Can pelvic floor trauma be predicted antenatally?

INTRODUCTION: Levator trauma is a risk factor for the development of pelvic organ prolapse. We aimed to identify antenatal predictors for significant damage to the levator ani muscle during a first vaginal delivery. MATERIAL AND METHODS: A retrospective observational study utilizing data from two studies with identical inclusion criteria and assessment protocols between 2005 and 2014. A total of 1148 primiparae with an uncomplicated singleton pregnancy were recruited and assessed with translabial ultrasound at 36 weeks antepartum and 871 (76%) returned for reassessment 3-6 months postpartum. The ultrasound data of vaginally parous women were analyzed for levator avulsion and microtrauma. The former was diagnosed if the muscle insertion at the inferior pubic ramus in the plane of minimal hiatal dimensions and within 5 mm above were abnormal on tomographic ultrasound imaging. Microtrauma was diagnosed in women with an intact levator and if there was a postpartum increase in hiatal area on Valsalva by >20% with the resultant area ≥25 cm2 . RESULTS: The complete datasets of 844 women were analyzed. Among them, 609 delivered vaginally: by normal vaginal delivery in 452 (54%), a vacuum birth in 102 (12%) and a forceps delivery in 55 (6%). Levator avulsion was diagnosed in 98 and microtrauma in 97. On multivariate analysis, increasing maternal age, lower body mass index and lower bladder neck descent were associated with avulsion. Increased bladder neck descent and a family history of cesarean section (CS) were associcated with microtrauma. CONCLUSIONS: Maternal age, body mass index, bladder neck descent and family history of CS are antenatal predictors for levator trauma.

Can we predict urinary stress incontinence by using demographic, clinical, imaging and urodynamic data?

OBJECTIVE: It has been claimed that urethral hypermobility and resting urethral pressure can largely explain stress incontinence in women. In this study we tried to replicate these findings in an unselected cohort of women seen for urodynamic testing, including as many potential confounders as possible. STUDY DESIGN: This study is a retrospective analysis of data obtained from 341 women. They attended for urodynamic testing due to symptoms of pelvic floor dysfunction. We excluded from the analysis women with a history of previous anti-incontinence and prolapse surgery. All patients had a standardised clinical assessment, 4D transperineal pelvic floor ultrasound and multichannel urodynamic testing. Urodynamic stress incontinence (USI) was diagnosed by multichannel urodynamic testing. Its severity was subjectively graded as mild, moderate and severe. Candidate variables were: age, BMI, symptoms of prolapse, vaginal parity, significant prolapse (compartment-specific), levator avulsion, levator hiatal area, Oxford grading, midurethral mobility, maximum urethral pressure (MUP), maximum cough pressure and maximum Valsalva pressure reached. RESULTS: On binary logistic regression, the following parameters were statistically significant in predicting urodynamic stress incontinence: age (P=0.03), significant rectocele (P=0.02), max. abdominal pressure reached (negatively, P<0.0001), midurethral mobility (P=0.0004) and MUP (negatively, P<0.0001). On multivariate analysis, accounting for multiple interdependencies, the following predictors remained significant: max. abdominal pressure reached (negatively, P<0.0001), cough pressure (P=0.006), midurethral mobility (P=0.003) and MUP (negatively, P<0.0001), giving an R(2) of 0.24. CONCLUSIONS: Mid-urethral mobility and MUP are the main predictors of USI. Demographic and clinical data are at best weak predictors. Our results suggest the presence of major unrecognised confounders.

Enlargement of the levator hiatus in female pelvic organ prolapse: cause or effect?

AIM: This study was undertaken to investigate whether female pelvic organ prolapse repair changes levator hiatal biometry. METHODS: Retrospective analysis of clinical and translabial ultrasound volume data of women who underwent prolapse surgery at a tertiary urogynaecological unit between March 2005 and April 2009. Data sets of 81 women were analysed who had undergone an interview, clinical assessment using POP-Q staging and 3D translabial ultrasound before and after prolapse surgery. Imaging data were obtained preoperatively and 3-12 months postoperatively to determine potential changes in levator hiatal dimensions. Type of surgery, mesh use, symptoms of recurrent prolapse, age, significant recurrent prolapse and length of follow-up were tested in linear regression as potential confounders. RESULTS: The mean preoperative hiatal area on Valsalva was 31.9 cm(2) (range 13.5-58.1 cm(2), SD 10.0 cm(2)). Mean postoperative hiatal area on Valsalva was 28.9 cm(2) (range 13.9-47.4 cm(2); SD 7.3 cm(2)), which implies a significant reduction of 9% (P = 0.001). None of the tested potential confounders were found to be significantly associated with a perioperative change in hiatal area on Valsalva on linear regression analysis. CONCLUSIONS: Surgery for female pelvic organ prolapse is associated with a small but significant reduction in hiatal area, but abnormal hiatal distensibility persists in most cases. This suggests that excessive hiatal distensibility is more likely the cause rather than the effect of prolapse.

What's a proper push? The Valsalva manoeuvre revisited.

In daily practice, the Valsalva manoeuvre is used to assess pelvic organ prolapse, virtually always without standardisation of pressure. We undertook a study to determine maximum pressures reached and pressures required to obtain 80% of maximal pelvic organ descent, to investigate the need for such standardisation. Clinical data and ultrasound data sets of 75 women seen for urodynamic testing were reviewed retrospectively, with three Valsalva manoeuvres registered per patient. Maximum rectal pressures generated during Valsalva were 107 cm H (2) O on average (range, 45-190 cm H (2) O). Ninety-seven percent of all women managed to reach pressures ≥60 cm H (2) O. On average, 80% of maximal bladder neck descent was reached at 56 cm H (2) O, 80% of maximal pelvic organ descent at 38 cm H (2) O. Our results imply that virtually all patients were able to generate pressures resulting in ≥80% of maximal pelvic organ descent. This implies that standardisation of Valsalva pressures for prolapse assessment may be unnecessary.

Sonographic detection of puborectalis muscle avulsion is not associated with anal incontinence.

BACKGROUND: The puborectalis muscle is believed to play an important role in anal continence. However, to date, there is very limited evidence to support this hypothesis. AIMS: This study was designed to test for an association between puborectalis trauma and ballooning of the levator hiatus on the one hand and anal incontinence on the other hand. METHODS: The records of 397 women who had attended a tertiary urogynaecological clinic were reviewed in a retrospective study. The history included questions on faecal urgency, soiling, faecal and flatus incontinence. Examination included puborectalis muscle assessment by palpation and 4D pelvic floor ultrasound. RESULTS: Mean age on presentation was 54 (19-89) years. Median vaginal parity was 2 (0-9). Of 397 women, 89 complained of faecal urgency, 65 of faecal incontinence (FI), 67 of soiling and 91 of flatus incontinence. Seventy-seven patients were diagnosed with puborectalis avulsion, of which 38 were bilateral. Puborectalis avulsion was not associated with FI (P = 0.801), faecal urgency (P = 0.894), soiling (P = 0.768) and flatus incontinence (P = 0.187). Hiatal dimensions at rest or on Valsalva were also found not to be associated with symptoms of anal incontinence. CONCLUSIONS: Surprisingly, we found no association between avulsion of the puborectalis muscle and hiatal biometry on the one hand and anal continence on the other hand. These findings argue against a major role of the puborectalis muscle in anal continence.

Levator defects are associated with prolapse after pelvic floor surgery.

OBJECTIVES: Pelvic organ prolapse recurrence after pelvic floor surgery is a common problem. This study was designed to assess whether avulsion defects of the puborectalis muscle are associated with recurrent pelvic organ prolapse and its symptoms. STUDY DESIGN: We retrospectively evaluated 737 data sets of patients who had presented to a tertiary urogynaecology unit with symptoms of pelvic floor dysfunction. All underwent a standardised interview including a surgical history, a clinical examination and 4D pelvic floor ultrasound. Avulsion injury was diagnosed on tomographic ultrasound. The prevalence of pelvic organ prolapse and its symptoms was calculated for patients with previous hysterectomy and previous anti-incontinence and prolapse surgery, with and without confirmed avulsion injury. RESULTS: Out of 737 patients, 248 (33.6%) reported a previous hysterectomy, 165 patients (22.4%) had undergone incontinence or prolapse procedures, 106 (14.4%) reported a previous anterior colporrhaphy, and 45 patients (6.1%) had undergone a colposuspension in the past. In all four groups avulsion injury was significantly associated with objective prolapse (relative risks between 2.3 and 3.3, odds ratios between 3.4 and 6). Symptoms of prolapse were significantly associated with avulsion injury post hysterectomy, incontinence or prolapse procedures and after anterior colporrhaphy. CONCLUSIONS: Avulsion injury of the puborectalis muscle is associated with prolapse in women with previous pelvic floor surgery.