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Objective: To analyse the associations between delivery mode and symptoms and signs of pelvic organ prolapse (POP) in a cohort of symptomatic women.Design: Retrospective observational study.Population: A total of 1258 consecutive women attending a tertiary urogynaecological unit for the investigation of lower urinary tract or pelvic floor disorders between January 2012 and December 2014.Methods: Obstetric history and clinical examination data were obtained from the unit database. Prolapse quantification on imaging was performed using stored four-dimensional translabial ultrasound volume data sets. Women were grouped into four groups according to the most traumatic delivery reported. The presence of symptoms and signs of POP were compared between delivery groups while controlling for potential confounders.Main Outcome Measures: Prolapse symptoms, visual analogue score for prolapse bother, International Continence Society Prolapse Quantification System findings and ultrasound findings of anterior, central and posterior compartment descent.Results: Nulliparae showed the lowest prevalence of most measures of POP, followed by women exclusively delivered by caesarean section. Highest prevalences were consistently found in women delivered at least once by forceps, although the differences between this group and women delivered by normal vaginal delivery and/or vacuum extraction were significant in three out of eight measures only. Compared with women in the caesarean section group, the adjusted odds ratios for reporting symptoms of prolapse were 2.4 (95% CI 1.30-4.59) and 3.2 (95% CI 1.65-6.12) in the normal vaginal delivery/vacuum extraction group and forceps group, respectively.Conclusions: There is a clear link between vaginal delivery and symptoms and signs of pelvic organ prolapse in urogynaecological patients.Tweetable Abstract: Compared with caesarean section a history of vaginal delivery more than doubles the risk for POP. [ABSTRACT FROM AUTHOR]

Objective Vaginal childbirth has a substantial effect on pelvic organ supports, which may be mediated by levator ani ( LA) avulsion or hiatal overdistension. Although the impact of a first vaginal delivery on the hiatus has been investigated, little is known about the effect of subsequent births. This study was designed to evaluate the association between vaginal parity and hiatal dimension. Design Retrospective observational study. Setting A tertiary urogynaecological unit in Australia. Population A total of 780 archived data sets of women seen for symptoms of lower urinary tract and pelvic floor dysfunction. Methods Standardised in-house interview and assessment using the International Continence Society ( ICS) pelvic organ prolapse quantification ( POP-Q), and four-dimensional translabial ultrasound. Offline analysis for hiatal dimensions was undertaken blinded to history and clinical examination. Main outcome measures Hiatal area on maximum Valsalva. Results Of 780 women, 64 were excluded because of missing ultrasound volumes, leaving 716 for analysis: 96% ( n = 686) were parous, with a median parity of three (interquartile range, IQR 2-3), and 91.2% ( n = 653) were vaginally parous. Levator avulsion was found in 21% ( n = 148). The mean hiatal area on Valsalva was 29 cm2 ( SD 9.4 cm2). On one-way anova, vaginal parity was significantly associated with hiatal area ( P < 0.001). Most of the effect seems to occur with the first delivery. Subsequent deliveries do not seem to have any significant effect on hiatal dimensions. This remained true after controlling for potential confounding factors using multivariate regression analysis ( P = 0.0123). Conclusions Vaginal parity was strongly associated with hiatal area on Valsalva. Most of this effect seems to be associated with the first vaginal delivery. [ABSTRACT FROM AUTHOR]

Objectives: Levator avulsion, a common childbirth-related traumatic abnormality of this muscle, is characterized by a widened gap between the muscle insertion and urethra. This study assessed the use of four-dimensional ultrasound imaging to measure the levator-urethra gap (LUG) in order to identify avulsion. Methods: In a retrospective study, we reviewed the records of 118 women seen for clinical assessment and imaging. Axial plane tomographic ultrasound slices were obtained at intervals of 2.5 mm. The distance between the center of the urethra and the levator insertion was measured, blinded to clinical data, and the results were analyzed with reference to the diagnosis on palpation. An interobserver agreement analysis was conducted on 20 randomly selected patients included in the study. Results: A defect had been palpated in 19/116 women (16%) with complete datasets. LUG measurements were significantly higher in women who had been diagnosed with a levator avulsion on palpation (mean +/- SD, 27.6 +/- 6.7 mm vs. 19.7 +/- 3.4 mm; P < 0.001). The interobserver intraclass correlation coefficient for LUG measurement was good (0.71; 95% CI, 0.61-0.79). Receiver-operating characteristics analysis suggested a cut-off of 25 mm, with a sensitivity of 63% and a specificity of 94%, for the diagnosis of levator avulsion injury. Conclusions: The measurement of LUG is reproducible and strongly associated with levator avulsion trauma diagnosed on vaginal palpation. A cut-off of 25 mm may be used for the diagnosis of levator avulsion injury. [ABSTRACT FROM AUTHOR]

Magnetic resonance imaging (MRI) has been used to identify both normal and abnormal female pelvic anatomy, permitting resolution and tissue definition not previously possible and faster acquisition times adding to our understanding of dynamic pelvic anatomy. These systems are, however, expensive and limited to tertiary centres. The alternative, three-dimensional ultrasound (3D USS), has undergone major advances in development, so that, today, dynamic axial plane imaging has become feasible.This study aimed to compare the two imaging modalities in the assessment of the levator hiatus. Eleven women undergoing prolapse surgery were assessed using MRI and 3D USS. Data volumes were acquired at rest and on maximum Valsalva, and were stored and reviewed independently at a later date to measure the dimensions of the levator hiatus. Similar measurements were undertaken in the equivalent axial slice on MRI using fast acquisition T2 weighted scanning. Independent, clinical pelvic examination was performed using the ICS POP-Q system. The mean age of participants was 58 years, median parity was 3, with 46% (5) having had a hysterectomy. A total of 82% (9) had a sensation of a lump, 55% (6) had constipation. Clinical grading on POP-Q was 2 (median). All had rectoceles at surgery, with 46% (5) having coexistent cystoceles, 18% (2) level 1 prolapse, and 82% (9) having enteroceles. The intra-class correlations were relatively poor-0.22 for levator area at rest and 0.47 on Valsalva. Possible explanations for the poor correlations observed were the use of different points of reference and the difficulties of obtaining equivalent Valsalva manoeuvres. In particular, it was virtually impossible to consistently image the plane of minimal dimensions on Valsalva by single-slice MR imaging. Further larger studies comparing the two imaging modalities are required before final conclusions can be drawn. [ABSTRACT FROM AUTHOR]

Objective: To date, the evidence on pelvic floor injury in labor remains sketchy due to a lack of prospective studies comparing pelvic floor imaging before and after childbirth. We intended to define the incidence of major trauma to the pubovisceral muscle. Methods: A total of 61 nulliparous women were seen at 36-40 weeks of gestation in a prospective observational study. The assessment included an interview and 3-dimensional translabial ultrasound and was repeated 2-6 months postpartum. Results: Fifty women (82%) were seen postpartum. Of the 39 women delivered vaginally, levator avulsion was diagnosed in 14 (36%, 95% confidence interval 21-51%). Among those delivered vaginally, there were associations with higher maternal age (P = .10), vaginal operative delivery (P = .07), and worsened stress incontinence postpartum (P = .02). Conclusions: Avulsion of the inferomedial aspects of the levator ani from the pelvic sidewall occurred in approximately one third of all women delivered vaginally and was associated with stress incontinence 3 months after childbirth. [ABSTRACT FROM AUTHOR]

The issue of traumatic damage to the pelvic floor in childbirth is attracting more and more attention amongst obstetric caregivers and laypersons alike. This is partly due to the fact that elective Caesarean section, as a potentially preventative intervention, is increasingly available and perceived as safe. As there are a multitude of emotive issues involved, including health economics and the relative roles of healthcare providers, the discussion surrounding pelvic floor trauma in childbirth has not always been completely rational. However, after 25 years of urogynaecological research in this field it should be possible to determine whether pelvic floor trauma in childbirth is myth or reality. On reviewing the available evidence, it appears that there are sufficient grounds to assume that vaginal delivery (or even the attempt at vaginal delivery) can cause damage to the pudendal nerve, the caudal aspects of the levator ani muscle, fascial pelvic organ supports and the external and internal anal sphincter. Risk factors for such damage have been defined and variously include operative vaginal delivery, a long second stage, and macrosomia. It is much less clear, however, whether such trauma is clinically relevant, and how important it is in the aetiology of pelvic floor morbidity later in life. [ABSTRACT FROM AUTHOR]

To compare the safety and efficacy of three types of suburethral slings for the treatment of urodynamic stress incontinence.Following ethics approval, 195 (3 × 65) patients with urodynamic stress incontinence were randomly assigned to undergo suburethral slingplasty with the Tension-free Vaginal Tape (TVT; Gynecare, Ethicon, Somerville, NJ, USA), Intravaginal Sling (IVS; Tyco Healthcare, Mansfield, MA, USA), or Suprapubic Arc Sling (SPARC; American Medical Systems, Minnetonka, MN, USA). The patients were blinded to the type of sling implanted.(1) operative and short-term complications; (2) pre- and postoperative symptomatology; and (3) pre- and postoperative urodynamic findings.There was a statistically significant increased rate of sling protrusion (13.1% vs. 3.3% and 1.7%;P = 0.04) in the SPARC group when compared to TVT and IVS. Otherwise, there were no significant differences between the groups with respect to the incidences of other operative complications, patients’ main subjective outcomes, satisfaction rates, or postoperative urodynamic findings. The overall objective stress incontinence cure rates were 87.9%, 81.5% and 72.4% for the TVT, IVS, SPARC groups respectively (P = 0.11).All three slings appear quite successful for the treatment of stress incontinence. The SPARC tapes showed more sling protrusion complications and a trend towards lower objective cure rates; probably as a result of the insertion method used in this study which favoured a loose SPARC sling placement. The authors recommend that the SPARC slings be left tighter than TVT, or for the cough test to be carried out. [ABSTRACT FROM AUTHOR]

Objective: To study the effect of child birth on pelvic organ mobility in a prospective observational study.Methods: A total of 200 women were recruited early in their first ongoing pregnancy and examined by translabial ultrasound in the first/early second trimester, the late third trimester, and 2-5 months postpartum. Peripartal changes in the mobility of urethra, bladder, cervix, and rectal ampulla were correlated with labor and delivery data.Results: A total of 169 women returned postpartum (84.5%). Highly significant increases in organ mobility on Valsalva were found after vaginal delivery (P <.001), with forceps causing the most marked changes. Length of second stage, especially active second stage, correlated with an increase in pelvic organ descent (P =.03 to P <.001). The influence of gestational age, length of first stage, and birth weight did not reach significance.Conclusion: Vaginal birth, in particular operative delivery, negatively affects pelvic organ support. This appears to be true for all three vaginal compartments. All forms of cesarean delivery were associated with relatively less pelvic organ descent. These findings may partly explain the protective effect of elective cesarean delivery for future symptoms of pelvic floor disorders. [ABSTRACT FROM AUTHOR]

The aim of this study was to define detrusor thickness in nulligravid women in order to determine the incidence of detrusor hypertrophy in young asymptomatic and symptomatic women. The study recruited 67 nulligravid volunteers who underwent three-dimensional (3-D) pelvic floor ultrasound using Kretz Voluson 730 systems. Three measurements each were taken for trigone and dome. Results showed that average detrusor thickness at the trigone was 4.0mm (SD=0.7, range 2.7-5.5mm) and at the dome 2.7mm (SD=0.7, range 1.8-5.0mm). Average measurements for both sites showed a mean of 3.4mm (SD=0.5, range 2.5-4.4mm). Symptoms of bladder irritability were not associated with detrusor wall thickness. In this group of 67 nulligravid women, almost all measurements were below 5mm, even in those who reported frequency, nocturia or urge incontinence. Detrusor thickness of >5mm seems to be acquired and may be an effect, rather than a cause, of symptoms of bladder irritability. [ABSTRACT FROM AUTHOR]