Pelvic floor injury during vaginal birth is life-altering and preventable: what can we do about it?

Pelvic floor disorders after childbirth have distressing lifelong consequences for women, requiring more than 300,000 women to have surgery annually. This represents approximately 10% of the 3 million women who give birth vaginally each year. Vaginal birth is the largest modifiable risk factor for prolapse, the pelvic floor disorder most strongly associated with birth, and is an important contributor to stress incontinence. These disorders require 10 times as many operations as anal sphincter injuries. Imaging shows that injuries of the levator ani muscle, perineal body, and membrane occur in up to 19% of primiparous women. During birth, the levator muscle and birth canal tissues must stretch to more than 3 times their original length; it is this overstretching that is responsible for the muscle tear visible on imaging rather than compression or neuropathy. The injury is present in 55% of women with prolapse later in life, with an odds ratio of 7.3, compared with women with normal support. In addition, levator damage can affect other aspects of hiatal closure, such as the perineal body and membrane. These injuries are associated with an enlarged urogenital hiatus, now known as antedate prolapse, and with prolapse surgery failure. Risk factors for levator injury are multifactorial and include forceps delivery, occiput posterior birth, older maternal age, long second stage of labor, and birthweight of >4000 g. Delivery with a vacuum device is associated with reduced levator damage. Other steps that might logically reduce injuries include manual rotation from occiput posterior to occiput anterior, slow gradual delivery, perineal massage or compresses, and early induction of labor, but these require study to document protection. In addition, teaching women to avoid pushing against a contracted levator muscle would likely decrease injury risk by decreasing tension on the vulnerable muscle origin. Providing care for women who have experienced difficult deliveries can be enhanced with early recognition, physical therapy, and attention to recovery. It is only right that women be made aware of these risks during pregnancy. Educating women on the long-term pelvic floor sequelae of childbirth should be performed antenatally so that they can be empowered to make informed decisions about management decisions during labor.

Functional Anatomy of Urogenital Hiatus Closure: the Perineal Complex Triad Hypothesis.

INTRODUCTION: Urogenital hiatus enlargement is a critical factor associated with prolapse and operative failure. This study of the perineal complex was performed to understand how interactions among its three structures: the levator ani, perineal membrane, and perineal body-united by the vaginal fascia-work to maintain urogenital hiatus closure. METHODS: Magnetic resonance images from 30 healthy nulliparous women with 3D reconstruction of selected subjects were used to establish overall geometry. Connection points and lines of action were based on perineal dissection in 10 female cadavers (aged 22-86 years), cross sections of 4 female cadavers (aged 14-35 years), and histological sections (cadavers aged 16 and 21 years). RESULTS: The perineal membrane originates laterally from the ventral two thirds of the ischiopubic rami and attaches medially to the perineal body and vaginal wall. The levator ani attaches to the perineal membrane's cranial surface, vaginal fascia, and the perineal body. The levator line of action in 3D reconstruction is oriented so that the levator pulls the medial perineal membrane cranio-ventrally. In cadavers, simulated levator contraction and relaxation along this vector changes the length of the membrane and the antero-posterior diameter of the urogenital hiatus. Loss of the connection of the left and right perineal membranes through the perineal body results in diastasis of the levator and a widened hiatus, as well as a downward rotation of the perineal membrane. CONCLUSION: Interconnections involving the levator ani muscles, perineal membrane, perineal body, and vaginal fascia form the perineal complex surrounding the urogenital hiatus in an arrangement that maintains hiatal closure.

A unified pelvic floor conceptual model for studying morphological changes with prolapse, age, and parity.

Several 2-dimensional and 3-dimensional measurements have been used to assess changes in pelvic floor structures and shape. These include assessment of urogenital and levator hiatus dimensions, levator injury grade, levator bowl volume, and levator plate shape. We argue that each assessment reflects underlying changes in an individual aspect of the overall changes in muscle and fascial structures. Vaginal delivery, aging, and interindividual variations in anatomy combine to affect pelvic floor structures and their connections in different ways. To date, there is no unifying conceptual model that permits the evaluation of how these many measures relate to one another or that reflects overall pelvic floor structure and function. Therefore, this study aimed to describe a unified pelvic floor conceptual model to better understand how the aforementioned changes to the pelvic floor structures and their biomechanical interactions affect pelvic organ support with vaginal birth, prolapse, and age. In this model, the pelvic floor is composed of 5 key anatomic structures: the (1) pubovisceral, (2) puborectal, and (3) iliococcygeal muscles with their superficial and inferior fascia; (4) the perineal membrane or body; and (5) the anal sphincter complex. Schematically, these structures are considered to originate from pelvic sidewall structures and meet medially at important connection points that include the anal sphincter complex, perineal body, and anococcygeal raphe. The pubovisceral muscle contributes primarily to urogenital hiatus closure, whereas the puborectal muscle is mainly related to levator hiatus closure, although each muscle contributes to the other. Dorsally and laterally, the iliococcygeal muscle forms a shelflike structure in women with normal support that spans the remaining area between these medial muscles and attachments to the pelvic sidewall. Other features include the levator plate, bowl volume, and anorectal angle. The pelvic floor conceptual model integrates existing observations and points out evident knowledge gaps in how parturition, injury, disease, and aging can contribute to changes associated with pelvic floor function caused by the detachment of one or more important connection points or pubovisceral muscle failure.

Aging effects on pelvic floor support: a pilot study comparing young versus older nulliparous women.

INTRODUCTION AND HYPOTHESIS: We sought to determine age-related changes to the pelvic floor in the absence of childbirth effects. METHODS: A case-control study was conducted from June 2017 to August 2018 comparing two groups of nulliparous women: <40 years old and ≥ 70 years old. Clinical evaluation included POP-Q, instrumented speculum testing, and handgrip strength. Dynamic 3D-stress MRI was performed on all women to obtain genital and levator hiatus (LH) lengths, LH area, and levator bowl volume. LH shape was quantified using a novel measure called the "V-U index." Pubovisceral muscle (PVM) cross-sectional area (CSA) was also measured. Bivariate comparisons between the two groups were made for all variables. Effect sizes were calculated for MRI measurements. RESULTS: Twelve young and 9 older nulliparous women were included. Levator bowl volume at rest was 83% larger in older women (108.0 ± 34.5 cm3 vs 59.2 ± 19.3 cm3, p = 0.001, d = 1.82). MRI genital hiatus at rest was larger among the older group (2.7 ± 0.6 cm vs 3.5 ± 0.6 cm, p = 0.007, d = 1.34). V-U index, a measure of LH shape where 0 = "V" and 1 = "U," differed between groups indicating a more "U"-like shape among older women (0.71 ± 0.23 vs 0.35 ± 0.18, p = 0.001, d = 1.72). Handgrip strength was lower in the older vs young group (23.2 ± 5.2 N vs 33.4 ± 5.2 N, p < 0.0001); however, the Kegel augmentation force and PVM CSA were similar (3.2 ± 1.1 N vs 3.3 ± 2.2 N, p = 0.89, and 0.8 ± 0.3 cm2 vs 0.7 ± 0.2 cm2, p = 0.23 respectively). CONCLUSIONS: Levator bowl volume at rest was over 80% larger among older women, reflecting a generalized posterior distension with age.

A novel measurement of pelvic floor cross-sectional area in older and younger women with and without prolapse.

BACKGROUND: An increase in size of the aperture of the pelvis that must be spanned by pelvic floor support structures translates to an increase in the force on these structures. Prior studies have measured the bony dimensions of the pelvis, but the effect of changes in muscle bulk that may affect the size of this area are unknown. OBJECTIVES: To develop a technique to evaluate the aperture size in the anterior pelvis at the level of the levator ani muscle attachments, and to identify age-related changes in women with and without prolapse. MATERIALS AND METHODS: This was a technique development and pilot case-control study evaluating pelvic magnetic resonance imaging from 30 primiparous women from the Michigan Pelvic Floor Research Group MRI Data Base: 10 younger women with normal support, 10 older women with prolapse, and 10 older menopausal women without prolapse. Anterior pelvic area measurements were made in a plane that included the bilateral ischial spines and the inferior pubic point, approximating the level of the arcus tendineus fascia pelvis. Measurements of the anterior pelvic area, obturator internus muscles, and interspinous diameter were made by 5 independent raters from the Society of Gynecologic Surgeons Pelvic Anatomy Group who focused on developing pelvic imaging techniques, and evaluating interrater reliability. Demographic characteristics were compared across groups of interest using the Wilcoxon rank sum test, χ2, or Fisher exact test where appropriate. Multiple linear regression models were created to identify independent predictors of anterior pelvic area. RESULTS: Per the study design, groups differed in age and prolapse stage. There were no differences in race, height, body mass index, gravidity, or parity. Patients with prolapse had a significantly longer interspinous diameter, and more major (>50% of the muscle) levator ani defects when compared to both older and younger women without prolapse. Interrater reliability was high for all measurements (intraclass correlation coefficient = 0.96). The anterior pelvic area (cm2) was significantly larger in older women with prolapse compared to older (60 ± 5.1 vs 53 ± 4.9, P = .004) and younger (60 ± 5.1 vs 52 ± 4.6, P = .001) women with normal support. The younger and older women with normal support did not differ in anterior pelvic area (52 ± 4.6 vs 53 ± 4.9, P = .99). After adjusting for race and body mass index, increased anterior pelvic area was significantly associated with the following: being an older woman with prolapse (ß = 6.61 cm2, P = .004), and interspinous diameter (ß = 4.52 cm2, P = .004). CONCLUSION: Older women with prolapse had the largest anterior area, suggesting that the anterior pelvic area is a novel measure to consider when evaluating women with prolapse. Interspinous diameter, and being an older woman with prolapse, were associated with a larger anterior pelvic area. This suggests that reduced obturator internus muscle size with age may not be the primary factor in determining anterior pelvic area, but that pelvic dimensions such as interspinous diameter could play a role. The measurements were highly repeatable. The high intraclass correlation coefficient indicates that all raters were able to successfully learn the imaging software and to perform measurements with high reproducibility.

The Composition of Hyperacute Serum and Platelet-Rich Plasma Is Markedly Different despite the Similar Production Method.

Autologous blood derived products, such as platelet-rich plasma (PRP) and platelet-rich fibrin (PRF) are widely applied in regenerative therapies, in contrast to the drawbacks in their application, mainly deriving from the preparation methods used. Eliminating the disadvantages of both PRP and PRF, hyperacute serum (HAS) opens a new path in autologous serum therapy showing similar or even improved regenerative potential at the same time. Despite the frequent experimental and clinical use of PRP and HAS, their protein composition has not been examined thoroughly yet. Thus, we investigated and compared the composition of HAS, serum, PRP and plasma products using citrate and EDTA by simple laboratory tests, and we compared the composition of HAS, serum, EDTA PRP and plasma by Proteome Profiler and ELISA assays. According to our results the natural ionic balance was upset in both EDTA and citrate PRP as well as in plasma. EDTA PRP contained significantly higher level of growth factors and cytokines, especially platelet derived angiogenic and inflammatory proteins, that can be explained by the significantly higher number of platelets in EDTA PRP. The composition analysis of blood derivatives revealed that although the preparation method of PRP and HAS were similar, the ionic and protein composition of HAS could be advantageous for cell function.

Technique development and measurement of cross-sectional area of the pubovisceral muscle on MRI scans of living women.

INTRODUCTION AND HYPOTHESIS: Measurements of the anatomic cross-sectional area (CSA) of the pubovisceral muscle (PVM) in women are confounded by the difficulty of separating the muscle from the adjacent puborectal (PRM) and iliococcygeal (ICM) muscles when visualized in a plane orthogonal to the fiber direction. We tested the hypothesis that it might be possible to measure the PVM CSA within a defined region of interest based on magnetic resonance images (MRI). METHODS: MRI scans of 11 women with unilateral PVM tears and seven primiparous women with intact muscles following elective C-section were used to identify the PVM injury zone defined by the mean location of its boundaries with the adjacent intact PRM and ICM from existing anatomic reference points using 3D Slicer and ImageJ software. Then, from the 15 or more 2-mm transverse slices available, the slice with the maximum anatomic CSA of the left and right PVM was found in 24 primiparous women with bilaterally intact muscles who had delivered via C-section. RESULTS: Mean [± standard deviation (SD)] of the maximum left or right PVM cross-section areas for the 24 women, measured by two different raters, was 1.25 ± 0.29 cm2 (range 0.75-1.86). The 5th, 50th, and 95th percentile values were 0.77, 1.23, and 1.80 cm2, respectively. Inter- and intrarater measurement repeatability intraclass correlation coefficients exceeded 0.89 and 0.90, respectively. CONCLUSIONS: It is possible to use MRI to identify the volume of interest with the maximum anatomic cross section of the PVM belly while minimizing the inadvertent inclusion of adjacent PRM or ICM in that measurement.

Serum albumin as a local therapeutic agent in cell therapy and tissue engineering.

Albumin is a major plasma protein that has become ubiquitous in regenerative medicine research. As such, many studies have examined its structure and advantageous properties. However, a systematic and comprehensive understanding of albumin's role, capabilities and therapeutic potential still eludes the field. In the present work, we review how albumin is applied in tissue engineering, including cell culture and storage, in vitro fertilization and transplantation. Furthermore, we discuss how albumin's physiological role extends beyond a carrier for metal ions, fatty acids, pharmacons and growth factors. Albumin acts as a bacteriostatic coating that simultaneously promotes attachment and proliferation of eukaryotic cells. These properties with the combination of free radical scavenging, neutrophil activation and as a buffer molecule already make the albumin protein beneficial in healing processes supporting functional tissue remodeling. Nevertheless, recent data revealed that albumin can be synthesized by osteoblasts and its local concentration is raised after bone trauma. Interestingly, by increasing the local albumin concentration in vivo, faster bone healing is achieved, possibly because albumin recruits endogenous stem cells and promotes the growth of new bone. These data also suggest an active role of albumin, even though a specific receptor has not yet been identified. Together, this discussion sheds light on why the extravascular use of the albumin molecule is in the scope of scientific investigations and why it should be considered as a local therapeutic agent in regenerative medicine. © 2016 BioFactors, 43(3):315-330, 2017.