Three-Dimensional Pelvic Floor Ultrasound Assessment of Pelvic Organ Prolapse: Minimal Levator Hiatus and Levator Ani Deficiency Score.

PURPOSE: The purpose of this study was to determine whether levator ani deficiency (LAD) scores and minimal levator hiatus (MLH) areas affect Pelvic Organ Prolapse Quantification (POP-Q) stage. METHODS: This study was a retrospective chart review of patients with pelvic organ prolapse (POP) at Seoul Songdo Hospital between August 2019 and August 2020. Three-dimensional (3D) pelvic floor ultrasound, preoperative anal manometry, and other physiological tests were performed in 78 patients with POP symptoms. We divided the patients into mild prolapse and severe prolapse groups based on the POP-Q. We examined the LAD and MLH areas. LAD scores were categorized as mild, moderate, or severe. RESULTS: There were 32 patients (41.0%) in the mild prolapse group (POP-Q stage I and II) and 46 (59.0%) in the severe prolapse group (POP-Q stage III and IV). The mean LAD score was significantly higher in severe prolapse group (13.33±2.49 vs. 8.19±2.92, P<0.001), and the rate of severe deficiency was also significantly higher in the severe prolapse group (29 [63.0%] vs. 2 [6.3%], P<0.001). The mean MLH was also significantly larger in the severe prolapse group (17.91±2.74 cm2 vs. 14.95±2.60 cm2, P<0.001). In addition, both MLH and LAD scores tended to increase at each stage. CONCLUSION: There is a strong positive correlation between the POP-Q stage and the MLH and LAD scores that can be seen on 3D pelvic floor ultrasound. The findings of this study, by objectively demonstrating LAD and MLH in women with POP, are an important contribution to POP.

Levator plate descent angle in pelvic floor disorders.

BACKGROUND: The levator plate descent angle (LPDA) quantifies the levator plate position with reference to the pubic bone and perineal body at rest. Unfortunately, research on this notable new parameter is lacking, but it is clear that levator ani deficiency (LAD) will undermine the fundamental role of the levator ani muscle (LAM) in organ support. The aim of this study was to establish the relationship between the LPDA and LAD in patients with pelvic floor disorders. METHODS: This retrospective study was conducted at Seoul Songdo Hospital, Korea between August 2019 and August 2020 on women with symptoms of pelvic floor disorder such as urinary incontinence, constipation, and fecal incontinence. In all cases, three-dimensional pelvic floor ultrasound was performed for LAD scoring, minimal levator hiatus, and LPDA evaluation. We evaluated LAD using a scoring system that graded levator injury according to the insertion point of each subdivision scored unilaterally. For the entire LAM group, a cumulative LAD score that ranged between 0 and 18 was possible. Scores were categorized as mild (0-6 points), moderate (7-12 points), and severe (13-18 points) deficiency RESULTS: A total of 93 patients were included in the study (mean age 65.89 ± 11.12 [range, 34-86] years). Thirteen participants had mild LAD scores (14.0%), 42 had moderate LAD scores (45.2%), and 38 had severe LAD scores (40.9%). There was a significant difference in mean age (59.23 ± 12.55 years vs. 64.43 ± 10.03 vs. 69.79 ± 10.55 years, p = 0.005) and mean parity (1.85 ± 0.90 vs 2.48 ± 1.15 vs 2.76 ± 1.10, p = 0.038) of patients between groups. There was also a significant difference in the mean Wexner incontinence score (7.14 ± 3.63 vs 7.24 ± 5.76 vs 11.41 ± 5.54, p = 0.028) and in the mean fecal incontinence quality of life (FIQOL) score (12.91 ± 3.11 vs 14.10 ± 3.87 vs 10.41 ± 3.65, p = 0.014). The mean value of the LPDA in the group with mild LAD scores was 14.65° (SD ± 3.54) and in the group with moderate LAD scores was 9.66° (SD ± 3.36). In the group with severe LAD scores, the mean LPDA was 1.83° (SD ± 4.71). The mean value for minimal levator hiatus (MLH) area in the mild LAD score group was 14.16cm2 (SD ± 2.72), that in the moderate LAD score group was 15.82cm2 (SD ± 2.30), and that in the severe LAD score group was 17.99cm2 (SD ± 2.81). There were significant differences between the three groups both in decreasing LPDA (p < 0.001) and increasing MLH (p < 0.001). There was a negative correlation between the LAD score and LPDA and the Pearson correlation coefficient was -0.528 (moderate correlation). There was a positive correlation between the LAD score and MLH, and the Pearson correlation coefficient was 0.303 (weak correlation). CONCLUSIONS: The LAD score and LPDA have a moderate negative correlation. In patients with severe pelvic floor symptoms and extensive LAM injury, high LAD scores and low LPDA results were confirmed. In the treatment of patients with pelvic floor disorders, the LPDA seems to be a very useful parameter in determining the severity of structural defects.

Comparison of 3-Dimensional Pelvic Floor Ultrasonography and Defecography for Assessment of Posterior Pelvic Floor Disorders.

PURPOSE: The aim of this study was to determine the accuracy of 3-dimensional (3D) pelvic floor ultrasonography and compare it with defecography in assessment of posterior pelvic disorders. METHODS: Eligible patients were consecutive women undergoing 3D pelvic floor ultrasonography at one hospital between August 2017 and February 2019. All 3D pelvic floor ultrasonography was performed by one examiner. A total of 167 patients with suspected posterior pelvic disorder was retrospectively enrolled in the study. The patients were divided into 3 groups according to the main symptoms. RESULTS: There were 82 rectoceles on defecography (55 barium trapping) and 84 on 3D pelvic floor ultrasonography. Each modality identified 6 enteroceles. There were 43 patients with pelvic floor dyssynergia on defecography and 41 on ultrasonography. There were 84 patients with intussusception on defecography and 41 on 3D pelvic floor ultrasonography. Agreement of the 2 diagnostic tests was confirmed using Cohen's kappa value. Rectocele (kappa, 0.784) and enterocele (kappa, 0.654) both indicated good agreement between defecography and 3D pelvic floor ultrasonography. In addition, pelvic floor dyssynergia (kappa, 0.406) showed moderate agreement, while internal intussusception (kappa, 0.296) had fair agreement. CONCLUSION: This study showed good agreement for detection of posterior pelvic disorders between defecography and 3D pelvic floor ultrasonography.

Prospective Comparative Analysis of the Incidence of Vasovagal Reaction and the Effect of Rectal Submucosal Lidocaine Injection in Stapled Hemorrhoidopexy: A Randomized Controlled Trial.

PURPOSE: This study was performed to evaluate the incidence of vasovagal reactions (VVRs) and the efficacy of lidocaine injection for prevention. METHODS: One hundred seventeen patients diagnosed with hemorrhoids and scheduled to undergo a stapled hemorrhoidopexy (SH) were randomly divided according to submucosal injection to the rectum: lidocaine group (n = 53, lidocaine injected just before full closure of the stapler) and control group (n = 58). Outcomes included baseline patient characteristics (American Society of Anesthesiologists physical status classification, body mass index, diabetes mellitus, hypertension, and previous VVR history), vital signs during the operation, incidence of VVRs (hypotension, bradycardia, dizziness, diaphoresis, and nausea/vomiting), and postoperative complications (pain, bleeding, and urinary retention). RESULTS: Baseline characteristics were similar between groups. The number of patients with lower abdominal pain after firing the stapler and incidence of dizziness were lower for the lidocaine group than for the control group (9.4% vs. 25.9%, P = 0.017; 0% vs. 8.6%, P = 0.035, respectively). However, there were no significant between-group differences in incidence of nausea and diaphoresis (0% vs. 3.4%, P = 0.172) and syncope (1.9% vs. 3.4%, P = 0.612). Fewer patients in the lidocaine group complained of postoperative pain (41.5% vs. 58.6%, P = 0.072), and these patients used analgesics less frequently than those in the control group (28.3% vs. 36.2%, P = 0.374). CONCLUSION: Patients who received a submucosal lidocaine injection prior to SH experienced less lower abdominal pain and dizziness compared with those who received standard treatment. A larger, more detailed prospective study is needed for further analysis.

Clinical Study and Review of Articles (Korean) about Retrorectal Developmental Cysts in Adults.

PURPOSE: A retrorectal developmental cyst (tailgut cyst, epidermoid cyst, dermoid cyst, teratoma, and duplication) is very rare disease, and the symptoms are not characteristic so that sometimes this disease is still misdiagnosed as a supralevator abscess or a complex anal fistula. We would like to present a clinical approach to this disease. METHODS: We retrospectively examined the charts of 15 patients who were treated for retrorectal cysts from January 2001 to November 2009. RESULTS: All 15 patients were female. The average age was 41 years (range, 21 to 60 years). Fourteen patients (93.3%) were symptomatic, and the most common symptom was anal pain or discomfort. Nine patients (60%) had more than one previous operation (range, 1 to 9 times) for a supralevator abscess, an anal fistula, etc. In 12 patients (80%), the diagnosis could be made by using the medical history and physical examination. Thirteen cysts (80%) were excised completely through the posterior approach. The average diameter of the cysts was 4.8 cm (range, 2 to 10 cm). Pathologic diagnoses were 8 tailgut cysts (53.3%), 5 epidermoid cysts (33.3%) and 2 dermoid cysts (13.3%). The average follow-up period was 18.3 months (range, 1 to 64 months). CONCLUSION: In our experience, high suspicion and physical examination are the most important diagnostic methods. If a female patient has a history of multiple perianal operations, a retrorectal bulging soft mass, a posterior anal dimple, and no conventional creamy foul odorous pus in drainage, the possibility of a retrorectal developmental cyst must be considered.

Comparison study between electrogalvanic stimulation and local injection therapy in levator ani syndrome.

BACKGROUND AND AIMS: Two theories have been reported for the pathophysiology of levator ani syndrome: the spastic cycle hypothesis and the local inflammation (Tendinitis) hypothesis. This study compared two treatment modalities in order to determine which of the two hypotheses is more appropriate. SUBJECTS AND METHODS: In this prospective study, Group EGS (n=22) underwent electrogalvanic stimulation twice a week. Group LI (n=31) underwent a local injection of a 40-mg triamcinolone acetonide mix with 1 ml 2% lidocaine into the maximal tender point of the arcus tendon in the levator ani muscle. RESULTS: The most common location of tenderness was the left anterior of the arcus tendon of the levator ani muscle. At the last follow-up (12 months), the LI group showed more relief, more improvement, and fewer failures than the EGS group. No difference was seen between the mean pain scores (verbal analog scale: 0-100) of the two groups at either the 1-week or the 12-month follow-up. However, the LI group showed better results at the 1-month, 3-month, and 6-month follow-ups. CONCLUSION: The LI group showed better short-term results than the EGS group. Therefore, the tendinitis hypothesis seems to be the more reliable one for levator ani syndrome. However, because the subjective responses of the patients indicated that a sufficient level of patient satisfaction had not been achieved, we cannot positively conclude that the tendinitis hypothesis is the more reliable one for the pathophysiology of levator ani syndrome.