez , Masculino , Prolapso de Órgão Pélvico/cirurgia , Prolapso de Órgão Pélvico/complicações , Estudos Retrospectivos , Colpotomia , Retenção Urinária/complicaçõesRESUMO
OBJECTIVES: To explore the differences in assessing obstetric anal sphincter injuries (OASI) between transperineal ultrasound (TPUS) and endoanal ultrasound (EAUS) and test relationships between ultrasound findings and anal incontinence (AI) symptoms. METHODS: A group of 196 women with a history of vaginal delivery was recruited. OASI was detected in a set of 5 slices by EAUS and 8 slices by TPUS. OASI grading was performed on TPUS rules and EAUS rules. A "significant sphincter defect" was diagnosed by TPUS and EAUS using "2/3 rules." Symptoms of AI were determined using the St Mark's Incontinence Score (SMIS). Ultrasound findings were compared between the two methods and correlated with symptoms. RESULTS: Of 196 women, 29 (14.8%) suffered from AI with a mean SMIS of 12.1 ± 4.5, and 70 (35.7%) women with a mean age of 57 years had suspected OASI on imaging. Twenty-one (10.7%) "significant defects" were diagnosed by TPUS and 24 (12.2%) by EAUS. OASI Grades on TPUS had good agreement with EAUS rules (k = 0.70, P < .001). Logistic regression analysis showed that OASI Grade on imaging and "significant sphincter defects" seen on both forms of imaging were associated with AI symptoms. The odds ratio was 46 and 38 for "significant defects" on TPUS and EAUS, and 14 and 7 for OASI 3b+ on TPUS and EAUS in predicting AI, respectively. CONCLUSIONS: "Significant defects" diagnosed by EAUS or TPUS and OASI Grade 3b+ predict AI symptoms. The diagnostic performance of endoanal and exoanal ultrasound (EAUS and TPUS) appear to be very similar.
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Canal Anal , Incontinência Fecal , Gravidez , Feminino , Humanos , Pessoa de Meia-Idade , Masculino , Canal Anal/diagnóstico por imagem , Canal Anal/lesões , Ultrassonografia/métodos , Parto Obstétrico , Incontinência Fecal/diagnóstico por imagemRESUMO
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.
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Cicatriz , Lacerações , Feminino , Humanos , Cicatriz/diagnóstico por imagem , Cicatriz/complicações , Projetos Piloto , Estudos Retrospectivos , Diafragma da Pelve/diagnóstico por imagem , Diafragma da Pelve/lesões , Canal Anal/lesõesRESUMO
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.
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Cistocele , Gravidez , Humanos , Feminino , Cistocele/diagnóstico por imagem , Paridade , Estudos Retrospectivos , Bexiga Urinária/diagnóstico por imagem , Vagina , Ultrassonografia/métodosRESUMO
INTRODUCTION AND HYPOTHESIS: Obstetric anal sphincter tears are the single major modifiable risk factor for anal incontinence (AI) in women. We undertook a retrospective observational study in a tertiary urogynecology unit to describe the prevalence of sonographic anal sphincter defects in a urogynecological population and investigate obstetric risk factors. METHODS: Files of women seen for investigation of pelvic floor disorders between January 2014 and May 2021 were reviewed. Sonographic defects of the external anal sphincter were analyzed using stored 4D ultrasound imaging data. Explanatory parameters were number of vaginal births, delivery mode, age at first vaginal birth, and birthweight of the first vaginally born baby. RESULTS: Of 3,037 women seen during the inclusion period, data were missing in 219, leaving 2,818. AI was reported by 508 (18%), with a mean St Marks score of 11 (1-23) and a mean bother score of 5.9 (0-10). External sphincter defects were detected in 945 women (34%), with a "residual defect" in 343 (12%). The strongest risk factors for a residual defect were first vaginal birth and forceps, with higher-order multiparity adding risk. On multivariate analysis, forceps and vaginal parity >5 remained significant predictors, as opposed to age at first birth and birthweight of the firstborn. CONCLUSIONS: In this observational study in urogynecological patients, 12% showed a residual EAS defect on imaging. The most obvious risk factors for the diagnosis of a residual defect on exo-anal imaging were the first vaginal birth and forceps, with higher-order vaginal parity conveying additional risk.
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Doenças do Ânus , Incontinência Fecal , Complicações do Trabalho de Parto , Gravidez , Humanos , Feminino , Canal Anal/lesões , Peso ao Nascer , Doenças do Ânus/epidemiologia , Parto , Incontinência Fecal/etiologia , Ultrassonografia/métodos , Fatores de Risco , Parto Obstétrico/efeitos adversos , Complicações do Trabalho de Parto/etiologiaRESUMO
INTRODUCTION AND HYPOTHESIS: Stress urinary incontinence is the most prevalent type of urinary incontinence and childbirth is a risk factor. The aim of this study is to evaluate the association between delivery mode and urethral sphincter function as measured by the maximum urethral pressure (MUP). METHODS: A retrospective study on women seen in a tertiary urogynaecological center for urodynamic testing between January 2017 to December 2019. Women were classified into the following groups: (1) nulliparous; (2) caesarean section only; (3) at least one spontaneous vaginal delivery but no instrumental deliveries; (4) at least one vacuum delivery but no forceps; (5) at least one forceps delivery. RESULTS: The complete data sets of 1238 women were analysed; 1112 (90%) were vaginally parous. Mean age was 58 (18-95) years. Mean parity was 2.6 (0-9); 57 (4.6%) were nulliparous, 69 (5.6%) had only been delivered by caesarean section, 762 (61.6%) had at least one spontaneous vaginal delivery but no instrumental deliveries, 41 (3.3%) had at least one vacuum but no forceps delivery, and 309 (25%) had at least one forceps delivery. Mean MUP was 41.8 cmH2O. There was a significant association between vaginal parity and MUP (P < 0.001). On ANOVA test, delivery mode was significantly associated with MUP. This became nonsignificant on regression analysis, with only age significantly associated with MUP (P < 0.001). CONCLUSIONS: The effect of childbirth on urethral sphincter function seems to be largely due to the first vaginal birth. We failed to show an effect of instrumental delivery.
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Cesárea , Incontinência Urinária por Estresse , Feminino , Gravidez , Humanos , Pessoa de Meia-Idade , Paridade , Cesárea/efeitos adversos , Estudos Retrospectivos , Incontinência Urinária por Estresse/etiologia , Parto Obstétrico/efeitos adversosRESUMO
INTRODUCTION AND HYPOTHESIS: Obstructed defecation (OD) is often associated with trauma to pelvic connective tissue and nerves sustained during pregnancy and childbirth. Although there are multiple potential etiologies of defecatory dysfunction, the pathophysiology of this symptom complex is not well understood. The purpose of this study is to determine the role of parity in the development of obstructed defecatory symptoms in women with normal anorectal anatomy in a search for evidence of a presumptive neuropathic effect of pregnancy and childbirth. METHODS: This study retrospectively evaluated the records of 754 women presenting at a tertiary urogynecology unit for pelvic floor dysfunction with no anatomical abnormalities of the anorectum on imaging. They were stratified according to parity. The authors determined the prevalence of obstructed defecation symptoms in these groups. Chi-squared test was performed for statistical analysis. RESULTS: Median age was 51 (range 16-88) years, and median vaginal parity was 2 (0-8); 399 (53%) women reported symptoms of OD. When anatomical abnormalities of the anorectum were excluded, parity did not seem to have a major effect on the prevalence of symptoms of OD. CONCLUSIONS: In this cohort, parity is unlikely to be a cause of OD in women with normal anorectal anatomy.
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Constipação Intestinal , Defecação , Gravidez , Feminino , Humanos , Adolescente , Adulto Jovem , Adulto , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Masculino , Defecação/fisiologia , Paridade , Constipação Intestinal/epidemiologia , Constipação Intestinal/etiologia , Estudos Retrospectivos , VaginaRESUMO
INTRODUCTION AND HYPOTHESIS: We assessed rotation/twisting of transobturator midurethral slings (TOTs) and tested for associations with de novo chronic pain and voiding dysfunction. METHODS: A retrospective pilot study including patients seen after Monarc™ TOT surgery at a single tertiary hospital in 2005-2016. Patients underwent an interview, clinical examination, uroflowmetry and 4D pelvic floor ultrasound. Volume datasets were analyzed blinded against all other data. Sling rotation/twisting was evaluated in volumes obtained at rest. The sling axis was measured relative to the vertical in the midline and in the most lateral parasagittal slice. Total sling rotation was calculated by summation of absolute angle differences between midline and lateral angles. "Corkscrew" rotation was noted when direction of rotation was opposite on the contra-lateral side. RESULTS: The study included 215 patients. Fifty-two (24%) were excluded, leaving 163. Mean age was 57 years (28-87; SD 12), mean BMI 29.4 kg/m2 (18.3-47.4, SD 6). Follow-up was at a median of 17 months (IQR 11-27). Chronic de novo pain was reported by 15 women (9%; dyspareunia by 11 and pelvic/vaginal pain by 4). On imaging, mean total sling rotation was 144° (12-335, SD 56). In the majority (n = 103, 63%) it rotated counter-clockwise from its midline position and in 30 (18%) it rotated clockwise. "Corkscrew" rotation was noted in 30 (18%). De novo chronic pain was associated with lower BMI and vaginal sling exposure but not with sling rotation. The latter was not found to be associated with voiding dysfunction either. CONCLUSIONS: Monarc™ TOTs rotate considerably throughout their course. The degree of twisting or rotation and its direction was not found to be associated with de novo postoperative chronic pain or voiding dysfunction.
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Dor Crônica , Slings Suburetrais , Incontinência Urinária por Estresse , Dor Crônica/etiologia , Feminino , Humanos , Pessoa de Meia-Idade , Projetos Piloto , Estudos Retrospectivos , Slings Suburetrais/efeitos adversos , Incontinência Urinária por Estresse/cirurgia , Procedimentos Cirúrgicos Urológicos/métodosRESUMO
INTRODUCTION AND HYPOTHESIS: This manuscript is the International Urogynecology Consultation (IUC) on pelvic organ prolapse (POP) chapter one, committee three, on the Pathophysiology of Pelvic Organ Prolapse assessing genetics, pregnancy, labor and delivery, age and menopause and animal models. MATERIALS AND METHODS: An international group of urogynecologists and basic scientists performed comprehensive literature searches using pre-specified terms in selected biomedical databases to summarize the current knowledge on the pathophysiology of the development of POP, exploring specifically factors including (1) genetics, (2) pregnancy, labor and delivery, (3) age and menopause and (4) non-genetic animal models. This manuscript represents the summary of three systematic reviews with meta-analyses and one narrative review, to which a basic scientific comment on the current understanding of pathophysiologic mechanisms was added. RESULTS: The original searches revealed over 15,000 manuscripts and abstracts which were screened, resulting in 202 manuscripts that were ultimately used. In the area of genetics the DNA polymorphisms rs2228480 at the ESR1 gene, rs12589592 at the FBLN5 gene, rs1036819 at the PGR gene and rs1800215 at the COL1A1 gene are significantly associated to POP. In the area of pregnancy, labor and delivery, the analysis confirmed a strong etiologic link between vaginal birth and symptoms of POP, with the first vaginal delivery (OR: 2.65; 95% CI: 1.81-3.88) and forceps delivery (OR: 2.51; 95% CI: 1.24-3.83) being the main determinants. Regarding age and menopause, only age was identified as a risk factor (OR : 1.102; 95% CI: 1.02-1.19) but current data do not identify postmenopausal status as being statistically associated with POP. In several animal models, there are measurable effects of pregnancy, delivery and iatrogenic menopause on the structure/function of vaginal support components, though not on the development of POP. CONCLUSIONS: Genetics, vaginal birth and age all have a strong etiologic link to the development of POP, to which other factors may add or protect against the risk.
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Prolapso de Órgão Pélvico , Parto Obstétrico/efeitos adversos , Feminino , Humanos , Parto , Prolapso de Órgão Pélvico/genética , Gravidez , Encaminhamento e Consulta , VaginaRESUMO
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.
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Prolapso de Órgão Pélvico , Feminino , Humanos , Obesidade/complicações , Diafragma da Pelve/diagnóstico por imagem , Prolapso de Órgão Pélvico/diagnóstico por imagem , Prolapso de Órgão Pélvico/etiologia , Percepção , Estudos Retrospectivos , Ultrassonografia/métodosRESUMO
BACKGROUND: Pregnancy and childbirth are thought to be the strongest environmental risk factors for pelvic organ prolapse, but prolapse does occur in nulliparae. AIM: To characterise prolapse in vaginal nulliparae. MATERIAL AND METHODS: This was a retrospective study using archived clinical and imaging data of 368 vaginally nulliparous women seen between 2006 and 2017 at two tertiary urogynaecological centres. Patients underwent a standardised interview, clinical examination and 3D/4D translabial ultrasound. Volume datasets were analysed by the second author, blinded against all clinical data, using post-processing software on a personal computer. Significant prolapse was defined as Pelvic Organ Prolapse Quantification system stage ≥2 for the anterior and posterior compartment, and stage ≥1 for the central compartment. On imaging, significant prolapse was defined as previously described. RESULTS: Of 4297 women seen during the inclusion period, 409 were vaginally nulliparous, for whom 368 volume data sets could be retrieved. Mean age was 50 years (17-89) and mean body mass index 29 (16-64). Eighty-one (22%) presented with prolapse symptoms. On clinical examination, 106 women (29%) had significant prolapse, mostly of the posterior compartment (n = 70, 19%). On imaging 64 women showed evidence of significant prolapse (17%), again mostly posterior (n = 47, 13%). Rectovaginal septal defects were even more common in 69 (19%). On multivariate analysis we found no differences between true nulliparae (n = 184) and women delivered exclusively by caesarean section (n = 184). CONCLUSIONS: Prolapse occurs in vaginal nulliparae, but it has distinct characteristics. Rectocele predominates, while cystocele and uterine prolapse are uncommon. Pregnancy and caesarean delivery seem to have little effect.
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Cistocele , Prolapso de Órgão Pélvico , Cesárea , Cistocele/diagnóstico , Feminino , Humanos , Pessoa de Meia-Idade , Diafragma da Pelve/diagnóstico por imagem , Prolapso de Órgão Pélvico/diagnóstico por imagem , Prolapso de Órgão Pélvico/epidemiologia , Gravidez , Estudos Retrospectivos , Ultrassonografia/métodosRESUMO
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.
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Episiotomia , Complicações do Trabalho de Parto , Canal Anal/lesões , Cicatriz/diagnóstico por imagem , Episiotomia/efeitos adversos , Episiotomia/métodos , Feminino , Humanos , Masculino , Períneo , Gravidez , UltrassonografiaRESUMO
AIMS: The objective of this study was to provide follow-up data on four-dimensional ultrasound (4DUS) morphometry for women having botulinum toxin type A (BoNT-A) treatment of pelvic floor tension myalgia (PFTM). MATERIALS AND METHODS: A prospective cohort study was performed from October 2013 to June 2018, recruiting women scheduled for BoNT-A injection in the pelvic floor musculature. Translabial 4DUS, vaginal pressure assessment by manometry and pain visual analog scales (VAS) were performed on all women before injection and again at 4, 12, and 26 weeks. The BoNT-A injection was performed under 4DUS guidance. RESULTS: Twenty-nine women had 44 injections over the course of the study. Although improvements were seen in VAS scores for dysmenorrhea, nonmenstrual pelvic pain, and dyspareunia, there were no significant differences in ultrasound biometry at either rest, Valsalva, or on contraction when comparing postinjection measurements at 4, 12, and 26 weeks with pre-injection baseline. Similarly, vaginal pressure readings at rest demonstrated a significant improvement throughout the 4, 12, and 26 week follow-up, with a reduction in maximal contraction at 4 and 12 but not 26 weeks. CONCLUSIONS: This study demonstrates that 4DUS biometry of the pelvic floor does not correlate with clinical pain and vaginal pressure outcomes for BoNT-A injection in the context of PFTM.
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Toxinas Botulínicas Tipo A , Biometria , Toxinas Botulínicas Tipo A/uso terapêutico , Feminino , Humanos , Diafragma da Pelve/diagnóstico por imagem , Dor Pélvica/tratamento farmacológico , Estudos Prospectivos , Resultado do TratamentoRESUMO
OBJECTIVE: To determine the diagnostic performance of digital palpation of levator ani muscle (LAM) avulsion compared with translabial tomographic ultrasound imaging (TUI). METHODS: A cross-sectional study, incorporating 195 women involved in a longitudinal cohort study. Palpation for levator integrity was performed, followed by a four-dimensional translabial ultrasound. LAM avulsion defects were diagnosed in the presence of puborectalis muscle detachment from its insertion. Post-processing analysis of ultrasound volumes for LAM integrity on TUI was performed blinded against palpation findings. Agreement between methods was assessed using Cohen's κ. RESULTS: In all, 388 paired assessments of LAM bilaterally, were available. Sixteen (8.2%) unilateral avulsion defects were detected on palpation. Sonographically, 31 (16%) were diagnosed with avulsions: 4.6% bilateral and 11.3% unilateral. An overall agreement of 91% was observed between digital palpation and TUI, yielding a Cohen's κ of 0.32 (95% confidence interval 0.15-0.48) demonstrating "fair agreement": and implying 25% sensitivity, 98% specificity, 63% positive predictive value, and 92% negative predictive value. Analysis of the first and last 20 palpations showed no change in performance during the 13-day study period. CONCLUSION: Assessment of LAM avulsion defects by digital palpation is feasible but may require substantial training. Confirmation by imaging is crucial, especially if the diagnosis of avulsion may influence clinical management.
Assuntos
Palpação , Diafragma da Pelve , Estudos Transversais , Feminino , Humanos , Estudos Longitudinais , Diafragma da Pelve/diagnóstico por imagem , UltrassonografiaRESUMO
INTRODUCTION AND HYPOTHESIS: Coital incontinence (CI) is an underreported symptom among sexually active women. It has been assumed that incontinence at penetration (CIAP) is due to urodynamic stress incontinence (USI), while coital incontinence at orgasm (CIAO) is thought to be due to detrusor overactivity (DO). METHODS: To evaluate demographic and urodynamic findings associated with coital incontinence (CI) and to confirm the hypotheses 'CIAP is associated with USI' and 'CIAO is associated with DO we performed a retrospective study of 661 sexually active women attending a tertiary clinic between January 2017 and December 2019 for pelvic floor dysfunction. All patients filled in a standardized questionnaire and had a clinical examination and multichannel urodynamic testing. Women were asked if they experienced urine leakage during intercourse and the timing of such leakage. RESULTS: Of 661 sexually active women, one third (n = 220) reported coital incontinence. While 121 (18%) women experienced CIAP, 172 (26%) had CIAO and 76 (11.5%) suffered both. For women with pure USI, the prevalence of CIAP (61.7%) and CIAO (69.5%) was significantly higher than for women with pure DO, where only 12.3% had CIAP and 8.6% had CIAO. Factors significantly associated with CI were body mass index, mid-urethral closure pressure (MUCP) and abdominal leak point pressure (ALPP). When only women with pure USI or DO were included, USI remained associated with CI while DO was not. CONCLUSIONS: CI is clearly associated with SUI and USI and is likely to share etio-pathogenetic mechanisms. CI seems to be a manifestation of USI, even when it occurs during orgasm.