Long-term sexual function after mid-urethral slings for stress urinary incontinence in women.

INTRODUCTION: There has been increasing concern about potential negative impact of mid-urethral slings (MUS) on sexual life. Our aim was to study sexual activity 10-20 years after MUS surgery and changes in impact of incontinence on sexual life over time and to compare subjective cure, pain, satisfaction, and incontinence between sexually active and inactive women 10-20 years after MUS. MATERIAL AND METHODS: Historical cohort study using the Norwegian Female Incontinence Registry to identify women who underwent MUS between 2001-2006 and 2011-2012. They answered validated questionnaires about sexual activity, incontinence, pain, and satisfaction with MUS. We assessed changes in urinary incontinence during intercourse and compared symptoms and satisfaction between sexually active and inactive women. The study was registered in Clinical Trials (NCT04912830). RESULTS: In total, 1210/1903 (64%) responded. Of women responding to questions about sexual activity, 63% (735/1166) were sexually active. 31.3% experienced negative impact of incontinence on sexual life preoperatively, decreasing to 5.9% at 10-20 years follow-up. A higher proportion of sexually inactive vs sexually active women had urinary incontinence (63.5% vs. 47.5%, aOR 1.60 [1.18-2.17]). In a subanalysis, only urgency and mixed urinary incontinence remained significant. A higher proportion of sexually inactive were dissatisfied with MUS (30.1% vs. 12.9%, aOR 2.53 [1.82-3.51]). Persistent pain after MUS was similar for sexually inactive and active women (4.0% vs. 3.2%, aOR 1.10 [0.55-2.19]). Furthermore, 3.4% of sexually inactive had persistent pain after MUS and stated pain as a reason for not being sexually active, whereas 1.7% of sexually active women had persistent pain after MUS and pain during intercourse. CONCLUSIONS: Negative impact of incontinence on sexual life was less prevalent at 10-20 years follow-up after sling surgery compared to preoperative assessment. A higher proportion of sexually inactive had urgency and mixed urinary incontinence and were dissatisfied with MUS. Only 3%-4% of sexually active and inactive women had persistent pain after MUS and this was not associated with sexual activity. This indicates that incontinence has a greater negative impact on sexual activity than persisting pain after MUS at long-term follow-up.

Pelvic floor status in opera singers. a pilot study using transperineal ultrasound.

BACKGROUND: Control of pelvic floor muscles (PFM) is emphasized as important to obtain functional breath support in opera singing, but there is not much research that proves PFM function as part of breath support in classical singing. Transperineal ultrasound is a reliable method for quantification of PFM contraction in urogynecology. Our aim was to establish if transperineal ultrasound can be used for observation of movement of the PFM during singing and to quantify pelvic floor contraction. METHODS: Cross sectional study of 10 professional opera singers examined with transperineal ultrasound in the supine position at rest and contraction, and standing at rest and during singing. Levator hiatal area was measured in a 3D rendered volume. Levator hiatal anteroposterior (AP) diameter and bladder neck distance from symphysis were measured in 2D images. RESULTS: The AP diameter was shortened from supine rest to contraction (15 mm), standing (6 mm) and singing (9 mm), all p < 0.01. The bladder neck had a non-significant descent of 3 mm during singing. The mean proportional change in AP diameter from rest to contraction was 24.2% (moderate to strong contraction) and from rest to singing was 15% (weak to moderate contraction). CONCLUSIONS: Transperineal ultrasound can be used to examine the PFM during singing. The classically trained singers had good voluntary PFM contraction and moderate contraction during singing. AP diameter was significantly shortened from supine to upright position, with further shortening during singing, confirming that female opera singers contracted their pelvic floor during singing.

Rates of subjective and objective cure, satisfaction, and pain 10-20 years after tension-free vaginal tape (TVT) surgery: A retrospective cohort study.

OBJECTIVE: To evaluate rates of subjective and objective cure, treatment satisfaction, pain, and the correlation between cure and body mass index (BMI), at 10 and 20 years after tension-free vaginal tape (TVT) surgery. DESIGN: Retrospective cohort study. SETTING: Multicentre study including 19 units in Norway. POPULATION: Women undergoing TVT surgery for stress urinary incontinence (SUI) during 2001-2006 (20-year cohort) and 2011-2012 (10-year cohort). METHODS: The Norwegian Female Incontinence Registry was used to identify women eligible for the study, who answered validated questionnaires about urinary incontinence, pain and satisfaction. MAIN OUTCOME MEASURES: Subjective cure of SUI (with stress index of <3, range 0-12), objective cure (<3 g on stress test) and persisting pain and satisfaction after TVT (scored on a five-point Likert scale). RESULTS: In total, 1210 of 1903 (64%) patients responded. The subjective cure rate was 68% after 10 years, versus 59% after 20 years, and did not significantly differ after adjusting for age, BMI, parity and preoperative stress index (adjusted OR 1.27, 95% CI 0.82-1.94). The objective cure rate was 100% versus 93% (P < 0.001), with 89% versus 76% reporting subjective satisfaction (P < 0.001), and with 4.7% versus 2.7% reporting persisting pain (P < 0.001), after 10 versus 20 years, respectively. Women in obesity classes I and II, compared with women of normal weight, had an increased risk of not being subjectively cured (crude OR 2.02, 95% CI 1.42-2.90; OR 2.95, 95% CI 1.60-5.46, respectively). CONCLUSIONS: Tension-free vaginal tape (TVT) provided high rates of subjective and objective cure at 10 and 20 years after surgery, with no significant difference between the two cohorts. Although 3%-5% of women experienced persisting pain, most women were satisfied with TVT surgery. Obesity was associated with a lower cure rate.

Ultrasound examination of the pelvic floor during active labor: A longitudinal cohort study.

INTRODUCTION: There is limited evidence about changes in the pelvic floor during active labor. We aimed to investigate changes in hiatal dimensions during the active first stage of labor and associations with fetal descent and head position. MATERIAL AND METHODS: We conducted a longitudinal, prospective cohort study at the National University Hospital of Iceland, from 2016 to 2018. Nulliparous women with spontaneous onset of labor, a single fetus in cephalic presentation, and gestational age ≥37 weeks were eligible. Fetal position was assessed with transabdominal ultrasound and fetal descent was measured with transperineal ultrasound. Three-dimensional volumes were acquired from transperineal scanning at the start of the active phase of labor and in late first stage or early second stage. The largest transverse hiatal diameter was measured in the plane of minimal hiatal dimensions. The levator urethral gap was measured as the distance between the center of the urethra and the levator insertion using tomographic ultrasound imaging. Measurements of the levator urethral gap were made in the plane of minimal hiatal dimensions and 2.5 and 5 mm cranial to this. RESULTS: The final study population comprised 78 women. The mean transverse hiatal diameter increased 12.4% between the two examinations, from 39.4 ± 4.1 mm (±standard deviation) at the first examination to 44.3 ± 5.8 mm at the last examination (p < 0.01). We found a moderate correlation between the transverse hiatal diameter and fetal station at the last examination (r = 0.44, r2 = 0.19; p < 0.01; regression equation y = 2.71 + 0.014x), and a weak correlation between the change in transverse hiatal diameter and change in fetal station (r = 0.29; r2 = 0.08; p = 0.01; regression equation y = 0.24 + 0.012x). Levator urethral gap increased significantly in all three planes on both the left and right sides. Head position was not associated with hiatal measurements after adjusting for fetal station. CONCLUSIONS: We found a significant, but only modest, increase of the hiatal dimensions during the first stage of labor. The risk of levator ani trauma will therefore be low during this stage. The change in transverse hiatal diameter was associated with fetal descent but not with head position.

Are levator hiatal dimensions in mid-pregnancy associated with mode of delivery?

INTRODUCTION AND HYPOTHESIS: Slow progress of labour is a risk for operative delivery. Smaller levator hiatal dimensions are possible risk factors for slow progress and operative delivery. Our aim was to explore associations between hiatal dimensions antenatally, duration of second stage of labour and mode of delivery. METHODS: Prospective cohort study of 65 nullipara examined at 20 weeks gestation and 6 months postpartum. Levator hiatal anteroposterior diameter and area were measured using 2D/3D transperineal ultrasound and compared between women with normal vaginal delivery and operative delivery (vacuum or caesarean) using t-test and with Spearman's rank to explore correlations with duration of second stage. ROC analysis established a cut-off for high risk of operative delivery. RESULTS: Two-dimensional anteroposterior diameter and 3D hiatal area at rest were smaller in women with operative delivery than with normal delivery, 5.0 cm vs. 5.7 cm, p = 0.007 and 18.5 cm2 vs. 14.9 cm2, p < 0.001. From the ROC curve for 2D anteroposterior diameter, a cut-off of 5.6 cm, (sensitivity = 0.94, specificity = 0.63) and for 3D hiatal area a cut-off of 17.6 cm2 (sensitivity = 0.94, specificity = 0.65) predicted operative delivery. We found inverse correlations between second stage of labour and anteroposterior diameter at rest, r = -0.330, contraction, r = -0.365, area at rest, r = -0.324, and contraction, r = -0.521, all p < 0.05. CONCLUSIONS: Smaller hiatal dimensions at 20 weeks gestation were associated with longer second stage of labour and increased risk of operative delivery in nullipara. A 2D anteroposterior hiatal diameter < 5.6 cm and 3D hiatal area < 17.6 cm2 at rest imply increased risk of operative delivery.

The effect of preoperative pelvic floor muscle training on urinary and colorectal-anal distress in women undergoing pelvic organ prolapse surgery-a randomized controlled trial.

INTRODUCTION AND HYPOTHESIS: Pelvic floor muscle training (PFMT) improves urinary incontinence and mild pelvic organ prolapse (POP). We aimed to investigate the effect of preoperative PFMT on urinary and colorectal-anal distress and related quality of life (QoL) in women with severe POP scheduled for surgery. METHODS: Randomized controlled trial of 159 women scheduled for POP surgery (intervention = 81, controls = 78). Intervention consisted of daily PFMT from inclusion to the day of surgery. Symptoms and QoL were assessed at inclusion, day of surgery and 6 months postoperatively using the Urinary Distress Inventory (UDI-6), Colorectal-Anal Distress Inventory (CRADI-8), Urinary Impact Questionnaire (UIQ) and Colorectal-Anal Impact Questionnaire (CRAIQ) (range 0-100). Mixed model statistical analyses were used. RESULTS: One hundred fifty-one (95%) women completed the study (intervention = 75, controls = 76). Mean waiting times until surgery and follow-up were 22 and 28 weeks. There was no difference in mean postoperative symptom and QoL scores (95% CI) between the intervention and control group: UDI-6 16 (12-21) vs. 17 (13-22), CRADI-8 15 (11-18) vs. 13 (10-16), UIQ 11 (7-15) vs. 10 (6-13) and CRAIQ 5 (2-7) vs. 6 (4-9), all p > 0.05. Overall mean scores were reduced from baseline to postoperative follow-up: UDI-6 37 (33-41) vs. 17 (14-20), CRADI-8 22 (19-25) vs. 14 (11-16); UIQ 28 (24-32) vs. 10 (7-13) and CRAIQ 16 (12-19) vs. 5 (3-7), all p < 0.01. CONCLUSIONS: We found no added effect of preoperative PFMT on symptoms or QoL related to urinary and colorectal-anal distress in women scheduled for POP surgery. They achieved symptomatic improvement postoperatively regardless of PFMT. CLINICAL TRIAL REGISTRATION: The study was registered in clinicaltrials.gov: NCT 03,064,750.

Prevalence of anal sphincter defects and association with anal incontinence in women scheduled for pelvic organ prolapse surgery.

AIMS: Some women with pelvic organ prolapse (POP) have concomitant symptoms of anal incontinence. Our aim was to assess the prevalence of anal sphincter defects and the association with incontinence in women undergoing POP surgery. METHODS: Cross-sectional study of 200 women scheduled for POP surgery. They answered yes/no and graded any symptoms of fecal and flatal incontinence on a visual analog scale (0-100). 3D/4D transperineal ultrasound was used to assess internal (IAS) and external anal sphincter (EAS) defects. A defect of ≥30° in ≥4 of 6 slices on tomographic imaging was regarded significant. The association between incontinence and sphincter defects was tested with multivariable logistic regression analysis. RESULTS: The prevalence of any sphincter defect was 50/200 (25%). Combined IAS/EAS defect was found in 19/200 (9.5%) women, 8/200 (4.0%) had isolated IAS, and 23/200 (11.5%) had isolated EAS defects. In women with defect and intact IAS, 37% and 11% reported fecal incontinence, respectively, adjusted odds ratio (aOR) 2.3 (95% confidence interval [CI], 0.7-7.0), p = .147 and in women with defect versus intact EAS, 36% and 9% had fecal incontinence, aOR 4.0 (95% CI, 1.5-10.8), p = .005. In women with defect and intact IAS, 85% versus 43% reported flatal incontinence, aOR 5.2 (95% CI, 1.6-17.2), p = .007 and in women with defect versus intact EAS, 71% versus 43% had flatal incontinence, aOR 1.9 (95% CI, 0.8-4.5), p = .131. CONCLUSIONS: One of four women scheduled for POP surgery had an anal sphincter defect. EAS defects were associated with fecal incontinence and IAS defects were strongly associated with flatal incontinence.

Is endoanal, introital or transperineal ultrasound diagnosis of sphincter defects more strongly associated with anal incontinence?

INTRODUCTION AND HYPOTHESIS: Our aim was to explore the association between anal incontinence (AI) and persistent anal sphincter defects diagnosed with 3D endoanal (EAUS), introital (IUS) and transperineal ultrasound (TPUS) in women after obstetric anal sphincter injury (OASI) and study the association between sphincter defects and anal pressure. METHODS: We carried out a cross-sectional study of 250 women with OASI recruited during the period 2013-2015. They were examined 6-12 weeks postpartum or in a subsequent pregnancy with 3D EAUS, IUS and TPUS and measurement of anal pressure. Prevalence of urgency/solid/liquid AI or flatal AI and anal pressure were compared in women with a defect and those with an intact sphincter (diagnosed off-line) using Chi-squared and Mann-Whitney U test. RESULTS: At a mean of 23.6 (SD 30.1) months after OASI, more women with defect than those with intact sphincters on EAUS had AI; urgency/solid/liquid AI vs external defect: 36% vs 13% and flatal AI vs internal defect: 27% vs 13%, p < 0.05. On TPUS, more women with defect sphincters had flatal AI: 32% vs 13%, p = 0.03. No difference was found on IUS. Difference between defect and intact sphincters on EAUS, IUS and TPUS respectively was found for mean [SD] maximum anal resting pressure (48 [13] vs 55 [14] mmHg; 48 [12] vs 56 [13] mmHg; 50 [13] vs 54 [14] mmHg) and squeeze incremental pressure (33 [17] vs 49 [28] mmHg; 37 [23] vs 50 [28] mmHg; 36 [18] vs 50 [30] mmHg; p < 0.01). CONCLUSIONS: Endoanal ultrasound had the strongest association with AI symptoms 2 years after OASI. Sphincter defects detected using all ultrasound methods were associated with lower anal pressure.

Levator ani muscle injury and risk for urinary and fecal incontinence in parous women from a normal population, a cross-sectional study.

AIMS: To study possible associations between levator ani muscle (LAM) injury and urinary incontinence (UI) and fecal incontinence (FI) and possible associations between bladder neck descent (BND), urethral funneling, and UI. METHODS: A cross-sectional study of 608 women with first delivery in 1990 to 1997 assessed in 2013 to 2014. The Urinary Distress Inventory (UDI-6) and Colorectal Anal Distress Inventory (CRADI-8) were used to quantify symptoms (range, 0-100). The proportion of women with UI and FI was calculated. LAM injury, BND ≥25 mm, and funneling were diagnosed with transperineal ultrasound. Women with LAM injury, BND, and urethral funneling were compared to those without, using the Mann-Whitney U test (symptom scores) and multiple logistic regression analysis (UI and FI). RESULTS: Four-hundred ninety-three (81%) women had intact LAM and 113 (19%) had LAM injury. They had similar median (range) UDI-6 score 8.3 (0-75) vs 4.2 (0-62.5), P = .35, and CRADI-8 score 6.3 (0-78.1) vs 6.3 (0-62.5), P = .90. Three hundred eleven out of six hundred (52%) women had UI and 65 of 594 (11%) had FI. This was similar for women with intact vs injured LAM; UI 53% vs 49%, P = .67; FI 11% vs 12%, P = .44 and with and without BND; stress UI 42% vs 42%, P = .93; urge UI 29% vs 35%, P = .34. Stress UI was more common in women with urethral funneling (50% vs 40%), odds ratio 1.56 (95% confidence interval: 1.03-2.37), P = .04. CONCLUSION: We found no associations between LAM injury and symptoms of UI and FI 15 to 24 years after the first delivery, but urethral funneling was associated with stress UI.

Comparing the diagnostic accuracy of 3 ultrasound modalities for diagnosing obstetric anal sphincter injuries.

BACKGROUND: The optimal imaging modality of obstetric anal sphincter injuries needs to take into consideration convenience, availability, and ability to assess the sphincter morphologic condition. Endoanal ultrasound imaging currently is regarded as the reference standard, but it is not widely available in obstetric units. Exoanal alternatives exist, such as 3-dimensional introital or transperineal ultrasound imaging, which are already readily available in most obstetrics and gynecology units. OBJECTIVE: The primary objective was to evaluate the diagnostic accuracy of 3-dimensional introital and 3-dimensional transperineal ultrasound imaging compared with 3-dimensional endoanal ultrasound imaging as the reference standard for the detection of anal sphincter defects in women who sustained obstetric anal sphincter injuries. The secondary objective was to correlate a diagnosis of anal sphincter defect on imaging to symptoms of anal incontinence, and to assess patient discomfort that is experienced for each imaging modality. STUDY DESIGN: A cross-sectional study was conducted of 250 women who sustained obstetric anal sphincter injuries, all of whom underwent 3-dimensional introital, transperineal, and endoanal ultrasound imaging. Introital and transperineal ultrasound imaging were assessed with tomographic ultrasound imaging. All of the women completed a validated modified St Mark's Score and Visual Analogue Score for discomfort. Optimal cut-off values for a significant defect on tomographic ultrasound imaging were defined as those with the greatest sensitivity and specificity based on receiver operating characteristic curves with endoanal ultrasound imaging as the reference standard. Diagnostic test characteristics of introital and transperineal ultrasound imaging were calculated with the use of these optimal cut-offs. RESULTS: Optimal cut-off for a significant external anal sphincter defect was ≥3 of 7 slices; sensitivity and specificity were 0.65 and 0.75 on introital imaging and 0.70 and 0.69 on transperineal ultrasound imaging. Optimal cut-off for a significant internal anal sphincter defect was ≥2 of 5 slices; sensitivity and specificity were 0.59 and 0.84 on introital imaging and 0.43 and 0.97 on transperineal ultrasound imaging. The area under the curve for the diagnosis of external and internal anal sphincter defects ranged from 0.70-0.74 (P<.001) for introital and transperineal imaging. Positive predictive value for external and internal sphincter defects ranged from 0.37-0.63, and negative predictive value ranged from 0.85-0.93 for introital and transperineal ultrasound imaging. Endoanal ultrasound imaging was the only modality for a defect to correlate with symptoms; mean modified St. Mark's score for a defect sphincter was 2.4 (standard deviation, 4.1) and for an intact sphincter was 0.9 (standard deviation, 2.7; P<.01). Introital and transperineal ultrasound imaging were associated with less discomfort than endoanal ultrasound imaging. CONCLUSION: Endoanal ultrasound imaging remains the most accurate diagnostic imaging modality. With low positive predictive values, introital and transperineal ultrasound imaging are not suitable for the identification of sphincter defects; however, high negative predictive values show a good ability to detect an intact sphincter. The optimal cut-off number of slices on tomographic ultrasound imaging for external and internal anal sphincters allows for standardization of a significant defect. In women with a history of obstetric anal sphincter injuries, introital and transperineal ultrasound imagings are suitable to screen for an intact sphincter if endoanal ultrasound imaging is not available. When defects are found, women should then have endoanal ultrasound imaging to verify the diagnosis.

Impact of levator muscle avulsions on Manchester procedure outcomes in pelvic organ prolapse surgery.

INTRODUCTION: Levator ani muscle avulsions potentially increase recurrence after anterior colporrhaphies. We aimed at evaluating the impact of avulsions on anatomical and patient-reported outcomes 1 year after the Manchester procedure for primary anterior compartment pelvic organ prolapse. MATERIAL AND METHODS: Prospective cohort study of 189 women undergoing the Manchester procedure between October 2014 and January 2017. Avulsions were diagnosed by transperineal ultrasound. Women with and without avulsions were compared for 1-year postoperative outcomes; Pelvic Organ Prolapse Quantification measurements, subjective satisfaction (1-worse to 4-cured), failure (new prolapse treatment), response to validated questionnaires on pelvic floor distress and sexual function, and a composite outcome (subjectively cured and optimal anterior compartment outcome (stage 0-I)). Optimal mid-compartment outcome was defined as cervix ≥5 cm above the hymen. Factors potentially associated with poor anatomical outcomes (anterior compartment stage ≥II) or pelvic floor distress were analyzed using regression analyses. RESULTS: Fewer women with avulsions (present in 50.8%) obtained optimal mid-compartment outcomes (88.2% vs 77.1%; P = 0.05). The groups were otherwise similar in terms of mid-compartment reduction, anterior compartment results, failure rate, subjective satisfaction, pelvic floor/sexual symptoms, and combined optimal subjective and anatomical outcome. Only preoperative anterior compartment stage ≥III was associated with poor anatomical outcome (P < 0.01). A high preoperative symptom score was associated with a high postoperative symptom score (P < 0.001). CONCLUSIONS: Although fewer women with avulsions obtained optimal mid-compartment results, avulsions had no impact on other anatomical or symptomatic outcomes 1 year after the Manchester procedure for primary anterior compartment prolapse.

Comparison of transperineal ultrasound with POP-Q for assessing symptoms of prolapse.

INTRODUCTION: Our aim was to study any correlation between pelvic organ prolapse quantification (POP-Q) and ultrasound measurement of prolapse in women from a normal population and to identify the method with a stronger association with prolapse symptoms. METHODS: A cross-sectional study of 590 parous women responding to the Pelvic Floor Distress Inventory was carried out. They were examined using POP-Q and transperineal ultrasound, and correlation was tested using Spearman's rank test. Numerical measurements and significant prolapse (POP-Q ≥ 2 in any compartment or bladder ≥10 mm, cervix ≥0 mm or rectal ampulla ≥15 mm below the symphysis on ultrasound) were compared in symptomatic and asymptomatic women (Mann-Whitney U and Chi-squared tests). RESULTS: A total of 256 women had POP-Q ≥ 2 and 209 had significant prolapse on ultrasound. The correlation (rs) between POP-Q and ultrasound was 0.69 (anterior compartment), 0.53 (middle), and 0.39 (posterior), p < 0.01. Women with a "vaginal bulge" (n = 68) had greater descent on POP-Q and ultrasound in the anterior and middle compartments than asymptomatic women, p < 0.01. For women with a symptomatic bulge, the odds ratio was 3.8 (95% CI 2.2-6.7) for POP-Q ≥ grade 2 and 2.4 (95% CI 1.4-3.9) for prolapse on ultrasound. A sensation of heaviness (n = 90) and incomplete bladder emptying (n = 4) were more weakly associated with ultrasound (p = 0.03 and 0.04), and splinting (n = 137) was associated with POP-Q Bp, p = 0.02. CONCLUSION: POP-Q and ultrasound measurement of prolapse had moderate to strong correlation in the anterior and middle compartments and weak correlation in the posterior compartment. Both methods were strongly associated with the symptom "vaginal bulge," but POP-Q had a stronger association than ultrasound.

Levator ani defects and the severity of symptoms in women with anterior compartment pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: The aims of this study were to evaluate the prevalence of levator ani muscle (LAM) avulsions in a selected cohort of patients with primary anterior compartment pelvic organ prolapse (POP) and to assess whether LAM avulsions, as an independent factor, affect the degree of POP symptoms and sexual dysfunction. Additionally, clinical and demographic variables of women with and those without avulsions were compared. METHODS: We carried out a cross-sectional analysis of a prospective cohort study including 197 women scheduled for anterior compartment POP surgery. LAM avulsions were diagnosed on transperineal 4D ultrasound. Preoperative symptom severity and sexual dysfunction were evaluated using validated questionnaires (Pelvic Floor Disability Index [PFDI-20] and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-Short Form 12 [PISQ-12]). Linear regression was performed with avulsion as the main independent variable against total PFDI-20 and domain scores, bulge symptoms, and PISQ-12 score. Clinical and demographic variables for women with and without avulsions were compared using independent samples t test, Mann-Whitney U test or Chi-squared test. RESULTS: The prevalence of LAM avulsions was 50.3%. Avulsions were not associated with symptom severity or sexual dysfunction. "Chronic disease causing pain, fatigue or increased intra-abdominal pressure" was the only independent factor associated with all domains of the PFDI-20. Women with avulsions were younger at presentation, older at their first delivery, had lower BMI, and more often had a history of forceps delivery (p < 0.01). CONCLUSIONS: LAM avulsions were highly prevalent in this preoperative POP cohort. Avulsions were not associated with the severity of POP symptoms or sexual dysfunction. Women with avulsions seem to require fewer additional cofactors for developing POP.

Is bladder neck and urethral mobility associated with urinary incontinence and mode of delivery 4 years after childbirth?

AIMS: To study changes in bladder neck, urethral mobility and urinary incontinence (UI) from pregnancy to 4 years postpartum and demonstrate any association to mode of delivery or presence of levator ani muscle (LAM) injury. Secondly, we aimed to correlate bladder neck and urethral mobility to UI symptoms. METHODS: Prospective study of 180 women, recruited in their first pregnancy and followed up 1 and/or 4 years postpartum. UI symptoms were assessed with a validated questionnaire. All underwent 4D transperineal ultrasound to assess LAM injury, bladder neck descent (BND), retrovesical angle at Valsalva (RVA), and urethral rotation between rest and Valsalva. A mixed model compared changes over time, different delivery modes, and women with and without LAM injury. Spearman's rank correlation tested the correlation of BND, RVA, and urethral rotation to UI symptoms. RESULTS: BND, RVA, and urethral rotation all increased following delivery. From 1 to 4 years postpartum, a larger increase in BND was found for women delivered vaginally with LAM injury, compared to women with intact LAM (P = 0.02) and women with cesarean section (P = 0.046). One year postpartum, BND and RVA correlated to UI symptoms, rs = 0.22, P = 0.01. Four years postpartum, RVA correlated to UI symptoms, rs = 0.19, P = 0.02. CONCLUSIONS: Although bladder neck and urethral mobility increased from pregnancy to 4 years postpartum irrespective of delivery mode, women with LAM injury had larger increase in BND, suggesting that this is important in the pathogenesis of bladder neck mobility and could lead to pelvic floor dysfunction in the long term.

Obstetric anal sphincter injury and incontinence 15-23 years after vaginal delivery.

INTRODUCTION: The primary aim was to study prevalence of obstetric anal sphincter injuries (OASIS) after normal vaginal deliveries (NVD) and operative vaginal deliveries (OVD) with a subgroup analysis of forceps (FD) vs. vacuum deliveries (VD). The secondary aim was to study the association between OASIS and anal incontinence 15-23 years later. MATERIAL AND METHODS: This was a cross-sectional study including 8137 primiparous women in Trondheim, Norway, from 1990 to 1997. The outcome measure was the adjusted odds ratio (aOR) for OASIS between delivery groups. A total of 1122 women responded to a postal questionnaire containing the Colorectal-Anal Distress Inventory (CRADI) in 2013. The aOR for anal incontinence and the difference in CRADI score between women with and without OASIS were calculated. RESULTS: OASIS prevalence was 2% for NVD and 10% for OVD (10% FD, 9% VD). aOR for OASIS was 5.01 (95%CI 3.85-6.51) comparing OVD with NVD. There was no difference between FD and VD (aOR 1.15, 95% CI 0.79-1.67). FD was associated with higher risk of fourth degree perineal tear than VD (aOR 5.08, 95% CI 1.47-17.49). OASIS was associated with increased risk of leakage of well-formed (aOR 8.61, 95% CI 3.08-24.12) and loose stool (aOR 2.75, 95% CI 1.43-5.27) and higher CRADI score (Mann-Whitney U-test, p = 0.01). CONCLUSIONS: OVD was associated with increased risk of OASIS. FD was associated with higher risk of fourth degree perineal tear compared with VD. OASIS was associated with increased risk of anal incontinence and higher CRADI score 15-23 years later.

Association between pelvic floor muscle trauma and pelvic organ prolapse 20 years after delivery.

INTRODUCTION AND HYPOTHESIS: It is known that pelvic floor muscle trauma (PFMT) after vaginal delivery is associated with pelvic organ prolapse (POP) symptoms (sPOP) and signs (POP-Q ≥2) in patient populations. Our aims were to establish the prevalence and investigate a possible association between PFMT and sPOP and POP-Q ≥2 in healthy women 20 years after their first delivery. METHODS: During 2013 and 2014 we conducted a cross-sectional study among 847 women who delivered their first child between 1990 and 1997. Women responded to a postal questionnaire and were offered a clinical examination including prolapse grading and pelvic floor ultrasonography. The main outcome measures were sPOP, POP-Q ≥2 and PFMT, defined by levator avulsion or a levator hiatal area on Valsalva manoeuvre of >40 cm(2) on ultrasonography. RESULTS: Of the 847 eligible women, 608 (72 %) were examined. Data on POP symptoms, POP-Q stage, levator avulsion and levator hiatal area were available in 598, 608, 606 and 554 women, respectively, and of these 75 (13%) had sPOP, 275 (45%) had POP-Q ≥2, 113 (19 %) had levator avulsion and 164 (30%) had a levator hiatal area >40 cm(2). Levator avulsion was associated with POP-Q ≥2 with an odds ratio (OR) of 9.91 and a 95% confidence interval (CI) of 5.73 - 17.13, and with sPOP (OR 2.28, 95% CI 1.34 - 3.91). Levator hiatal area >40 cm(2) was associated with POP-Q ≥2 (OR 6.98, 95% CI 4.54, - 10.74) and sPOP (OR 3.28, 95 % CI 1.96 - 5.50). CONCLUSION: Many healthy women selected from the general population have symptoms and signs of POP 20 years after their first delivery, and PFMT is associated with POP-Q ≥2 and sPOP.