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Introduction: Medical and surgical simulation is in high demand. It is widely used in North America as a method of education and training of medical students and surgical residents. Learning anatomy and vaginal surgery are based on palpation recognition of different structures. The absence of visual control of actions learners is a limiting factor for the reproducibility of surgical techniques prolapse and urinary incontinenence. However, this reproducibility is the only guarantee of success and safety of these minimally invasive surgeries., Methods: We evaluated the contribution of an educational module perineal anatomy using a system combining anatomic mannequin and a computerized 3D virtual simulator (Pelvic Mentor®, Simbionix) in the knowledge of pelvic-perineal anatomical structures for eight residents of obstetrics and gynecology hospitals in Paris., Results: The self-study training module has led to substantial improvements in internal rating with a proportion of structures recognized from 31.25 to 87.5 % (P<0.001) for the front compartment and 20 to 85 % (P<0.001) for the posterior compartment., Conclusion: The preliminary results suggest that the 3D virtual simulator enhances and facilitates learning the anatomy of the pelvic floor., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

Introduction and Hypothesis: Posterior vaginal compartment repairs (PR) have traditionally involved a subjective approach. We aim to quantify such repairs using key anatomical indicators (KAI)., Methods: At 50 consecutive PRs: perineal gap (PG); posterior vaginal vault descent (PVVD); mid-vaginal laxity (MVL-vault undisplaced/displaced); and recto-vaginal fascial laxity (RVFL) were measured. The total posterior vaginal length (TPVL) and from POP-Q, TVL, GH, Ap, Bp C, D were also measured. Surgical details deemed appropriate to each repair were recorded., Results: A mean preoperative PG of 2.5 cm was reduced to 0.0 cm postoperatively by excision (100 % cases) with an average increase of 21.6 % in total vaginal length over that if the repair was commenced at the hymen. There was an average reduction of 25.0 % in the genital hiatus (GH). Mean PVVD was 5.3 cm overall; 6.4 cm for 31 out of 50 (62 %) undergoing sacrospinous colpopexy; 3.5 cm for 19 out of 50 (38 %) with no ligamentous vault fixation. An approximate "cut-off" for PVVD of 5 cm may assist with the differentiation of cases where vault fixation may be desirable. Up to 52 % (1.4/2.7 cm) of preoperative MVL displacement was due to vaginal vault descent. The MVL undisplaced (mean 1.3 cm) may better guide vaginal mucosal trimming. RVFL averaged just 0.8 cm with 22 out of 50 (44 %) RVFL being 0.5 cm or less, and not requiring any RVF plicatory sutures., Conclusions: It is possible to use KAI to assist the planning and execution of posterior vaginal compartment surgery. The PG, PVVD, MVL, and RVFL can indicate surgical measures in the perineum, vaginal vault, vaginal mucosa, and recto-vaginal space respectively.

Objective: Animal models have suggested that anogenital distance (AGD) at birth reflects androgen levels during in utero development and predicts adult AGD. A recent study showed an association between perineal length and androgen levels in men, suggesting that serum testosterone levels in adulthood will depend on factors involved during the fetal period. The aim of this study is to assess the relationship between AGD measures and reproductive hormone levels in women., Design: Cross-sectional study conducted between February and November 2011., Setting: University-affiliated fertility clinics., Population: 100 young college students., Methods: Physical and gynaecological examinations were conducted on university students. All participants provided a blood sample for determination of reproductive hormones and completed an epidemiological questionnaire on lifestyles and gynaecological history. We used multiple linear regression analysis to examine the associations between perineal length measurements [anus-fourchette (AGDAF ) and anus-clitoris (AGDAC )] and reproductive hormone levels., Main Outcome Measures: Anogenital distance measurements and reproductive hormone levels., Results: In the multiple linear regression analyses, AGDAF was positively associated with serum testosterone levels. Serum testosterone increased 0.06 ng/ml (95%CI 0.01, 0.10; P = 0.02) for each 1-cm increase in AGDAF . None of the measurements was associated with other reproductive hormones., Conclusions: Anogenital distance may predict normal reproductive development in women, and may be a new tool of potential clinical interest to evaluate ovarian function. Our results suggest that serum testosterone levels in adulthood may depend on factors operating in the prenatal period., (© 2014 Royal College of Obstetricians and Gynaecologists.)

Our aim is to develop a clinically viable, fast-acquisition, prostate MR elastography (MRE) system with transperineal excitation. We developed a new actively shielded electromagnetic transducer, designed to enable quick deployment and positioning within the scanner. The shielding of the transducer was optimized using simulations. We also employed a new rapid pulse sequence that encodes the three-dimensional displacement field in the prostate gland using a fractionally encoded steady-state gradient echo sequence, thereby shortening the acquisition time to a clinically acceptable 8-10 min. The methods were tested in two phantoms and seven human subjects (six volunteers and one patient with prostate cancer). The MRE acquisition time for 24 slices, with an isotropic resolution of 2 mm and eight phase offsets, was 8 min, and the total scan, including positioning and set-up, was performed in 15-20 min. The phantom study demonstrated that the transducer does not interfere with the acquisition process and that it generates displacement amplitudes that exceed 100 µm even at frequencies as high as 300 Hz. In the in vivo human study, average wave amplitudes of 30 µm (46 µm at the apex) were routinely achieved within the prostate gland at 70 Hz. No pain or discomfort was reported. Results in a single patient suggest that MRE can identify cancer tumors, although this result is preliminary. The proposed methods allow the integration of prostate MRE with other multiparametric MRI methods. The results of this study clearly motivate the clinical evaluation of transperineal MRE in patients., (Copyright © 2014 John Wiley & Sons, Ltd.)

Background: Perineal trauma after vaginal delivery can have significant long-term consequences. It is unknown if a larger infant head circumference or smaller maternal perineal anatomy are risk factors for perineal trauma after vaginal delivery., Methods: We conducted a prospective cohort study of low-risk nulliparous women. Data collected included maternal characteristics, antepartum Pelvic Organ Prolapse Quantification measurements of the perineal body and genital hiatus, labor characteristics, perineal trauma, and infant head circumference. Perineal trauma was defined as trauma that extended into the muscles of the perineum (second-degree or deeper). Univariate and multivariate logistic models were created to calculate odds ratios (OR) and 95 percent confidence intervals (CI)., Results: We observed 448 vaginal births. Multivariate analysis demonstrated a significant association between infant head circumference at birth and perineal trauma: OR 1.22 for each increase of 1 cm in head circumference (95% CI 1.05-1.43). There was no association between perineal body or genital hiatus length and perineal trauma., Conclusions: In nulliparous low-risk women a larger infant head circumference at birth increases the likelihood of perineal trauma, although the effect is modest. Antenatal perineal body and genital hiatus measurements do not predict perineal trauma. These results do not support alteration in mode of delivery or other obstetric practices., (© 2014 Wiley Periodicals, Inc.)

Introduction and Hypothesis: Shortened perineal body (PB) is associated with an increased risk of ultrasound-detected obstetric anal sphincter tear. The objective was to determine if shortened perineal body length (<3 cm) is a risk factor for ultrasound-detected anal sphincter tear at first delivery., Methods: Pregnant nulliparous women were recruited over 18 months. At 35-37 weeks' gestation and 6 weeks' postpartum perineal body length (PB) was measured and subjects completed quality of life questionnaires. Primary outcome was ultrasound-diagnosed anal sphincter tear at 6 weeks postpartum. Secondary outcomes were also assessed. A priori power analysis determined that 70 subjects were needed to detect a difference in anal sphincter tear based on a PB cut-off of 3 cm., Results: Seventy-three subjects completed the study. Mode of delivery was 69.9% spontaneous vaginal, 15.1% operative vaginal, and 15.1% labored cesarean. There were 25 anal sphincter abnormalities (34.2%) seen on ultrasound: 11 (15.1%) internal or external sphincter tears, 3 (4.1%) internal sphincter atrophy, 6 (8.2%) external sphincter thinning, and 7 (9.6%) external sphincter scarring. Only the 11 sphincter tears qualified as abnormal for the primary outcome. In the vaginal delivery group 16.4% (10 out of 61) had a sphincter tear, compared with 8.3% (1 out of 12) in the labored cesarean group (p = 0.68). Women with PB < 3 had a significantly higher rate of ultrasound-diagnosed anal sphincter tear (40.0% vs 11.1%, p = 0.038). When comparing women with and without sphincter tear, there was a significant difference in mean antepartum PB (3.1 vs 3.7 cm, p = 0.043)., Conclusions: A shortened perineal body length in primiparous women is associated with an increased risk of anal sphincter tear at the time of first delivery.

Objective: To analyse anatomical characteristics of the pelvic floor in young nulliparous volunteers based on three-dimensional MRI., Methods: Thin-slice MRI was performed in 25 young nulliparous volunteers in Southern Medical University, MRI were imported into Mimics 10.01 for 3D reconstruction.Using 3D models we measured follow indicators: the levator ani muscle volume (LVOL) , levator plate angle (LPA), levator hiatus width (LH-W)and length (LH-L), distance between symphysis and levator sling muscle (LSG)., Results: (1) 25 cases of pelvic three-dimensional models was successfully constructed, including the pelvis, pelvic organs and the pelvic floor muscles (including the ischial coccyx muscle, levator ani muscle and its various components, perineal muscles), the models could be able to clearly reflect the level of the pelvic floor muscles; (2) 25 cases of levator ani muscle measurement results:LVOL: (34 ± 6) cm(3), LPA: (43 ± 4) °, LH-W: (33 ± 4) mm, LH-L: (54 ± 5) mm, left LSG: (18.8 ± 2.5) mm, right LSG: (18.3 ± 2.5) mm., Conclusions: It is an effective way to use the computer to reconstruct the 3D model of female pelvic floor muscles using MRI data set. The quantitative analysis of levator ani muscle three-dimensional model can be assessed pelvic floor function, which is of great value in clinical practice.It is helpful to understand the pelvic floor disorders pathogenesis, clinical diagnosis, treatment options and treatment evaluation to provide reference standards.

Objective: Anogenital distance (AGD) is a sexually dimorphic trait; AGD is an external marker of sexual differentiation at birth in animals., Study Design: The present study used a prospective, cross-sectional design. Data were collected from newborn infants that were delivered at hospital in Bucheon between March and September 2009. The mothers of the infants provided sociodemographic information and obstetric history. The relationships between AGD and other anthropometric measures (i.e., weight, height, and head circumference) were analyzed. Moreover adjusted AGD values were compared with obstetric characteristics, including number of deliveries, abortion history, preterm history, and duration of gestation., Results: Significant correlations were noted for all anthropometric measures in male and female newborns (p < 0.0001). The adjusted AGD values in males and females were also significantly associated with the duration of gestation (p = 0.0008 and p = 0.0148, respectively). Moreover, the adjusted AGD in female newborns, but not in males, was significantly associated with maternal abortion history (p = 0.0242)., Conclusion: The AGD is a valuable anthropometric marker in term infants.

A 1-year-old boy was referred to our department with a pseudoduplication of the external genitalia present since birth. At surgery, we performed a complete excision of the mass through a "Y-type" perineal incision. The boy was taken to our department for a regular physical examination 2 years after the surgery. The appearance of the perineal region was satisfactory.

Traditional dissections of the female urogenital (UG) triangle can lead to early destruction of the erectile tissues, associated musculature, and neurovascular structures. Here, we present an alternate dissection of the female UG triangle. Rather than begin the female UG triangle dissection with the fatty tissue of the labia majora, we utilize an early identification of the suspensory ligament of the clitoris to organize the dissection. The suspensory ligament leads to the body of the clitoris, which can be palpated from distal to proximal to find the crura of the clitoris with overlying ischiocavernosus muscles. Once the crura have been defined, the bulbs of the vestibule with overlying bulbospongiosus muscles can be palpated medially and posteriorly. This dissection approach results in a clean dissection that well demonstrates homologies between male and female external genitalia. Through the use of this method, most student dissection attempts are able to demonstrate the erectile tissues and associated musculature that comprise the female UG triangle. This technique can also be used for male UG triangle dissections, encouraging identification of male and female homologies., (Copyright © 2013 Wiley Periodicals, Inc.)

Benjamin Alcock (1801-?) was a prominent anatomist from Ireland who is remembered most for his description of the pudendal canal. He was privileged to train under the great Irish anatomist, Abraham Colles. Following his training and several early teaching engagements, he was appointed as the first Professor of Anatomy and Physiology at Queen's College, Cork. He became a Fellow of the Royal College of Surgeons in Ireland. After several years of teaching at Queen's College, Alcock was forced to resign after a dispute over the Anatomy Act of 1832, during which he conveyed his disapproval of participation in the procurement of corpses for the school. Several years after his resignation, he left for the United States and removed himself from the view of the profession. His anatomical contributions were published in The Cyclopaedia of Anatomy and Physiology. The description he gave of the sheath enclosing the pudendal nerve and internal pudendal vessels is his most famous contribution to the literature. He is remembered eponymously for Alcock's canal. This article's intent is to clearly and concisely depict the life and contribution of Benjamin Alcock., (Copyright © 2012 Wiley Periodicals, Inc.)

Purpose: We correlated urogenital hiatus size and levator ani contraction strength with early postoperative emptying disorders. We also determined whether postoperative emptying disorders could be predicted before anti-incontinence procedures and pelvic organ prolapse repair., Materials and Methods: We retrospectively reviewed the charts of 225 consecutive patients after surgery for pelvic organ prolapse and/or stress urinary incontinence. Urogenital hiatus size was evaluated using pelvic organ prolapse quantification. Levator contraction strength was determined by the Oxford 0 to 5 classification scale. Emptying disorders were defined as post-void residual urine volume greater than 100 ml 48 hours postoperatively and/or discharge home with a Foley catheter or on intermittent self-catheterization., Results: Median patient age, post-void residual urine volume and urogenital hiatus size were significantly related to levator contraction strength (each p <0.05). Univariate logistic regression analysis revealed a significant association of urogenital hiatus size (p = 0.001), post-void residual urine volume (p = 0.005) and levator contraction strength (p = 0.001) with emptying disorder status. Multivariate logistic regression analysis showed that levator contraction strength (p = 0.001) and post-void residual urine (p = 0.01) were independent predictors of emptying disorders., Conclusions: A wide urogenital hiatus, decreased levator ani contraction strength, increasing age and increased post-void residual urine correlated with an increased chance of early postoperative emptying disorders. The most independent predictors of early emptying disorders were decreased levator contraction strength and increased post-void residual urine., (Copyright © 2013 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

The anatomy of the perineum and pelvis is complex. Those outside the specialist fields of colorectal surgery, urology and gynaecological surgery often have a less-than-complete understanding of the anatomical details of this region. The recent increase in complicated pelvic and perineal injuries caused by the detonation of Improvised Explosive Devices has brought into sharp focus, the importance of this area of surgical anatomy. The following article describes, in a systematic and detailed manner, the anatomy of the urogenital and anal regions of the perineum. The terminology in relation to the fascial layers and structures encountered in the perineum is elucidated. In addition, the surgical anatomy of the scrotum and its contents and the ligamentous support of the penis are described, with clear illustrations throughout. It is intended that this article will go some way towards clarifying the anatomy underlying the surgical management of complex perineal/pelvic injuries, and benefit both the specialist and non-specialist military surgeon.

Purpose: We aimed to propose a practical selection method predicting the easier radical perineal prostatectomy (RPP) cases before the operation., Methods: Fifty sequential RPP cases were divided into two groups according to the estimated difficulty of the operation (Group I: Easier, Group II: Difficult) which was assessed by using a RPP difficulty scale, constituted by three parameters (operation time, blood loss, and the judgment of the surgeon) each ranging between 1 and 3 points. As the localization parameters, skin-to-prostatic apex (SPAD) and skin-to-prostatic base (SPBD) distances and distance between bilateral ischial tuberosities (ITD) were measured. During suprapubic ultrasonography, a probe-divergence angle (PDA) and prostate volumes (PV) were recorded. These parameters were compared between the groups., Results: In Group I (n = 29) and Group II (n = 21), the difficulty scores were 4.37 (3-5) and 6.80 (6-9), respectively. Data of age, clinical stages, and findings of digital rectal examination were not different between groups. While SPBD, SPAD, and ITD values were found similar (p > 0.05), PDA and PV were significantly different. PDA was > 45 degree in 21 cases in Group I (72.4 %) and in 7 cases in Group II (33.3 %) (p = 0.011). The mean of PV was 37.4 (20-60) cc and 49.9 (30-75) cc in Group I and Group II, respectively (p = 0.001)., Conclusions: While planning RPP operations, by selecting the prostate cancer cases with a prostate of low volume and localized deeper in the pelvis during suprapubic ultrasonography, urologists may have a chance to perform this technique more easily during the learning period.

Perineal glands in guinea pigs are part of the sebaceous glandular complex. Their secretions are used for scent marking. This is important for social status and can be seen in both sexes and castrated males. Discrepancy exits about the existence of these glands in female guinea pigs and knowledge of the anatomical consequences of castration on the male perineal glands is sparse. To examine these uncertainties related to gender, perineal glands from 13 sexually mature pet guinea pigs were examined macro- and microscopically. Clear gender differences in the anatomy of perineal glands were found, and castrated males showed signs of atrophy and fatty infiltration in the glands. Females do have perineal glands, although smaller than the glands in the male. The glands are typically sebaceous with multiple excretory ducts. A macroscopic unique feature in the males was the clearly evident orifices of a large excretory duct on each side of the slightly everted perineal sac. However, the reason for this gender difference is not clear. In castrated males, the orifices were atrophied and difficult to see. In addition, the sebaceous glands of the hair follicles in the skin folds of the perineal opening were smaller and less abundant in females and castrated males. The changes in castrated males are presumably linked to the hormonal changes and decreased secretion after castration. The dense keratin layer in the perineal sac was thicker in males than in both castrated males and females and could contribute to the concrement formation seen mainly in males., (© 2012 Blackwell Verlag GmbH.)

The pelvic floor is the support of the pelvic viscera. The levator ani muscle (LA) with its two bundles (pubo- and iliococcygeus) is the major component of this pelvic floor. LA is formed essentially by type I fibers (slow twitch, with high oxidative capability and presence of slow myosin) as in postural muscles. The aerobic metabolism makes LA fragile to excentric contraction and to mitochondrial dysfunction. The innervation of the pelvic floor comes from the 2nd, 3rd, 4th anterior sacral roots; denervation affects pelvic dynamism. Perineum includes the musculofascial structures under the LA: ventrally the striated sphincter of urethra and the ischiocavernosus and bulbospongiosus, caudally the fatty tissue filling the ischioanal fossa. Pelvic fascia covers the muscles ; it presents reinforcements : the uterosacral and cardinal ligaments, the arcus tendineus fascia pelvis (ATFP) and the arcus tendineus levator ani (ATLA). The pelvis statics is supported by the combined action of all this anatomical structures anteriorly forming the perineal "hammock," medially the uterosacral and cardinal ligaments, posteriorly the rectovaginal fascia and the perineal body. The angles formed by the pelvic viscera with their evacuation ducts participate to the pelvic statics. During the pelvic dynamics the modification of these angles expresses the action of the musculofascial structures.

A recently observed developmental instability of the ano-genital distance (AGD) in female mice indicates that natural prenatal androgens do not have such a robust effect on female genital morphology as has been generally assumed. Part of this instability might be caused by oestrous cyclicity. To check this assumption, we examined the effect of the stage of the oestrous cycle on the AGD in adult (61-75 days old) female mice. Consistent with our assumption, the female AGD (1) varied during the oestrous cycle (p < 0.05), indicating thus rapid changes in morphology of female external genitalia, and (2) showed good repeatability (>0.66) in each stage of the oestrous cycle, suggesting that female genital morphology systematically varied within the oestrous cycle. Therefore, the stage of the oestrous cycle should be considered when assessing prenatal masculinization in adult female mice., (© 2012 Blackwell Verlag GmbH.)

Purpose: We compared cuff sites and assessed anatomical and manometric differences between the transscrotal and perineal approaches to artificial urinary sphincter placement in fresh male cadavers., Materials and Methods: Artificial urinary sphincter implantation using perineal and transscrotal incisions was performed in 15 fresh male cadavers. The artificial urinary sphincter cuffs were placed as proximal as possible using each approach. After measuring urethral circumference at each cuff site, an appropriately sized cuff was placed at each location. The 61 to 70 cm H(2)O pressure reservoir and control pump were then connected to the cuffs. Retrograde leak point pressure was assessed sequentially across each cuff. The paired t test was used to compare urethral circumference and retrograde leak point pressure between the 2 approaches., Results: Mean urethral circumference using the perineal and transscrotal approaches was 5.38 (range 3.2 to 7.5) and 3.81 cm (range 3 to 4.5), respectively (p <0.0001, 95% CI of difference 0.99-2.13). Mean retrograde leak point pressure using the perineal and transscrotal approaches was 90.1 and 64.9 cm H(2)O, respectively (p = 0.0002, 95% CI of difference 13.7-33.5). On visual inspection of cuff sites, the perineal approach was more proximal on the urethra than the transscrotal approach., Conclusions: While the transscrotal approach to artificial urinary sphincter placement has the advantage of technical ease, the anatomical and manometric findings of this cadaver study suggest that the perineal approach offers a more proximal cuff location, more robust urethral size and more effective urethral coaptation than the transscrotal approach., (Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Aim: There is poor consensus in the literature about measuring perineal descent. We aimed to assess symptoms and quality of life in constipated patients with abnormal perineal descent., Method: Constipated patients were categorized into those with obstructed defaecation, colonic inertia, mixed disorders and irritable bowel syndrome constipation types. Anal physiology was performed. KESS score, Irritable Bowel Syndrome Quality of Life and SF-12 questionnaires were completed. The position of the perineum was measured by defaecography. Patients were divided into two groups according to the position of the perineal descent at rest: group 1 (normal < 3.5 cm) and group 2 (abnormal > 3.5 cm)., Results: Fifty-eight patients were identified, 23 (40%) in group 1 and 35 (60%) in group 2. Patients in group 2 were older (P = 0.007), had a higher body mass index (BMI; P = 0.003), a higher rate of hysterectomy (P = 0.04) and more vaginal deliveries (P = 0.001). Obstructed defaecation was the predominant subtype of constipation. Group 1 had more difficulty in initiating defaecation and group 2 presented more cases with intussusception and enterocele (P = 0.03 for both). Group 2 had a lesser degree of perineal descent between rest and straining. Rectal compliance was greater in group 2 (P = 0.03). Symptoms and quality of life scores were similar between the groups., Conclusion: Radiologically determined excessive perineal descent is not indicative of worse symptoms or quality of life. This radiological finding does not warrant further investigation., (© 2012 The Authors. Colorectal Disease © 2012 The Association of Coloproctology of Great Britain and Ireland.)

Objective: Anatomic differences among racial groups may contribute to observed differences in the occurrence of severe perineal lacerations at the time of vaginal delivery. The purpose of this study was to identify differences in perineal body length between racial groups., Methods: Perineal body length was measured in primigravid women aged 18 to 45 years who were admitted in labor. Women were classified into 1 of 6 racial groups: White, Filipino, Japanese, Chinese, Native Hawaiian, or Micronesian. The primary outcome, perineal body length, was compared using analysis of variance., Results: A total of 200 women were recruited. There were no significant differences in perineal body length (P = 0.42) and severe perineal lacerations (P = 0.82) between the different racial groups. The mean (SD) perineal body length of women who had a severe laceration was 3.9 (0.5) versus 3.9 (0.6) cm in women who did not have a severe laceration (P= 0.98)., Conclusion: Perineal body length does not seem to differ among the different racial groups studied and therefore an unlikely cause of racial variation in rates of severe perineal lacerations.

In the case of some mammalian species, females with larger anogenital distance (AGD) have smaller litters, where the sex ratio is male-biased. The first aim of the present study was to test whether this phenomenon exists in the Lagomorph group, especially in rabbits. The results revealed that does with large AGD have significantly smaller and lighter litters with a male biased sex ratio; with fewer females but not more males. The second aim of the present study was to test whether males differentiate between females differing in their AGD and are thus capable of choosing the more fertile and fecund does. Males showed a stronger response to the chin marks of females with small AGD than to the marks of females with large AGD. Our results suggest that variation in the prenatal hormonal environment, reflected through variation in AGD, could have long-term consequences on mate choice and population dynamics., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Introduction: There are numerous genital complaints in women cyclists, including pain, numbness, and edema of pelvic floor structures. Debate ensues about the best saddle design for protection of the pelvic floor., Aim: To investigate the relationships between saddle design, seat pressures, and genital nerve function in female, competitive cyclists., Methods: We previously compared genital sensation in healthy, premenopausal, competitive women bicyclists and runners. The 48 cyclists from our original study comprise the study group in this subanalysis., Main Outcome Measures: Main outcome measures were: (i) genital vibratory thresholds (VTs) determined using the Medoc Vibratory Sensation Analyzer 3000 and (ii) saddle pressures as determined using a specially designed map sensor., Results: More than half of the participants (54.8%) used traditional saddles, and the remainder (45.2%) rode with cut-out saddles. On bivariate analysis, use of traditional saddles was associated with lower mean perineal saddle pressures (MPSP) than riding on cut-out saddles. Peak perineal saddle pressures (PPSP) were also lower; however, the difference did not reach statistical significance. Saddle design did not affect mean or peak total saddle pressures (MTSP, PTSP). Saddle width was significantly associated with PPSP, MTSP, and PTSP but not with MPSP. Women riding cut-out saddles had, on average, a 4 and 11 kPa increase in MPSP and PPSP, respectively, compared with women using traditional saddles (P = 0.008 and P = 0.010), after adjustment for other variables. Use of wider saddles was associated with lower PPSP and MTSP after adjustment. Although an inverse correlation was seen between saddle pressures and VTs on bivariate analysis, these differences were not significant after adjusting for age., Conclusion: Cut-out and narrower saddles negatively affect saddle pressures in female cyclists. Effects of saddle design on pudendal nerve sensory function were not apparent in this cross-sectional analysis. Longitudinal studies evaluating the long-term effects of saddle pressure on the integrity of the pudendal nerve, pelvic floor, and sexual function are warranted., (© 2011 International Society for Sexual Medicine.)

Background: Circumferential margin positivity and tumor perforations are the main reasons for the poor oncological outcome following standard abdominoperineal excision for low rectal cancer. The extralevator abdominoperineal excision approach has been developed to avoid "coning down" or "surgical waisting"; however, surgical education in this area has been neglected., Purpose: This study aims to define correct surgical anatomical planes for extralevator abdominoperineal excision and show the differences in excision planes between standard and extralevator abdominoperineal excision., Design and Setting: Macroscopic surgical dissections were performed in a clinical anatomy laboratory. The dissections were recorded as video clips., Methods: In accordance with the surgical technique of extralevator abdominoperineal excision, abdominal and then perineal dissections were performed on 1 female and 5 male cadavers. Neurovascular, muscular, and fascial structures located in or near the excision field were carefully revealed., Results: The surgical planes of extralevator abdominoperineal excision, which widen the tumor-free margins and prevent inadvertent bowel perforation, are described in this step-by-step anatomical dissection study. Within the surgical excision planes, sacral vessels and sympathetic chains form a neurovascular network at the level of the sacrococcygeal joint. Although pelvic autonomic plexuses were away from the lateral incision line, their branches extending to urogenital organs were very close to the anterolateral dissection line. Perineal dissection showed that the internal pudendal vessels and pudendal nerve were close to the lateral excision plane. The superficial transverse perineal muscle and perineal body were the most important landmarks to determine the anterior boundary of dissection., Limitations: The study focused on the perineal dissection of extralevator abdominoperineal excision., Conclusions: Successful extralevator abdominoperineal excision crucially depends on an accurate knowledge of surgical anatomical planes.

Background: Extralevator abdominoperineal excision results in superior oncologic outcome for advanced low rectal cancer. The exact definition of surgical resection planes is pivotal to achieving negative circumferential resection margins., Objective: This study aims to describe the surrounding anatomical structures that are at risk for inadvertent damage during extralevator abdominoperineal excision., Design and Setting: Joint surgical and macroanatomical dissection was performed in a university laboratory of clinical anatomy., Methods: A stepwise dissection study was conducted according to the technique of extralevator abdominoperineal excision by abdominal and perineal approaches in 4 human cadaveric pelvises. Muscular, fascial, tendinous, and neural structures were carefully exposed and related to the corresponding surgical resection planes., Results: In addition to the autonomic nerves to be identified and preserved during total mesorectal excision, further structures endangered during extralevator abdominoperineal excision can be clearly identified. Terminal pudendal nerve branches come close to the surgical resection plane at the outer surface of the puborectal sling. Likewise, the pelvic plexus and its neurovascular bundles embedded within the parietal pelvic fascia extend close to the apex of the prostate where the parietal pelvic fascia has to be divided. These neural structures converge in the region of the perineal body, an area that provides no "self-opening" planes for surgical dissection. Thus, the necessity to sharply detach the anorectal specimen anteriorly from the perineal body and the superficial transverse perineal muscle bears the risk of both inadvertent damage of the aforementioned anatomical structures and perforation of the specimen., Limitations: The study focused primarily on the macroscopic topography relevant to the surgical procedure, so that previously published histologic examinations were not performed., Conclusion: The present anatomical dissection study highlights those anatomical landmarks that require clear identification for the successful achievement of both negative circumferential resection margins and preservation of urogenital functions during extralevator abdominoperineal excision.

Objectives: To report the surgical anatomy of the muscles of the urogenital diaphragm and the pattern of its vessels in the classic exstrophy bladder and incontinent epispadias., Methods: A total of 11 patients, 9 with unoperated classic exstrophy and 2 with incontinent epispadias, who were >5 years old at presentation, were selected for the present study. Magnetic resonance imaging of the pelvis was performed using a 3.0 T magnetic resonance imaging scanner and an 8-channel coil. Computed tomography was performed for 5 patients using a multidetector row helical computed tomography scanner. Angiograms of the vessels of the urogenital diaphragm were also obtained using magnetic resonance imaging and computed tomography., Results: A central perineal body was seen in all the patients, with attachment of the bulbospongiosus anteriorly, superficial transverse perinei laterally, and anal sphincter posteriorly. At the root of corpora, the ischiocavernosus muscle was also seen. The triangle among the ischiocavernosus, bulbospongiosus, and superficial transverse perinei muscle was accentuated and contained the perineal artery, indirectly indicating the course of the perineal nerve. The dorsal penile artery was nearer to the posterior edge of the ischiopubic ramus, before coursing on the lateral aspect of the anterior segment of the corpora. The deep transverse perinei muscle and laid open external urethral sphincter were also seen in the proximal planes of the urogenital diaphragm., Conclusions: First, all the muscles of the urogenital diaphragm, including the external urethral sphincter, were present in the exstrophy bladder. Second, the perineal artery and its sphincteric branches were in the triangular space between the ischiocavernosus, bulbospongiosus, and superficial transverse perinei muscle. Finally, the dorsal penile artery ran along the inner edge of the ischiopubic ramus before lying on lateral aspect of the corpora., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: The precise relationship of the structures dorsal to the membranous urethra, including the rectourethralis muscle, the rhabdosphincter, the deep transverse perineal muscle (DTPM), the perineal body, and Denonvillier's fascia, remains controversial., Objective: Our aim was to reexamine the detailed anatomy of the rectourethralis muscle and the deep transverse perineal muscle and their relationship with adjacent structures., Design, Setting, and Participants: The pelvic viscera, including bladder, prostate, and rectum, were obtained from 20 formalin-fixed adult male cadavers., Measurements: The pelvic viscera were embedded in celloidin and then cut into successive slices with an immersing-alcohol microtome. All slices were explored with anatomic microscopy., Results and Limitations: The longitudinal muscle of the anterior rectal wall was divided into anterior and posterior bundles at the junction of the rectum and anal canal. The intermediate fibers of the anterior bundle ended at the perineal body. The lateral fibers of the anterior bundle terminated at the posterior connective tissue of the bulbus penis. The DTPM occupied the space between the rhabdosphincter, rectum, and the bilateral levator ani muscle. Denonvillier's fascia terminated at the junction of the prostate and rhabdosphincter. Numerous slender nerves coming from the neurovascular bundle perforated the DTPM., Conclusions: The anterior bundle of the longitudinal muscle of the rectum inserts into the bulbus penis forming the rectourethralis muscle and ends at the perineal body forming the rectoperinealis muscle. The anterior bundle and DTPM together may contribute to the rectal angle of the anterior rectal wall, and they support the posterior border of the rhabdosphincter., (Copyright © 2010 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Objective: To clarify whether the 'plane of minimal dimensions' of the levator hiatus on three-dimensional (3D) ultrasound accurately represents the minimal anatomical transverse hiatal dimension during a Valsalva maneuver., Methods: In this retrospective study of 3D transperineal ultrasound and magnetic resonance (MR) imaging, datasets from 19 female participants were used to measure the transverse diameter of the levator hiatus using the plane of minimal dimensions on maximum Valsalva maneuver. The term 'apparent minimal transverse diameter' (aMTD) was used to define the transverse diameter measured using axial ultrasound and comparable axial or coronal MR images. Coronal MR images, using the plane of the vagina as a reference, were also obtained on maximum Valsalva. The transverse diameter measured between the caudal margin of the pubococcygeus/puborectalis on the MR coronal image is denoted by the term 'true minimal transverse diameter' (tMTD). Statistical comparisons between the aMTD and tMTD were made using Student's t-test., Results: No significant difference was demonstrated between the aMTD as measured by ultrasonography and MRI. However, there were significant differences found between the aMTD measured by both ultrasound and MRI and the tMTD measured on coronal MR images (both P < 0.01), with mean ( ± SD) values of 4.36 ± 0.85, 4.13 ± 1.09 and 3.23 ± 0.49 cm, respectively., Conclusion: This study highlights the complexity and 3D nature of the levator hiatus and pelvic floor muscles. Investigators have previously assumed that the plane of minimal dimensions of the hiatus can be measured in a flat plane, however, the 3D nature of the hiatus means that the true levator hiatus occupies a warped (non-Euclidean) plane. Hiatal measurements on Valsalva may be subject to systematic error if performed in a single section, i.e. using a flat (Euclidean) plane., (Copyright © 2010 ISUOG. Published by John Wiley & Sons, Ltd.)

Objective: The objective of the study was to describe a framework for visualizing the perineal body's complex anatomy using thin-slice magnetic resonance (MR) imaging., Study Design: Two millimeter thick MR images were acquired in 11 women with normal pelvic support and no incontinence/prolapse symptoms. Anatomic structures were analyzed in axial, sagittal, and coronal slices. Three-dimensional (3-D) models were generated from these images., Results: Three distinct perineal body regions are visible on MR imaging: (1) a superficial region at the level of the vestibular bulb, (2) a midregion at the proximal end of the superficial transverse perineal muscle, and (3) a deep region at the level of the midurethra and puborectalis muscle. Structures are best visualized on axial scans, whereas craniocaudal relationships are appreciated on sagittal scans. The 3-D model further clarifies interrelationships., Conclusion: Advances in MR technology allow visualization of perineal body anatomy in living women and development of 3-D models that enhance our understanding of its 3 different regions: superficial, mid, and deep., (Copyright © 2010 Mosby, Inc. All rights reserved.)

The purpose of this pictorial essay is to describe the main morpho- functional imaging features, physiological and pathological, of the recto-anal region and pelvic floor as depicted with conventional video defecography. Defecography has dramatically improved our knowledge of dysfunctions of evacuation. The most frequent indications and related disorders are presented from a database of more than 2500 examinations conducted in two radiology departments over a period of 15 years. Imaging features of the common recto-anal and pelvic floor disorders are described: rectal prolapse, rectocele, intussusception, descending pelvic floor syndrome, puborectalis muscle syndrome, enterocele, and sigmoidocele. Conventional video defecography still represents the gold standard examination for the identification and staging of morphological and functional disorders of the recto-anal region and pelvic floor in evacuation dysfunctions.

Prenatal androgens are generally assumed to permanently affect the morphology of external genitalia. In laboratory rodents, the ano-genital distance index (AGDI) has become widely used as a marker of natural prenatal masculinization. A greater value should indicate a greater masculinization. The aim of this study was to assess the developmental stability of the AGDI in female mice during pre- (Days 1-21) and postweaning (Days 21-61) periods. Presuming that the AGDI reflects a permanent effect of prenatal masculinization, we hypothesized that the AGDI will be a developmentally stable morphometric measurement (interindividual differences in the AGDI measurement should persist over time). In contrast to our prediction, the AGDI showed poor repeatability both during pre- (.15) and postweaning (.22) periods, indicating developmental instability. (A value of 1 indicates perfect repeatability and a value of 0 indicates no repeatability.) The AGDI thus does not seem to be a reliable marker of prenatal female masculinization.

To investigate intergender differences in muscle cleavage and joining during development of the external anal sphincter (EAS), we examined semiserial sections of 16 fetuses between 15 and 30 weeks of gestation (6 males and 10 females). The subcutaneous part of the EAS (EASsc) developed along the male perineal raphe and extended posteriorly. Thus, the male EAS was characterized by anterior protrusion of the subcutaneous muscle, in contrast to the almost circular female EAS. In both genders, the bulbospongiosus anlage (or the levator ani anlage) issued muscle fibers to form the superficial (or deep) part of the EAS. The EASsc communicated with the superficial part in males, whereas the female bulbospongiosus tended to communicate with the levator ani rather than the EAS. In both genders, the longitudinal muscle bundle(s) of the anorectum contributed to perineal body formation. However, the male perineal body also had a thick fascia between the rhabdosphincter and the levator. The bulbospongiosus seems to play a critical role in forming the EAS. A strict intergender difference in subcutaneous muscle development is evident along the perineal raphe, as the raphe is not evident in females. These results help to explain variations in the EAS, including anal malformations.

Objective: To compare biometric measurements of the pubovisceral muscle during rest, measured using transperineal three-dimensional (3D) ultrasound and magnetic resonance imaging (MRI)., Methods: In this prospective study, 18 female volunteers underwent 3D perineal ultrasound examination and MRI. All women were examined at rest in the supine position and the following measurements were taken: area and anteroposterior and transverse diameters of the levator hiatus; thickness of the pubovisceral muscle, measured lateral to the vagina and to the rectum, on the right and left sides; length of the levator-urethra gap (LUG), measured from the center of the urethra to the insertion of the pubovisceral muscle on the pubic bone. Interclass correlation coefficients (ICC) between the measurements obtained with 3D ultrasound and with MRI were calculated. To quantify the intermeasurement agreement, the bias and SDs were calculated, and limits of agreement constructed. One investigator performed all the analyses., Results: There was no significant difference between the mean values of the measurements by 3D perineal ultrasound and those by MRI. The ICC values showed very good agreement (range, 0.80-0.97). There was a significant positive bias for LUG on the left side and muscle thickness on the right side of the vagina., Conclusion: These results suggest that 3D ultrasound could be used instead of MRI when evaluating static pelvic floor anatomy in women without pelvic organ prolapse at rest., ((c) 2010 ISUOG. Published by John Wiley & Sons, Ltd.)

Objective: To identify the morphological characteristics of pelvic diaphragm hiatus in pregnant women with stress urinary incontinence (SUI) by transperineal three-dimensional (3-D) ultrasound., Methods: From Oct. 2008 to Mar. 2009, 145 pregnant women (third trimester group) at 37-41 weeks of gestation underwent transperineal 3-D ultrasound investigation at Department of Obstetrics and Gynecology, the Sixth People's Hospital, Shanghai Jiaotong University, including 38 pregnant women with stress urinary incontinence (SUI) and the other 107 non SUI pregnant women. In the mean time, 50 normal nulliparous healthy women were chosen as control group. The morphological characteristics of pelvic diaphragm hiatus, the diameter of pelvic diaphragm hiatus, pubovisceral muscle thickness and genitohiatal and levator ani angle were measured at rest, on maximum Valsalva and maximum pelvic floor contraction by 3-D ultrasound, respectively., Results: Loosen connective tissue and pubococcygeus avulsion were observed in some pregnant women at third trimester. The area of pelvic diaphragm hiatus were (15.2+/-1.9), (16.4+/-2.0) and (13.6+/-1.9) cm2, pubovisceral muscle thickness were (0.72+/-0.11), (0.68+/-0.14) and (0.77+/-0.11) cm, levator ani angle were (60+/-8) degrees, (57+/-10) degrees and (64+/-14) degrees at rest, on maximum Valsalva and maximum pelvic floor contraction respectively. These parameters were significantly increased than those in control group [(11.2+/-2.6), (14.5+/-4.5) and (9.2+/-2.6) cm2; (0.66+/-0.10), (0.67+/-0.14) and (0.71+/-0.14) cm; (50+/-4) degrees, (51+/-5) degrees and (46+/-5) degrees] at three maneuvers, respectively (P<0.05). And those parameters of the anteroposterior hiatal diameter, lateral hiatal diameter, perimeter of pelvic diaphragm hiatus and area of pelvic diaphragm hiatus in SUI pregnant women were increased than those in non SUI pregnant women at three maneuvers, respectively (P<0.05). Pubovisceral muscle thickness in SUI pregnant women was significantly lower than that in non SUI pregnant women at maximum pelvic floor contraction (P<0.05), but there were not significant difference between SUI and non SUI pregnant women at rest and on maximum Valsalva in pubovisceral muscle thickness and genitohiatal and levator ani angle (P>0.05)., Conclusions: Pelvic floor anatomic remodeling is identified in late pregnant women. When compared with non pregnant women, the loosen pelvic floor connective tissue and the bigger diameters of pelvic diaphragm are observed in late pregnant women. It is observed that the increased diameters of pelvic diaphragm and decreased thickness of pubovisceral muscle in later pregnant SUI women than those in non SUI pregnant women.

Objective: To identify a seat pressure threshold that corresponds to significant compression of the perineum., Design: Quasiexperimental crossover., Setting: Hospital radiology department., Participants: Convenience sample of six male recreational cyclists., Intervention: Compression of the corpus spongiosum and corpora cavernosa of the perineum without bicycle seat pressure (0%) and at 10%, 40% and 80% of the mean bicycling pressure was assessed using magnetic resonance imaging. Seat pressure was applied using a custom loading device., Outcome Measure: Measure Diameter measurements of the cavernous spaces at the point of peak compression., Results: The mean diameter values for the corpus spongiosum in the unloaded and 10% of load conditions were 105% and 172% greater than the 40% and 80% loaded conditions, respectively (p=0.002-0.004). The corpora cavernosa values displayed a similar trend., Conclusions: Substantial compression of the perineal cavernous spaces may occur with total seat pressure values of less than 40% of typical seat loads.

Objectives: Morphological changes of the pelvic floor during pregnancy and delivery can be visualized by three-dimensional (3D) perineal ultrasound. The aim of this study was to compare biometric measurements of the levator ani muscle according to maternal constitutional factors, delivery mode and size of the baby immediately after the first delivery., Methods: In this prospective observational study, 130 primiparae were recruited (all of them Caucasians with singleton pregnancy and cephalic presentation). A 3D perineal ultrasound scan was performed on the second day after delivery with standardized settings. Volumes were obtained at rest and on Valsalva maneuver, and biometric measurements of the levator hiatus were determined in the axial plane. Different obstetric and constitutional parameters were obtained from our clinical files., Results: All biometric measurements of the levator hiatus were significantly greater in the vaginal delivery group than in the Cesarean section group (P < 0.001), whereas subgroup analysis within the vaginal (spontaneous vs. operative vaginal) and Cesarean (primary vs. secondary) delivery groups did not show statistically significant differences. There was no demonstrable influence of maternal constitutional factors (age, body mass index (BMI)) or different obstetric parameters (length of second stage of labor, episiotomy, maternal injuries) on levator hiatus size postpartum, even in subgroups that delivered vaginally. Women with de novo postpartum stress incontinence showed a significantly higher mean levator hiatus transverse diameter and larger hiatal area on Valsalva maneuver (P < 0.05). There was also a positive but very weak correlation between the newborn's head circumference and hiatal dimensions at Valsalva maneuver (P < 0.05)., Conclusions: Pelvic floor imaging by 3D ultrasound is easily accessible even on the first days after delivery and can provide useful information on morphological changes of the levator ani muscle. In our study, women with vaginal or operative vaginal delivery had a significantly larger hiatal area and transverse diameter than women who delivered by Cesarean section. Maternal constitutional factors (BMI, age) and duration of second stage of labor had no influence on the biometric measurements of hiatal area, whereas weight and head circumference of the baby showed a positive correlation with area of the levator hiatus., (Copyright 2010 ISUOG. Published by John Wiley & Sons, Ltd.)

The anatomy of the pelvis is complex, multilayered, and its three-dimensional organization is conceptually difficult for students to grasp. The aim of this project was to create an explorable and projectable stereoscopic, three-dimensional (3D) model of the female pelvis and pelvic contents for anatomical education. The model was created using cryosection images obtained from the Visible Human Project, in conjunction with a general-purpose three-dimensional segmentation and surface-rendering program. Anatomical areas of interest were identified and labeled on consecutive images. Each 2D slice was reassembled, forming a three-dimensional model. The model includes the pelvic girdle, organs of the pelvic cavity, surrounding musculature, the perineum, neurovascular structures, and the peritoneum. Each structure can be controlled separately (e.g. added, subtracted, made transparent) to reveal organization and/or relationships between structures. The model can be manipulated and/or projected stereoscopically to visualize structures and relationships from different angles with excellent spatial perception. Because of its ease of use and versatility, we expect this model may provide a powerful teaching tool for learning in the classroom or in the laboratory., ((c) 2010 American Association of Anatomists.)

Objective: The purposes were to evaluate the communication and the extent of the spaces formed by fasciae of the male external genitalia and the perineum and to correlate the spaces with clinical observations regarding anatomic progression of diseases., Materials and Methods: Multi-detector row computed tomography (CT) was performed through the perineum and the pelvis of 5 fresh cadavers injected with contrast material in the space between dartos and Buck fasciae of the penis. Two of the 5 cadavers, injected with the contrast material mixed with blue ink, were dissected to confirm the observations made on multi-detector row computed tomography. Computed tomographic images of 11 patients with diseases involving the potential spaces formed by the fasciae of the male genitalia and the perineum were correlated with observations made on CT of the cadavers., Results: The contrast material filling the scrotal cavity extended posteriorly in the perineum, remained far below the urogenital diaphragm, and reached superiorly to the potential space along Scarpa fascia in all cadavers. At cadaveric dissection, the ink-stained spaces were confined by the fascial planes involving Colles, Buck, dartos, and Scarpa fasciae. Spread of disease in the 11 patients (6 patients with localized genital edema, 4 with Fournier gangrene, and 1 with bulbous urethral rupture) was confined in the spaces demonstrated on CT images of the cadavers., Conclusions: Free communication and disease spread occur within the confines of the superficial perineal, scrotal, penile, and abdominal wall spaces formed by Colles, Buck, dartos, and Scarpa fasciae.

Aims: To compare the degree of pelvic organ prolapse between examinations performed with full and empty bladder in patients without any prolapse and with pelvic organ prolapse stage I or II using the pelvic organ prolapse quantification (POPQ) system., Methods: A prospective observational study with 120 consecutive patients with and without symptoms of pelvic organ prolapse was evaluated. All women were examined with full and empty bladder. The data were analyzed by Wilcoxon's signed-rank test., Results: With empty bladder 54% had the same stage, 41% had a one-step higher stage and 5% had a two-step higher stage of prolapse. There was an increase in the extent of prolapse in the empty bladder setting at all six site-specific points (Aa, Ba, C, D, Ap, Bp; p < 0.001) but not in the results of genital hiatus, perineal body and total vaginal length., Conclusion: Our results suggest that the full extent of prolapse may be only assessed with an empty bladder., (Copyright 2010 S. Karger AG, Basel.)

The pelvic floor is the support of the pelvic visceras. The levator ani muscle (LA) with its two bundles (pubo- and ilio-coccygeus) is the major component of this pelvic floor. LA is formed essentially by type I fibers (with high oxidative capability and presence of slow myosin) as in postural muscles. The aerobic metabolism makes LA susceptible to injury caused by excentric contraction and mitochondrial dysfunction. The innervation of the pelvic floor comes from the 2nd, 3rd, 4th anterior sacral roots; denervation affects pelvic dynamism. Perineum includes the musculofascial structures under the LA: ventrally the striated urethral sphincter and the ischio-cavernous and bulbospongious, caudally the fatty tissue filling the ischioanal fossa. Pelvic fascia covers the muscles; it presents reinforcements: the uterosacral and cardinal ligaments, the arcus tendineus fascia pelvis (ATFP) and the arcus tendineus levator ani (ATLA). The pelvis statics is supported by the combined action of all this anatomical structures anteriorly forming the perineal "hammock", medially the uterosacral and cardinal ligaments, posteriorly the rectovaginal fascia and the perineal body. The angles formed by the pelvic visceras with their evacuation ducts participate to the pelvic statics. During the pelvic dynamics the modification of these angles expresses the action of the musculofascial structures.

Introduction: The purpose of this study was to generate normative data for perineal length for Caucasian and Asian women in labour., Methods: The distance from the posterior fourchette to the centre of the anal orifice was measured in 1,000 women in the first stage of labour. Data on ethnicity, body mass index, delivery mode and perineal trauma were collected prospectively., Results: The mean perineal length in Caucasian women was 3.7 +/- 0.9 cm and in Asian women, 3.6 +/- 0.9 cm. Primigravid women with short perineum were more likely to have a third-degree perineal tear in labour (p = 0.03)., Conclusion: This is the first paper to report normative data for perineal length in Caucasian and Asian women in labour. We found a negative correlation between perineal length and third-degree tear in primigravid women. These data may be useful in clinical practice to determine the risk of significant perineal tears in labour.

The location, number, and size of the neurons innervating the bulbospongiosus muscle (BSM) were studied in male pigs, by means of Fast Blue (FB) retrograde transport. After injection of FB into the left BSM, labeled neurons were found bilaterally in the L2-S4 sympathetic trunk ganglia (STGs), in the caudal mesenteric ganglia (CMGs), in the microganglia of the pelvic plexus (PGs), in a dorsolateral area with respect to the central canal of S1-S3 segments of the spinal cord (SC) and in the S1-S4 ipsilateral and S2-S3 contralateral spinal ganglia (SGs). The mean number of labeled FB cells was 3,122 +/- 1,968 in STGs, 979 +/- 667 in CMGs, 108 +/- 104 in PGs, 89 +/- 39 in SC and 77 +/- 23 in SGs. The area of the multipolar neurons was 852 +/- 22 microm(2) in the STGs, 878 +/- 23 microm(2) in the CMGs and 922 +/- 31 microm(2) in the PGs. The multipolar SC neurons had an area of 1,057 +/- 38 microm(2), while pseudounipolar SG cells had dimensions of 2,281 +/- 129 microm(2). Our research enables us to highlight two peculiarities regarding the innervation of the boar BSM: the very high number of labeled autonomic neurons and the particular localization of the motor somatic nucleus.

Background: African mole-rats (Bathyergidae, Rodentia) exhibit a wide range of social structures, from solitary to eusocial. We previously found a lack of sex differences in the external genitalia and morphology of the perineal muscles associated with the phallus in the eusocial naked mole-rat. This was quite surprising, as the external genitalia and perineal muscles are sexually dimorphic in all other mammals examined. We hypothesized that the lack of sex differences in naked mole-rats might be related to their unusual social structure., Methodology/principal Findings: We compared the genitalia and perineal muscles in three African mole-rat species: the naked mole-rat, the solitary silvery mole-rat, and the Damaraland mole-rat, a species considered to be eusocial, but with less reproductive skew than naked mole-rats. Our findings support a relationship between social structure, mating system, and sexual differentiation. Naked mole-rats lack sex differences in genitalia and perineal morphology, silvery mole-rats exhibit sex differences, and Damaraland mole-rats are intermediate., Conclusions/significance: The lack of sex differences in naked mole-rats is not an attribute of all African mole-rats, but appears to have evolved in relation to their unusual social structure and reproductive biology.

Purpose: The purpose of this study is to reexamine the detailed anatomy of Denonvilliers' fascia in women and to study its relationship with the fascia propria of the rectum., Methods: Macroscopic dissection was performed and successive slices of celloidin-embedded pelvic viscera were examined. Of 25 formalin-fixed pelvic splanchnic organs removed from adult female pelves, 14 were cut midsagittally, dissected, and observed under anatomic microscopy, and 11 were embedded in celloidin and then made into successive slices., Results: The rectovaginal septum was composed of anterior and posterior layers. The anterior layer was identified as Denonvilliers' fascia; the posterior layer as the fascia propria of the rectum. The bilateral insertions of Denonvilliers' fascia differ at different levels: at the cervix, Denonvilliers' fascia merged into the parametrium; at the upper vagina, it ended laterally at the paracolpium or fused with the fascia anterior to the vagina; at the middle vagina, the fasciae anchored to the arcus tendineus fasciae pelvis; at the lower vagina, it ended at the lateral side of the outlet of the levator ani muscles., Conclusions: The rectovaginal septum is formed by Denonvilliers' fascia and the fascia propria of rectum and can potentially limit the spread of malignancy.

Objective: To evaluate the interobserver repeatability of measurement of the pubovisceral muscle and levator hiatus, and the position of related organs, during rest, muscle contraction and Valsalva maneuver using three- and four-dimensional (3D and 4D) transperineal ultrasound., Methods: Seventeen women were included in the study. The position and dimensions of the pubovisceral muscle and levator hiatus in patients at rest and during contraction and Valsalva were determined from stored 3D and 4D ultrasound volumes. Analyses were conducted offline by two observers blinded to the clinical data and to each others' measurements., Results: Measurements of levator hiatal dimensions at rest demonstrated intraclass correlation coefficient (ICC) values of 0.92 to 0.96. The ICC values for pubovisceral muscle thickness at rest varied between good and very good (ICC, 0.61-0.93), regardless of plane. During contraction, the ICC values for all measured parameters were very good, varying between 0.61 and 0.92. Measurement of the transverse diameter of the levator hiatus during the Valsalva maneuver showed good reliability (ICC, 0.86), but assessment of the anterior and posterior borders of the levator hiatus was only possible in 29% of cases., Conclusions: 3D and 4D transperineal ultrasound measurement of the pubovisceral muscle and levator hiatus is reliable in women with no or minor symptoms of prolapse at rest and during contraction. The technique for recording during the Valsalva maneuver requires improvement if it is to be useful in the diagnosis of pelvic organ prolapse.

Objective: Recent cadaver research demonstrates the perineal membrane's ventral and dorsal portions and close relationship to the levator ani muscle. This study seeks to show these relationships in women by magnetic resonance (MR) images., Study Design: The subjects were 20 asymptomatic nulliparous women with normal pelvic examinations. MR images were acquired in multiple planes. Anatomical relationships from cadaver studies were examined in these planes., Results: In the coronal plane the ventral perineal membrane forms an interconnected complex with the compressor urethrae, vestibular bulb, and levator ani. The dorsal part connects the levator ani and vaginal side wall via a distinct band to the ischiopubic ramus. In the sagittal plane the parallel position of perineal membrane and levator ani are seen., Conclusion: The perineal membrane's anatomical features can be seen in women with MR. The close relationship between the perineal membrane and levator ani is evident.

Background: A baboon, a non-human primate, is phylogenetically close to human and has been used to study in detail aspects of reproductive physiology that cannot be studied in humans for ethical reasons., Objective: To determine the histological changes in baboon vagina associated with cyclic variations during normal menstrual cycle., Setting: The experiments were carried out at Institute of Primate Research (IPR), Karen, Nairobi, Kenya., Subjects: Nine adult healthy female olive baboons were used in this study. These baboons were monitored over a period of one year and found to have regular menstrual cycles. The vaginal biopsies were taken at different menstrual stages, fixed in 10% formalin and processed to evaluate histological changes., Results: Observation of the histological sections of the biopsies by light microscopy showed that there were histological changes associated with cyclic variations in female olive baboon. During the luteal phase, menstrual phase and pregnancy the squamous epithelium was very thin. The layer gradually thickens throughout the proliferative phase and was thickest during the ovulation period., Conclusion: The changes in squamous epithelium suggest that the baboon vagina undergoes histological changes throughout the menstrual cycle which may be associated with hormonal variations. The data from this study also suggest that olive baboon is a good model for investigating possible effects of hormonal contraceptives on vaginal epithelium and the mechanism of female heterosexual transmission of HIV.

Objective: To evaluate the risk of vascular injury during transobturator approach of cystocele repair., Design: Dissection of the obturator area by perineal approach was performed after placement of mesh needles used for cystocele mesh repair., Setting: Surgery school of Paris., Population or Sample: Twenty obturator regions in ten fresh female cadavers., Methods: Transperineal dissection of the obturator area was conducted in ten fresh female anatomic subjects after inserting anterior Prolift needles., Main Outcome Measures: The vascular anatomy of the obturator region was mapped. Distances between needles and vascular structures of the obturator area were measured three times and averaged for each side., Results: The anterior cannula-equipped needle perforated the gracilis and the adductor brevis muscles. The mean (SD) distance to the anterior obturator vessels was 21.2 (1.6) mm on the right side and 20.4 (1.5) mm on the left. The posterior needle perforated the adductor magnus. Its distance to the posterior division of the obturator vessels was 1.8 (1.0) mm on the right side and 1.1 (0.9) mm on the left., Conclusions: During mesh cystocele repair by transobturator approach, the posterior obturator vessels division seems at risk of injury during the posterior needle insertion.

To describe the architecture and topohistology of the female perineal structures, especially the perineal membrane (PM), we examined frontal sections (one side) and horizontal or transverse sections (another side) of 15 bisectioned pelvic floors. The PM, notably comprising elastic fibers, extended mediolaterally or transversely on the immediately inferior side of the rhabdosphincter area. More posteriorly, the elastic fibers more tilted along the long axis of the vagina and became lining the lateral vaginal wall as a fibrous skeleton. The compressor urethrae and urethrovaginal sphincter were embedded in and interdigitated with the PM. The elastic fiber architecture of the PM was similar to the rectovaginal septum. We hypothesize that the PM plays a role of a shock-absorber at the interface between the levator ani and distalmost vagina. A standard diagram of the female perineal structures is necessary to be revised.