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The Pelvic Floor Disorders Consortium (PFDC) is a multidisciplinary organization of colorectal surgeons, urogynecologists, urologists, gynecologists, gastroenterologists, radiologists, physiotherap...

This article discusses various pelvic floor ultrasonographic modalities and the clinical applications of ultrasonography of the pelvic floor. Ultrasonography provides a detailed anatomic assessment of the muscles and surrounding organs of the pelvic floor. Different anatomic variabilities and pathologic conditions, such as prolapse, fecal incontinence, urinary symptoms, vaginal wall cysts, synthetic implanted material, and pelvic pain, are assessed with pelvic floor ultrasonography. This imaging modality is an important adjunct to the evaluation and diagnosis of pelvic floor disorders.

OBJECTIVE To determine whether use of an intravaginal motion-based digital therapeutic device for pelvic floor muscle training (PFMT) was superior to PFMT alone in women with stress-predominant urinary incontinence (SUI). METHODS A multicenter, randomized-controlled trial was conducted where women with SUI or SUI-predominant mixed urinary incontinence were treated with either PFMT using the device (intervention group) or PFMT alone (control group). Primary outcomes, measured at 8 weeks, included change in Urinary Distress Inventory, short-version and improvement in the Patient Global Impression of Improvement, defined as "much better" or "very much better." Participants also completed Pelvic Organ Prolapse and Colorectal-anal Distress Inventories, Pelvic-Floor-Impact Questionnaire and a 3-day bladder diary. Primary analysis used a modified intention-to-treat approach. Statistical analysis used Student t test and χ2 test. The trial was prematurely halted due to device technical considerations. RESULTS Seventy-seven women were randomized, and final analysis included 61 participants: 29 in intervention and 32 in control group. There was no statistical difference in Urinary Distress Inventory, short-version scores between the intervention (-13.7 ± 18.7) and the control group (-8.7 ± 21.8; P = 0.85), or in Patient Global Impression of Improvement (intervention 51.7% and control group 40.6%; P = 0.47). Pelvic Organ Prolapse and Colorectal-anal Distress Inventories and Pelvic-Floor-Impact Questionnaire scores improved significantly more in the intervention group than the control group (all P < 0.05). Median number of SUI episodes decreased from baseline to 8 weeks by -1.7 per-day [(-3)-0] in the intervention group and -0.7[(-1)-0] in the control group, (P = 0.047). CONCLUSIONS In this prematurely terminated trial, there were no statistically significant differences in primary outcomes; however, PFMT with this digital therapeutic device resulted in significantly fewer SUI episodes and greater improvement in symptom-specific quality of life outcomes. A larger powered trial is underway.

The Pelvic Floor Disorders Consortium (PFDC) is a multidisciplinary organization of colorectal surgeons, urogynecologists, urologists, gynecologists, gastroenterologists, radiologists, physiotherapists, and other advanced care practitioners. Specialists from these fields are all dedicated to the diagnosis and management of patients with pelvic floor conditions, but they approach, evaluate, and treat such patients with their own unique perspectives given the differences in their respective training. The PFDC was formed to bridge gaps and enable collaboration between these specialties. The goal of the PFDC is to develop and evaluate educational programs, create clinical guidelines and algorithms, and promote high quality of care in this unique patient population. The recommendations included in this article represent the work of the PFDC Working Group on Magnetic Resonance Imaging of Pelvic Floor Disorders (members listed alphabetically in Table 1). The objective was to generate inclusive, rather than prescriptive, guidance for all practitioners, irrespective of discipline, involved in the evaluation and treatment of patients with pelvic floor disorders.

INTRODUCTION AND OBJECTIVE:Women with persistent or recurrent SUI following prior surgical intervention have an unmet medical need with symptoms which substantially impact daily functioning and qua...

INTRODUCTION AND OBJECTIVE:This multicenter Phase 3 study (NCT01893138) evaluated efficacy and safety of AMDC-USR compared to PBO for SUI treatment.METHODS:297 adult women with average 14.4 ± 11.4 ...

Background The occurrence of retained surgical instruments in vaginal surgery, although low, carries unique complications. Appropriate imaging to find retained surgical instruments allows for timely diagnosis and retrieval of the vaginal foreign body. Case The patient is a 33-year-old woman with recurrent cervical cancer who was undergoing radiation therapy. During interstitial implantation, a reverse cutting needle was broken into the anterior vaginal wall. Three-dimensional endoluminal ultrasonography allowed for timely retrieval with minimal surgical exploration in the operating room. Conclusion Intraoperative three-dimensional endoluminal ultrasonography allows for accurate visualization and mapping of a vaginal foreign body. This highlights an innovative and highly useful feature of this imaging technique.

Objectives The objective of this study was to identify differences in pain perception and satisfaction with pain control in women receiving nonsteroidal anti-inflammatory drugs postoperatively. Methods This was a prospective, randomized controlled trial including urogynecology surgical patients. After surgery, all patients were randomized to receive either intravenous (IV) ketorolac or ibuprofen. The patients completed 3 visual analog scales (VAS) assessing pain at rest, pain with ambulation, and satisfaction with pain control. Postoperative opioid use was also measured. Results A total of 224 patients (112 in each arm) were included. Pain scores (SD) at rest in all patients who received ketorolac versus those who received ibuprofen was 2.30 (2.1) versus 2.68 (2.34) (P = 0.20). Pain scores (SD) with ambulation was 3.94 (2.57) versus 4.16 (2.73) (P = 0.57) in patients who received ketorolac and ibuprofen, respectively. Patients who received ketorolac rated their satisfaction with their pain regimen similarly to those who received ibuprofen (P = 0.50). The average amount (SD) of hydromorphone used in the ketorolac and ibuprofen arm was 3.68 (4.58) mg and 4.04 (4.97) mg, respectively (P = 0.58). A subgroup analysis based on type of surgery showed decreased pain at rest (VAS, 2.77 vs 4.88; P = 0.04) and increased satisfaction (VAS, 1.69 vs 4.67; P = 0.003) in patients who had laparotomy and received ketorolac. Conclusions There was no difference in pain and satisfaction with IV ketorolac compared with IV ibuprofen in patients who underwent all modalities of urogynecologic surgery. A subgroup of patients who underwent laparotomy had less pain with ketorolac.

Objective: To determine whether endovaginal ultrasound is a reliable measure in visualization of the sacrospinous ligament among women with prolapse versus women without prolapse, and thus might be clinically applicable in the design of an ultrasound-guided device for performing sacrospinous ligament anchor placement as a treatment for pelvic organ prolapse. Methods: In the first phase of this study we performed a sacrospinous anchor placement in four normal fresh-frozen female pelves. Afterwards, an endovaginal ultrasound was performed to visualize the anchor localization which was validated by dissection of the cadaveric pelves. In the second phase of the study: two groups of volunteer females with and without pelvic organ prolapsed (POP-group, vs NON-POP group) were evaluated by endovaginal ultrasound to localize the sacrospinous ligament. Results: Cadaveric dissection demonstrated accurate anchor placement into the 8/8 sacrospinous ligament. We performed endovaginal ultrasound in a total of 17 N-POP and 10 (POP) patients. Among the N-POP group, the right and left ischial spines were visible in 6/17 (35%) and (6/17) 35% vs 0/10 (0%) for both right and left sides in POP group (p = 0.008). The right sacrospinous ligament was visualized in 4/17 (23%) N-POP subjects and 0/10 POP subjects (p = 0.27) and the left sacrospinous ligament was visualized in 7/17 (41%) N-POP subjects and 2/10 POP subjects (p = 0.48). Conclusions: Sacrospinous ligament and the ischial spines couldn’t be reliably visualized among women with or without pelvic organ prolapse using endovaginal ultrasound, although the structures are visualized more in some of the non-prolapsed women. The sacrospinous anchoring device demonstrated accurate placement by cadaveric dissections.

The complex levator ani anatomy is perhaps best visualized with three-dimensional endovaginal ultrasonography. In this chapter we will investigate imaging of different levator ani subdivisions and their relationship to the levator plate movement and function. We will also address the occurrence of levator ani muscle injury during childbirth and investigate the role of pelvic ultrasound to identify and quantify the amount of birth-related levator ani muscle trauma.

OBJECTIVE: The goal of this study was to evaluate differences in levator ani hematoma formation within 3 days of delivery between adult women after their first vaginal delivery and adult women who have had multiple vaginal deliveries. METHODS: This was a cross-sectional study at a single institution from 2013 to 2015 using a high-resolution endovaginal ultrasound transducer to identify postvaginal delivery hematoma formation. Logistic regression was used to examine the association between hematoma formation and vaginal parity while considering potential confounders including induction, vaginal operative delivery, vaginal birth after cesarean, fetal weight, fetal head circumference, race and ethnicity, body mass index, age at delivery, gestational age, and length of second-stage labor. RESULTS: Ninety women (46 vaginal-primiparous; 44 vaginal-multiparous) were included in this study. After adjusting for oxytocin use, length of second-stage labor, and body mass index, the odds of pelvic floor hematoma of 1000 mm(3) or greater were 2.93 (95% confidence interval, 0.78–10.91) times greater in women after their first vaginal delivery compared with women with a history of multiple vaginal deliveries. The adjusted odds of pelvic floor hematoma of 1500 mm(3) or greater were 6.02 (95% confidence interval, 1.09–33.24) times greater in vaginal-primiparous compared with vaginal-multiparous women. CONCLUSIONS: Although the prevalence of pelvic floor hematoma was higher in vaginal-primiparous women than vaginal-multiparous women after vaginal delivery, hematomas were present in both groups. Future prospective studies are needed to evaluate the additive effect of multiple vaginal deliveries on the pelvic floor.

Objectives The aim of this study was to determine the prevalence of opioid pain medication use among patients presenting for a new visit to the urogynecology clinic compared with those presenting to general gynecology. Methods We identified all patients who presented for new patient visits to the urogynecology and gynecology clinics between January 1, 2016, and December 31, 2016. Any previous or current opioid use was extracted from the electronic medical record medication list. Statistical analysis was performed using χ and Fisher exact tests for comparisons of categorical variables. Modified Poisson regression models were used to estimate prevalence proportion ratios (PPRs). Results There were 1835 (955 gynecology, 880 urogynecology) patients included. Median age was 47 years (interquartile range, 29 years), and median body mass index was 28.15 kg/m (interquartile range, 9.96 kg/m). Prevalence of opioid use was lowest among women who identified as Asian or other race and highest among black and Native American women; however, when compared by ethnicity, use was lowest among Hispanic women (P = 0.01). Among new urogynecology patients, 14% had self-reported opioid pain medication usage. Opioid use was almost twice as likely in the urogynecology group (PPR, 1.86; 95% confidence interval, 1.4-2.4). When adjusted for confounders, the urogynecology group was 1.3 times as likely to report opioid use (PPR 1.29; 95% confidence interval, 1.0-1.8), with this result approaching statistical significance. Conclusions Opioid use is greater in patients presenting to the urogynecology clinic compared with general gynecology. Urogynecologists need to know this information for planning and optimizing pain management in this population.

OBJECTIVE The objective of this study was to investigate the ultrasound characteristics of vaginal mesh in women with vaginal mesh complications. METHODS This was a cross-sectional study of women presenting with extrusion complications from vaginal mesh kit for prolapse at our tertiary care center between years 2009 and 2014. We included women who concurrently underwent a 3-dimensional endovaginal ultrasound (EVUS) as part of the clinical evaluation. We excluded women with incomplete charts and poor imaging quality. Subjects were categorized by the presence or absence of associated pelvic pain. Based on ultrasound findings, we compared the location of mesh, the appearance of mesh pattern (flat, folding, prominence, convoluted), and other EVUS characteristics of mesh. RESULTS Forty-six women with vaginal mesh complications and good image quality were included. When comparing mesh length between posterior and anterior compartments, the posterior meshes were significantly longer than the anterior meshes (42.1 [SD, 11.9] mm vs 25.8 [SD, 9] mm; P < 0.0001) and more often associated with pain. In the posterior compartment, the mean mesh length seen on EVUS was significantly longer in women with pain than in women without pain (46.5 [SD, 9] mm vs 31.8 [SD, 12.1] mm; P = 0.0001). There was also a higher proportion of a "flat" mesh pattern, 14 (58.3%) of 25, in the posterior compartment associated with the presence of pain (P = 0.013). In the posterior compartment, a smaller distance between the distal edge of the mesh and the anal sphincter was significantly associated with the presence of pain (8 mm [0-37] vs 21 mm [8-35], P = 0.024). In both compartments, the EVUS had 100% sensitivity for detection of mesh extrusions. CONCLUSIONS In this population of patients presenting with mesh complications, the posterior meshes were more often visualized as a "flat" pattern with a higher frequency of pain. Mesh complications of the anterior compartment had a higher frequency of folding and shrinkage.

Objective To investigate the association between the minimal levator hiatus (MLH) area at rest with its surrounding soft-tissue and bony structures in nulliparous asymptomatic women with a normal levator ani muscle. Methods A subanalysis was undertaken of a prospective study of the appearance of the levator ani in asymptomatic nulliparous women conducted between September 2010 and September 2011. The subanalysis included women with a normal levator ani muscle. Three-dimensional ultrasonography volumes were used to obtain pelvic floor measurements. Results The analysis included 56 women with mean age of 43.0 ± 13.4 years. The mean MLH area was 13.1 ± 1.8 cm2 (range 9.0–17.3). The pubic arch angle had no influence on the MLH area (Pearson correlation coefficient r = 0.13). Height and pubic arch length were positively correlated with the MLH area (r = 0.26 [P = 0.52] and r = 0.50 [P Conclusion The MLH size of nulliparous women varied widely and was positively correlated with the height and pubic arch length of the women. Therefore, caution is warranted when interpreting the MLH area as an indicator of a levator ani defect or a predictor of pelvic organ prolapse without taking a woman’s pelvic bone characteristics into account.

Objectives To use 3-dimensional endovaginal ultrasound to describe the location and distribution of bulking agent after an uncomplicated transurethral injection. Methods Endovaginal ultrasound was performed in 24 treatment-naive patients immediately after bulking agent was injected. The distance between the center of the hyperechoic density of bulking agent and the urethrovesical junction (UVJ) was measured in the sagittal and axial views. This was calculated in percentile length of urethra. Also, the pattern of tracking of bulking agent was assessed if it is presented. Results After the 2 subjects were excluded because of the poor quality of images, 22 patients were included in this study. Eighteen (82%) subjects showed 2 sites of bulking agents, and mostly, they were located around 3- and 9-o'clock positions. The average distance of bulking agent from left UVJ was at 16.9% of the length of the urethra (6.2 mm; range, 0.5-17 mm) and at 25.5% of the length of the urethra (8.9 mm; range, 0-24.8 mm) in the right side. The average length of urethra was 36.7 mm. Eleven of the 22 subjects (50%) had both sides within upper one third of urethra. The difference in distance between the 2 sides was less than 10 mm in 12 of 22 patients (54%). Nine of the 22 patients (41%) had a significant spread of bulking agent mostly either into the bladder neck or toward the distal urethra. Conclusions Although the bulking agent is most often found at 3- and 9-o'clock positions as intended, the distance from the UVJ is highly variable after an uncomplicated office-based transurethral injection. The bulking material does not form the characteristic spheres in 41% of cases and tracks toward the bladder neck or the distal urethra.

Introduction and Hypothesis To compare magnetic resonance imaging (MRI) to 3D endovaginal ultrasound (EVUS) in the evaluation of major levator ani defects in women with pelvic floor disorders. Methods A total of 21 subjects with pelvic floor with complaints of pelvic floor disorders were included in this study. EVUS imaging of the levator ani muscle (LAM) was performed in all subjects, and the LA muscle groups of interest evaluated were the puboanalis (PA), puborectalis (PR), and pubovisceralis (PV) muscles. The right and left subdivisions were evaluated separately, and classified as (i) normal, normal with only minor irregularities, grossly abnormal, or absent, or (ii) by the levator ani deficiency (LAD) score and classified by no defect (complete attachment of muscle to the pubic bone), 50% detachment or loss, and completely detached or complete muscle loss. Paired data were analyzed with McNemar's test or Bowker's test of symmetry. Results When unilateral LAM subdivisions were classified as “normal,” “normal with minor irregularity,” “grossly abnormal,” and “absent,” there were no significant differences between MRI and EVUS by categorization of LAM defects. Comparing “normal” versus “abnormal,” there was no difference between imaging modalities. When compared by LAD score evaluation, there were no differences in the categorization of unilateral defects between MRI and EVUS. Conclusions Endovaginal 3D US is comparable to MRI in its ability to identify both normal and abnormal LAM anatomy. Neurourol. Urodynam. © 2015 Wiley Periodicals, Inc.

OBJECTIVE: The aim of this study was to characterize clinical success, impact on quality of life, and durability up to 1 year in women with fecal incontinence (FI) responsive to an initial test period with a trial vaginal bowel control system. METHODS: This was a prospective open-label study in subjects with FI and successfully fit who underwent an initial 2-week trial period. Those achieving 50% or greater reduction in FI episodes were provided the long-term system. Primary outcome was success at 3 months defined as 50% or greater reduction in baseline FI episodes, also assessed at 6 and 12 months. Secondary outcomes included symptom impact measured with Fecal Incontinence Quality of Life scale, symptom severity by the St Mark’s (Vaizey) questionnaire, Patient Global Impression of Improvement, and satisfaction. Adverse events were collected. Primary analysis was intention to treat (ITT). RESULTS: Seventy-three subjects with baseline mean of 14.1 ± 12.15 FI episodes over 2 weeks entered the treatment period. Success rate at 3 months was 72.6% (53/73, P < 0.0001); per-protocol, 84.1% (53/63, P < 0.0001). Significant improvement in all Fecal Incontinence Quality of Life subscales and St Mark’s questionnaire meeting minimally important differences was noted. Satisfaction was 91.7%, 89.7%, and 94.4% at 3, 6, and 12 months, respectively; 77.4%, 77.6%, and 79.6% were very much/much better on the Patient Global Impression of Improvement at 3, 6, and 12 months, respectively. Most common adverse event was vaginal wall injury, with most adverse events (90/134, 67%) occurring during fitting period. CONCLUSIONS: In women with successful fitting and initial treatment response, durable efficacy was seen at 3, 6, and 12 months by objective and subjective measures, with favorable safety.

OBJECTIVES To compare digital palpation with levator plate lift measured by endovaginal and transperineal dynamic sonography. METHODS Dynamic transperineal and endovaginal sonographic examinations were performed as part of multicompartmental pelvic floor functional assessment. Patients were instructed to perform Kegel contractions while a probe captured a video clip of levator plate movement at rest and during contraction in a 2-dimensional midsagittal posterior view. We measured the distance between the levator plate and the probe on endovaginal sonography as well as the distance between the levator plate and the gothic arch of the pubis on transperineal sonography. The change in diameter (lift) and levator plate lift ratio (lift/rest × 100) were calculated. Pelvic floor muscle strength was assessed by digital palpation and divided into functional and nonfunctional groups according to the Modified Oxford Scale. Mean differences in levator plate upward lift were compared by Modified Oxford Scale scores using Student t tests and analysis of variance. RESULTS Seventy-four women were available for analysis. The mean age was 55 (SD, 11.9) years. When measured by vaginal dynamic sonography, mean lift and lift/rest ratio values increased with increasing Modified Oxford Scale score (analysis of variance, P= .09 and .04, respectively). When scores were categorized to represent nonfunctional (0-1) and functional (2-5) muscle strength groups, the mean lift (3.2 versus 4.6 mm; P = .03) and lift/rest ratio (13% versus 20%; P = .01) values were significantly higher in women with functional muscle strength. All patients with lift of 30% or greater detected by vaginal sonography had functional muscle strength. CONCLUSIONS A greater levator plate lift ratio detected by dynamic endovaginal sonography was associated with higher muscle strength as determined by the Modified Oxford Scale. This novel measurement can be incorporated into sonographic evaluation of levator ani function.

As the US population continues to age, the impact of pelvic floor trauma and the sequelae of these injuries will continue to be a common place for the practicing gynecologist. In this review, the authors will highlight pertinent pelvic floor muscular anatomy, explain basic pelvic floor biomechanics, identify mechanisms of pelvic floor birth injury, discuss pelvic floor muscle recovery and birth injury sequelae, review methods of birth injury prevention, and specify future directions of birth related pelvic floor injury research.

OBJECTIVE To analyze the characteristics of providers performing stress urinary incontinence (SUI) and pelvic organ prolapse (POP) procedures in the United States. METHODS The Centers for Medicare Services public database, released for years 2012 through 2014, was queried for SUI-related and POP-related Healthcare Common Procedure Coding System. Providers were categorized as Female Pelvic Medicine and Reconstructive Surgery (FPMRS) providers and non-FPMRS providers, using a list of FPMRS board-certified providers compiled through the American Board of Medical Subspecialties website. Other physician specialties that submitted SUI and POP procedures claims were tabulated. RESULTS Six hundred twenty-nine FPMRS and 833 non-FPMRS providers submitted claims for SUI and POP procedures. The SUI procedures claims had the following provider specialty distribution: obstetrics and gynecology (OB/GYN)-FPMRS, 46.7%; urology, 26.3%; OB/GYN, 12.2%; and urology-FPMRS, 13.9%, with the remaining 0.9% being performed by other specialties. The POP procedures had the following specialty distribution: OB/GYN-FPMRS, 63.4%; OB/GYN, 16.7%; urology, 8.3%; and urology-FPMRS, 7.1%, with the remaining 4.5% being performed by other specialties.Provider distribution was compared between transvaginal mesh and sling insertion procedures to transvaginal mesh and sling removal procedures. The FPMRS providers claimed 63.6% of sling and transvaginal mesh insertion procedures and performed 84.9% of mesh and sling removal procedures. CONCLUSIONS Medicare reimbursement data provides a unique insight into the distribution of provider specialties performing SUI-related and POP-related procedures in the Medicare population. The OB/GYN-FPMRS providers submitted the majority of claims for SUI and POP procedures from 2012 to 2014. The FPMRS providers are also performing the majority of mesh removal procedures.

Objectives The aims of this study were to determine the association between x-ray funneling and ultrasound urethral sphincter complex measurements and to compare the reliability of funneling versus urethral volume measurement in the detection of intrinsic sphincter deficiency (ISD). Methods This was a retrospective analysis, which included 54 stress incontinent women dichotomized into those with (1) ISD and (2) no ISD. The presence of bladder neck funneling was diagnosed by fluoroscopic images obtained at the time of video-urodynamics testing. Measurements of the urethral sphincter complex were obtained from ultrasound volumes. Reliability measures were obtained for both funneling and urethral volume measurements. Results Rhabdomyosphincter length and area were found to be smaller in patients with funneling compared with those with no funneling (P = 0.0161, P = 0.0359). The urethral volume was significantly smaller in the ISD versus no-ISD group (P = 0.0002). For those who had funneling, the ISD group had smaller urethral volume compared with the no-ISD group (P = 0.0019). For those who did not have funneling, the ISD group still had a smaller urethral volume compared with the no-ISD group (P = 0.0054). An ultrasound urethral volume of less than 3.5 cm had a sensitivity of 81% and a specificity of 64% for the presence of ISD, whereas x-ray funneling had a sensitivity of 76% and a specificity of 73%. Conclusions Smaller rhabdomyosphincter length and area on ultrasound are associated with x-ray funneling. Ultrasound urethral volume of 3.5 cm as a cutoff provides the same reliability as x-ray funneling for the diagnosis of ISD.

Introduction and hypothesis Three-dimensional endovaginal ultrasound has been used for evaluation of levator ani muscle deficiency. The aim of this study was to assess interrater agreement/reliability of 3D endovaginal ultrasound for scoring levator ani deficiency (LAD).

Aims Measurements such as the minimal levator hiatus dimension, levator plate angle, iliococcygeal angle, and anorectal angle have been used for assessing the impact of levator damage on static and dynamic imaging features. The primary aim of this study was to investigate the association between levator ani muscle deficiency (LAD) and the position of the levator plate. Methods 3D endovaginal ultrasounds of 186 women were reviewed. The levator ani muscle groups, the puboanalis, puborectalis, and pubovisceralis, were scored for abnormalities, (0 no defect and 3 total absence of the muscle). The levator plate descent angle, minimal levator hiatus dimensions, and the anorectal angle were measured. Levator plate descent towards the perineum was assessed and correlated with levator ani muscle deficiency. Results The correlation between puborectalis scores and minimal levator hiatus area, anorectal angle and levator plate descent angle were 0.43 (P

Our aim was to determine the association between visualizing periurethral structures in the midsagittal plane with 3D endovaginal ultrasonography (EVUS) and stress urinary incontinence (SUI) status. In a cross-sectional study, we measured urethral length and scored for presence or absence of the following in midsagittal plane in patients with and without stress SUI: striated urogenital sphincter, longitudinal/circular smooth muscle, vesical trigone, trigonal plate, trigonal ring, and compressor urethra. Summary statistics were calculated for the study population. Fisher’s exact test was used to compare continuous data. Categorical data was compared with the chi-square. Data from 161 patients was available for review. Mean patient age was 54.4 [±15.6 standard deviation (SD)] years, and median parity was two (range 0–5). Among these women, 137/161(85 %) did not have SUI and 24/(15 %) did; 20/161 (12 %) had anterior-compartment prolapse stage 2 or greater, and among them, only two had urinary incontinence (UI). No association was found between UI and visualization of the periurethral structures. Mean urethral lengths did not differ between groups (p = 0.37). Visualization of periurethral structures by 3D EVUS in the midsagittal plane is not associated with SUI status.

Objective To determine the muscles comprising the minimal levator hiatus. Design Cross-sectional study. Setting The University of Oklahoma Health Sciences Center, USA. Population Eight female fresh frozen pelves and 80 nulliparouswomen. Methods Three-dimensional endovaginal ultrasound was performed in eight fresh frozen female pelves. The structures of the levator hiatus were tagged with needles and the cadavers were dissected to identify the tagged structures. A group of 80 nullipara underwent 3D endovaginal ultrasound, and the minimal levator hiatus area, puborectalis area, and anorectal angle were assessed, and normal values were obtained. Main outcome measures Anatomic borders of minimal levator hiatus and normality in pelvic floor measurements. Results The pubococcygeus forms the inner lateral border and anterior attachment of the minimal levator hiatus to the pubic bone. The puboanalis fibres are immediately lateral to pubococcygeus attachments. There are variable contributions of the puborectalis fibres lateral to the puboanalis attachment. The posterior border of the minimal levator hiatus is formed by the levator plate. Eighty community-dwelling nulliparous women underwent 3D endovaginal ultrasound. The median age was 47 years (range 22–70 years). The mean of minimal levator hiatus and puborectalis hiatus areas were 13.4 cm2 (±1.89 cm2 SD) and 14.8 cm2 (±2.16 cm2 SD). The mean anorectal and levator plate descent angles were 156° (±10.04° SD) and 15.9° (±8.28° SD). Conclusion Anterior and lateral borders of the minimal levator hiatus are formed mostly by pubococcygeus. The puborectalis, pubococcygeus, and iliococcygeus form the bulk of the levator plate.

Pelvic floor disorders such as urinary incontinence, pelvic organ prolapse and anal incontinence affect women of all ages and are strongly associated with a significant economic burden and detriment to a woman’s quality of life. Clinical and epidemiologic findings indicate that women who undergo vaginal childbirth are at an increased risk of developing pelvic floor disorders. Trauma to the pelvic floor in the process of vaginal childbirth is common, yet symptomatic development of pelvic floor disorders is difficult to predict. Imaging modalities have provided further information as to the mechanism of pelvic floor trauma, yet the effects of mode of delivery and other modifiable risk factors to implement secondary prevention methods need further investigation.

This article discusses the background and appraisal of endoluminal ultrasound of the pelvic floor. It provides a detailed anatomic assessment of the muscles and surrounding organs of the pelvic floor. Different anatomic variability and pathology, such as prolapse, fecal incontinence, urinary incontinence, vaginal wall cysts, synthetic implanted material, and pelvic pain, are easily assessed with endoluminal vaginal ultrasound. With pelvic organ prolapse in particular, not only is the prolapse itself seen but the underlying cause related to the anatomic and functional abnormalities of the pelvic floor muscle structures are also visualized.

We used direct histologic comparison to validate the use of 3D endovaginal ultrasound (EVUS) as a novel and emerging technology for evaluating the structures found in the anterior and posterior pelvic floor compartments.A young nulliparous female pelvis specimen was dissected and histologic slides were prepared by making 8-Micron-thick sagittal cuts. The slides were stained with Mallory trichrome and arranged to form large sections encompassing each anterior and posterior sagittal plane. Healthy nulliparous women underwent 3D EVUS to obtain 3D cubes of the anterior and posterior compartments. Two investigators independently evaluated the anterior and posterior midsagittal structures. The investigators mutually viewed the images and calculated urethral and anal sphincter measurements.Thirty-one nulliparous women underwent 3D EVUS; 77% of the participants were Caucasian, with mean age 31.8 [standard deviation (SD) 5.8] and mean body mass index (BMI) of 28.5 (SD 7.9). The following mean (SD) measurements were obtained: urethral length 36 mm (± 5); striated urogenital sphincter area 0.6 cm(2) (± 0.16); longitudinal and circular smooth muscle area 1.1 cm(2) (± 0.4); urethral complex width 14 mm (± 2); urethral complex area 1.3 cm(2) (± 0.4); internal anal sphincter length 26 mm (± 4); internal anal sphincter thickness 3.2 mm (± 0.8); and rectovaginal septum length 31 mm (± 5). The agreement for visualization of structures was as follows: vesical trigone 96% (κ = 0.65), trigonal ring 94% (κ = 0.8), trigonal plate 84% (κ = 0.6); longitudinal and circular smooth muscle 100%; compressor urethra 97% (κ = 0.85); striated urogenital sphincter 97% (κ = 0.85); rectovaginal septum 100%; internal anal sphincter 100%; external anal sphincter subdivisions 100%.Three-dimensional EVUS can be used to visualize structures of the anterior and posterior compartments in nullipara.

We sought to describe maternal satisfaction with childbirth among women planning either cesarean or vaginal birth. We enrolled primiparous women planning cesarean birth and a comparison group planning vaginal birth. After delivery, the maternal subjective experience was assessed with a visual analogue satisfaction scale and the Salmon questionnaire, with scale scores for these aspects of the maternal experience of birth: fulfillment, distress, and difficulty. The sample included 160 women planning vaginal birth and 44 women planning cesarean. Eight weeks postpartum, women planning cesarean reported higher satisfaction ratings ( P = 0.023), higher scores for fulfillment ( P = 0.017), lower scores for distress ( P = 0.010), and lower scores for difficulty ( P < 0.001). The least favorable scores were associated with unplanned cesarean ( N = 48). Women planning cesarean reported a more favorable birth experience than women planning vaginal birth, due in part to low satisfaction associated with unplanned cesarean. Maternal satisfaction with childbirth may be improved by efforts to reduce unplanned cesarean, but also by support for maternal-choice cesarean.

We sought to compare rates of recurrent cystocele following sacrocolpopexy with and without paravaginal repair (PVR). This retrospective cohort study compared outcomes for patients undergoing sacrocolpopexy with (group A) and without (group B) concomitant PVR. Defining anterior failure as point Ba ≥ −1 cm, we compared anatomic outcomes and reoperation rates for recurrence of cystocele. One hundred seventy patients undergoing sacrocolpopexy had anterior wall prolapse at or beyond the hymen before surgery (62 in group A and 108 in group B). Ten (16.1%) patients in group A and 29 (26.9%) in group B experienced anterior wall prolapse to or beyond −1 cm (p = 0.13, power 0.38). Among these groups, one (1.6%) and five (4.6%) underwent reoperation for cystocele recurrence (p = 0.42, power

We sought to compare the complications and efficacy of tension-free vaginal tape (TVT) and Pelvilace. Chart reviews and telephone questionnaires documented complications, urinary symptoms [Urogenital Distress Inventory short form (UDI-6) and Patient Global Impression of Improvement (PGII)], and re-operations. Failure was defined as PGII > or = 4 (no change or worse) or reoperation for urinary incontinence. There were 91 TVT and 22 Pelvilace slings. The TVT group had lower rates of urinary retention beyond 1 week (8% vs. 43%, p < 0.001) and reoperation for retention (1% vs. 19%, p < 0.001). Median changes in UDI-6 scores were -33.3 for the TVT group and -29.6 for the Pelvilace group (p = 0.21). Median PGII scores were 1 for the TVT group and 2 for the Pelvilace group (p = 0.024). Ten percent of the TVT group and 24% of the Pelvilace group (p = 0.095) were failures. Urinary retention was more common after Pelvilace than TVT slings. Symptomatic outcomes and failure rates were similar.

To investigate perioperative complications of mesh removal performed in the operating room from a single-site, tertiary care center with a large volume of referrals for mesh removal and to compare the morbidity associated with single-compartment mesh removal compared with removal from multiple vaginal compartments.A retrospective review was performed on all patients who underwent mesh removal from January 2008 to April 2014. Patients were identified based on Current Procedural Terminology codes for removal of vaginal mesh or sling. Summary statistics were calculated for the patient population. Complications were compared between single-compartment mesh removal surgery and multicompartment mesh removal surgery. A P value of.05 was considered significant for all analyses.During a 75-month period, a total of 398 procedures were performed for the removal of vaginally placed mesh. A total of 326 (82%) patients underwent single-compartment surgery, 48 (12%) underwent multicompartment surgery, and in 26 (6%), the type of surgery was unclear. The indications for mesh removal included: pain (63%), dyspareunia (57%), mesh exposure (54%), and voiding dysfunction (39%). The mean length of mesh removed was 4 cm (standard deviation±2.8). Those with multicompartment surgery had approximately three times higher estimated blood loss compared with single-compartment surgery (P.001). The odds of blood transfusion after multicompartment surgery were more than nine times higher than the odds of transfusion after a single-compartment surgery (odds ratio 9.7, 95% confidence interval 2.1-44.6; P.01).Bleeding complications are higher with concomitant removal of mesh from multiple vaginal compartments.III.

Objectives: The objectives of this study were to review the recent literature on surgical pain management strategies and to identify those pertinent to urogynecologic surgery. Methods: A literature search using Pubmed and MEDLINE was performed for trials on pain management in gynecologic surgery. Evidenced-based recommendations for preoperative, intraoperative, and postoperative pain control strategies for gynecologic procedures by various surgical routes were identified. Articles specifically describing urogynecologic procedures were sought, but quality, randomized trials on pain management modalities in other gynecologic procedures were also included. Results: Although few randomized trials on pain management strategies in urogynecologic surgery exist, quality evidence suggests that several preemptive and multimodal analgesia strategies reduce pain and opioid-related adverse events in abdominal, laparoscopic, and vaginal surgery. Evidence supporting these strategies is outlined. Many are likely applicable to urogynecologic procedures. Conclusions: Evidence guiding pain management in specific urogynecologic procedures is sparse and should be sought in future studies. When possible, procedure-specific strategies, including preemptive and multimodal techniques, should be implemented.

We aimed to evaluate the association between obstructive defecatory symptoms in women with levator ani deficiency (LAD), worsened minimum levator hiatus measurements, widened anorectal angle (ARA), and increased levator-plate descent angle (LPDA).Using a cross-sectional study design, patients who had undergone 3D endovaginal ultrasound (3D EVUS) imaging of the pelvic floor were sampled and categorized into two groups: those with and those without obstructive defecatory symptoms (ODS) based on their Colorectal and Anal Distress Index (CRADI-8) questionnaire. The levator ani (LA) muscle was scored based on severity of defect. ARA and LPDA were measured and dichotomized (ARA ± 170°; LPDA ± 9°.One hundred patients were analyzed: 52 asymptomatic and 48 with ODS. The mean (standard deviation ) age was 59 years (SD ±14.97). There was no difference in the distribution of LAD severity between groups (p = 0.1438) or mean minimal levator hiatus (MLH) (p = 0.3326). ARA and LPDA were significantly different in those with ODS compared with their asymptomatic counterparts (p 0.0001 and 0.0004, respectively) (Table 1). On multivariable logistic regression, ARA and LPDA were included in the final model. Patients with an ARA170° had seven times the odds of ODS than those with ARA ≤170° [odds ratio (OR) = 7.01, 95 % confidence interval (CI) 2.30-21.35; p = 0.0006). Patients with an LPDA9° had 3 times the odds of ODS than those with an LPDA ≥9° (OR = 3.30, 95 % CI 1.22, 8.96, p = 0.0190).This study demonstrates that increased levator plate descent and widened ARA as measured on 3D endovaginal ultrasound imaging are associated with ODS.

The aim of our study was to determine the accuracy of a new three-dimensional (3D) endoluminal ultrasound probe in assessing the levator ani muscle and anal sphincter complex. A total of 85 patients who had undergone concurrent 3D endovaginal (EVUS) and 3D endoanal (EAUS) ultrasound with both the standard BK 2052 probe and the new high-definition BK 8838 probes were included. For EVUS volumes, the levator ani deficiency (LAD) scores were calculated for each probe. For the EAUS volumes, any defects in the external anal sphincter (EAS) and the internal anal sphincter (IAS) visualized with each probe were recorded. The 3D volumes were evaluated in a blinded fashion. Appropriate statistics were utilized to assess absolute agreements between each pair of imaging modalities. The mean age of the patient population was 59 years ( SD ± 10.76), the mean body mass index (BMI) was 28.36 ( SD ± 5.99), and the median parity was 2 (range 1, 7). In all, 93% of the patients were Caucasian, 31% had stage 0 or 1 prolapse, while 59% had stage 2 prolapse. The mean total LAD score obtained on EVUS with the standard and the new probes were 11.49 ( SD ± 4.94) and 11.53 ( SD ± 5.01), respectively, p = 0.3778. Among the 53 patients who had EAUS with both probes, exact agreement for visualization of EAS and IAS for the standard and the new probes was 83% and 98%, respectively. Both transducers can be used for endovaginal imaging of the levator ani muscles interchangeably. Both transducers can be used for endoanal imaging of anal sphincter complex interchangeably.

Objective This study aimed to pilot a cystoscopy training program for community gynecologists that is validated by posttraining examination. Methods Twenty-eight gynecologists were trained to perform cystoscopy using a competency-based training approach. Baseline information included years in practice and number of incontinence procedures and/or cystoscopies performed per month. Three 5-hour workshops were administered that included applied practice. After learners individually trained until they felt comfortable with their skills on a model, they were individually tested on a cadaver. Performance was evaluated with 2 instruments, namely, a task-specific checklist and a global rating scale based on the objective structured assessment of technical skill model. Failure was defined as inability to independently complete elements of the task-specific checklist for cystoscopic examination. Likert-type self-report scales were used during pretesting and posttesting, assessing confidence to perform component tasks for diagnostic cystoscopy. Results Twenty-four of 28 trainees successfully performed a systematic cadaveric bladder examination during the primary posttest. After debriefing, the 4 trainees who initially failed successfully performed cystoscopy during a second trial. Median age was 51 years and median time in practice was 19.5 years. All participants reported high confidence in identifying ureteral injury at the course's conclusion. Conclusions A task-specific training program can successfully improve the confidence and skill of community gynecologists to perform intraoperative diagnostic cystoscopy. Professionals may not be able to define when they have received enough instruction in terms of hands-on training with models, before acquisition of technical skills. Formal evaluation of technical skills is recommended after training to ensure competence.

The objective was to investigate the relationship between new onset postoperative stress urinary incontinence (SUI) after sacrocolpopexy (SCP) and anatomical change/surgical approach. We analyzed a retrospective cohort of patients with negative preoperative testing for SUI who underwent SCP from 2005 to 2012. Our primary outcome was new onset postoperative SUI. Logistic regression was used to examine the relationship among anatomical change, defined as ΔAa, ΔBa, ΔC, and ΔTVL, and surgical approach, categorized as abdominal (ASCP) for open cases and minimally invasive (MISCP) for laparoscopic and robot-assisted cases, and postoperative SUI. Of 795 cases, 33 ASCP (43%) and 44 MISCP (57%) met the inclusion criteria for analysis. New onset SUI was demonstrated by 15 patients (45%) of the ASCP group and 7 patients (15%) of the MISCP group (p = 0.005). New onset SUI was significantly associated with route of SCP and ΔAa (p = 0.006 and p = 0.033 respectively). Controlling for ΔAa, the odds of new onset SUI were 4.4 times higher in the ASCP group compared with the MISCP group (OR 4.37, 95% CI 1.42, 13.48). Controlling for route of SCP, the odds of new onset SUI were 2.2 times higher with moderate ΔAa compared with low ΔAa (OR 2.16 95% CI 1.07, 4.38). The odds of new onset SUI was 4.7 times higher in those with high ΔAa than in those with low ΔAa (OR 4.67 95% CI 1.14, 19.22). ΔBa, ΔC, and ΔTVL were not associated with new onset SUI. Greater reduction in point Aa and abdominal surgical route are risk factors for new onset postoperative SUI after SCP.

The puborectalis muscle is an important muscle for the maintenance of fecal continence. We present a novel surgical technique for repair of symptomatic avulsed puborectalis muscle.This woman presented with dyspareunia and fecal incontinence since the vaginal birth of her child 2 years before. The diagnosis of an avulsed right puborectalis was made by physical examination and confirmed by magnetic resonance imaging and three-dimensional ultrasonography. Fascia lata was harvested from the patient's thigh and used to reconstitute the missing portion of the puborectalis muscle. At 12 months postoperatively, the patient was continent of stool and relieved of dyspareunia.The patient's dyspareunia and fecal incontinence were alleviated by restoring normal anatomy.

The purpose of this study is to review our experience with a technique for diagnosing small rectovaginal fistulas that occasionally permit passage of air or mucus.During an in-office visit suspicious areas of the vagina were probed with a cone-tip catheter and injected with a contrast dye to visualize the suspected fistula tract communicating to the rectum under fluoroscopic guidance. The fistulous tracts were further isolated using a flexi-tip glide wire.Five out of nine patients were found to have fistulas not diagnosed by other means. Three patients had recurrent rectovaginal fistula after a vaginal delivery, one patient was identified with a high rectovaginal fistula due to diverticular disease, and one patient had a rectovaginal fistula due to prior hemorrhoidectomy. One patient had a negative test, and the fistula that was diagnosed intraoperatively was due to underlying Crohn's disease.Direct fistulography is a useful technique to visualize otherwise elusive symptomatic rectovaginal fistula tracts.

Patients with anorectal dysfunction are common and can be quite challenging to diagnose. The common underlying causes for such conditions are usually anatomical in nature, which may be difficult to fully evaluate by clinical examination alone. The aim of this video was to demonstrate how multicompartmental ultrasound imaging can be utilized clinically in the evaluation of patients with anorectal dysfunction.Pertinent ultrasound findings of the common anatomical causes of defecatory dysfunction were discussed in this video.Different ultrasound techniques were shown.In conclusion, multicompartmental ultrasound imaging is an easy, cost-efficient, and valuable tool in the evaluation of patients with anorectal dysfunction.

The aim of our study was to determine the association between the severity of anal incontinence and levator ani deficiency, anal sphincter defects, anorectal angle, and colonic motility abnormalities. This was a retrospective study. Subjects were categorized into three groups: normal, minor anal incontinence, and major anal incontinence according to their answers to the PFDI-20 questionnaire. 3D endovaginal ultrasound was utilized to assess levator ani muscle and the anorectal angle. Levator ani muscle subdivisions were scored based on avulsion from the pubic bone and muscle thickness, based on our previous work. 3D endoanal ultrasound was utilized to assess anal sphincters. Colonic motility abnormalities were defined as diarrhea, constipation or both. Ninety-seven patients were included in the analysis: 45 with major anal incontinence, 29 with minor anal incontinence, and 23 continent women. On multivariate logistic regression, sphincter defect, anorectal angle, and colonic motility abnormalities were associated with anal incontinence severity. Women with an external anal sphincter defect had a 20.36-fold chance of having severe anal incontinence compared with patients with no defect (OR 20.36, 95 % CI 5.4, 76.6); those with both defective sphincters had a 102.5-fold chance of having severe anal incontinence (OR 102.5, 95 % CI 10.2, >999). Anorectal angle ≥170° was significantly associated with the severity of anal incontinence (OR = 4.07, 95 % CI 1.53, 10.79), as was the presence of colonic mobility abnormality (OR 5.31, 95 % CI 1.86, 15.19). 3D pelvic floor ultrasound can be an efficient tool for anal incontinence evaluation in women. Anal sphincter defects, colonic motility abnormalities, and anorectal angle were associated with the severity of anal incontinence. While there was a trend toward worsening levator ani deficiency among those with major anal incontinence, this did not reach statistical significance.

The purpose of this pictorial essay is to describe the utility of 3-dimensional endovaginal and endoanal sonography in the assessment of vulvovaginal cysts and masses. It is accepted that compared with transabdominal pelvic sonography, transvaginal end-fire sonography provides improved resolution for visualization of female reproductive organs with fewer artifacts. To visualize the structures that are located in or lateral to the vaginal canal, side-fire 3-dimensional endovaginal or endoanal sonography can be used. This special technique has the advantage of maintaining the spatial anatomic relationship of any abnormality in the vagina.

To estimate whether levator ani deficiency severity is a predictor of clinically significant pelvic organ prolapse (POP) and to determine whether there is a levator ani deficiency threshold above which POP occurs.Two-hundred twenty three-dimensional ultrasound scans performed on urogynecologic clinic patients were reviewed, and each levator ani muscle subdivision was individually scored (0=no defect, 1=50% or less defect, 2=more than 50% defect, 3=total absence of the muscle) on each side. A levator ani deficiency score was calculated and categorized as mild (score 0-6), moderate (score 7-12), and severe (score more than 13). Clinically significant prolapse was defined as stage 2 or higher.The mean age was 56.50 (standard deviation ±15.58) and median parity was 2 (range 0-6). A mild positive correlation was demonstrated between levator ani deficiency category and prolapse stage (rs=0.44; P.001). Score distribution significantly differed by prolapse stage (P.001). No patients with stage 3 prolapse had a levator ani score less than 6, and no patients with stage 4 prolapse had a levator ani score less than 9. In patients with prolapse, those with moderate levator ani deficiency had 3.2 times the odds of POP compared with patients with a minimal defect; those with severe levator ani deficiency had 6.4 times the odds of prolapse than those with minimal deficiency.Levator ani deficiency severity is associated with clinically significant prolapse.II.

Objectives This study aimed to investigate the effects of age on pelvic floor symptoms (PFSs) in nulliparous women. Methods Eighty community-dwelling nulliparous women, aged 21 to 70 years, were recruited. Pelvic floor support was assessed with pelvic organ prolapse quantification system. Participants completed the Pelvic Floor Distress Inventory 20 and Pelvic Floor Impact Questionnaire 7. Sexual function was assessed with the Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire 12 and health status with the Short-Form Health Survey. The correlation between age and questionnaire scores was evaluated using Pearson coefficient. Logistic regression assessed predictors associated with PFS. Results Participants had a median age of 47 years, average body mass index of 28.3 kg/m, and most were white; 52.5% were healthy and 30% were postmenopausal. The most common stage of prolapse was stage I.Age was associated with slightly higher Pelvic Floor Distress Inventory-20 scores (r = 0.41, P = 0.002), corresponding to more bothersome PFS, and lower Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire-12 scores, corresponding to worsening sexual function with advancing age (r = -0.41, P = 0.0012). There was no association between age and overall Pelvic Floor Impact Questionnaire scores (P = 0.12). For symptomatic patients, logistic regression showed age to be associated with increased odds of having PFS [odds ratio (OR), 1.881; 95% confidence interval (CI), 1.216-2.91]. Menopausal status was not associated with increased odds of reporting symptoms (OR, 3.05; 95% CI, 0.80-11.62). When age and age by menopause were incorporated in the model, age remained a significant predictor of having PFS (OR, 1.78; 95% CI, 1.13-2.78). Conclusions In this population of community-dwelling nulliparous women, age was associated with worsening sexual function and slightly increased odds of reporting symptoms of pelvic floor disorders.

Our aim was to assess whether differences in the ages of nulliparous women affect: (1) interobserver reliability, and (2) visualization of the levator ani (LA) muscle subdivisions in nulliparous women using 3D endovaginal ultrasound (3D-EVUS). This was a cross-sectional study. Community-dwelling nulliparous women ages 21–70 years were recruited. Participants underwent a standard examination and a 3D-EVUS. LA subdivisions of interest included the puboperinealis, puboanalis, pubococcygeus, puborectalis, and ileococcygeus muscles. Each ultrasound (US) volume was scored using a validated scale and assessed by two observers. Defect severity was scored for each muscle from 0 (no defect) to 6 (complete muscle loss). A summed score of the two sides was grouped as normal (0), minor (1–3), or major (4–6). Bias was examined using Bland–Altman plots. Intraclass coefficients were calculated to report agreement of total scores. Spearman’s rank correlation was used to evaluate the association between age and LA scores. Eighty nulliparous women were evaluated. Exact agreement for bilateral scoring of each LA subdivision ranged from 82 % to 84 %. Bilateral scoring of the puboperinealis, puborectalis, and ileococcygeus showed moderate to substantial agreement. Bilateral scores of the puboperinealis demonstrated substantial agreement between observers, with an ICC of 0.8 and a mean difference of −0.2 using the Bland–Altman analysis. When women were analyzed by age decade, reader agreement was overall good to excellent. There was no significant correlation between increasing age and total LA muscle scores (r = 0.179, p = 0.113). Interobserver reliability or visualization of the LA muscle in nulliparous women was not affected by a woman’s age.

Separation of the levator ani muscles from pubic bone is a common major levator trauma that may occur in vaginal delivery and is associated with pelvic floor dysfunctions. We describe a novel ultrasound-guided technique to repair these muscles. A 33-year-old woman presented with a history of difficult vaginal delivery and complaint of numbness and weakness of the vagina. In evaluation, bilateral levator defects were diagnosed by physical examination, three-dimensional endovaginal ultrasound, and magnetic resonance imaging. With ultrasound guidance the detached ends of muscles were tagged and sutured to their insertion points at the pubic bone. The patient’s normal anatomy was restored with the return to normal pelvic floor tone. A follow-up ultrasound showed restored levator anatomy at 3 months.

OBJECTIVE Although gynecologists perform a large number of surgeries in close proximity to the ureters and the urinary bladder, traditionally, Obstetrics and Gynecology resident physicians are not formally taught to perform cystoscopy. The primary objective was to document resident physicians' performance in diagnostic cystoscopic instrumentation and technique. The secondary objective was to examine if reported prior cystoscopic experience was associated with superior performance. METHODS Fifty-one postgraduate year 4 residents with reported experience with cystoscopy were evaluated using an operation-specific checklist and a global ratings scale based on the Objective Structured Assessment of Technical Skill model. Before evaluation, they attended a formal training session in cystoscopy, which included practice on a bench model of a simulated bladder. RESULTS Forty-three of the 51 residents were able to successfully perform a thorough diagnostic examination immediately after the course. Six of the 8 failures were re-evaluated 2 weeks later and successfully performed a complete examination at that time. Before the course, the residents had performed a mean of 12.2 cystoscopic examinations as the primary surgeon (median, 12; range, 2-33). The number of reported cystoscopic examinations performed before the course did not correlate with the ability to perform a thorough cystoscopic examination (r = -0.109; P = 0.496). CONCLUSIONS For this group of residents, there was poor correlation between the number of reported cystoscopic examinations and the ability to perform diagnostic cystoscopy. Trainees may not be able to determine when they have received enough instruction in hands-on training with models before acquisition of technical skills.