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Autonomic Neuroscience : Basic &... Oct 2016The pelvic floor plays an integral part in lower urinary tract storage and evacuation. Normal urine storage necessitates that continence be maintained with normal... (Review)
Review
The pelvic floor plays an integral part in lower urinary tract storage and evacuation. Normal urine storage necessitates that continence be maintained with normal urethral closure and urethral support. The endopelvic fascia of the anterior vaginal wall, its connections to the arcus tendineous fascia pelvis (ATFP), and the medial portion of the levator ani muscles must remain intact to provide normal urethral support. Thus, normal pelvic floor function is required for urine storage. Normal urine evacuation involves a series of coordinated events, the first of which involves complete relaxation of the external urethral sphincter and levator ani muscles. Acquired dysfunction of these muscles will initially result in sensory urgency and detrusor overactivity; however, with time the acquired voiding dysfunction can result in intermittent urine flow and incomplete bladder emptying, progressing to urinary retention in severe cases. This review will start with a discussion of normal pelvic floor anatomy and function. Next various injuries to the pelvic floor will be reviewed. The dysfunctional pelvic floor will be covered subsequently, with a focus on levator ani spasticity and stress urinary incontinence (SUI). Finally, future research directions of the interaction between the pelvic floor and lower urinary tract function will be discussed.
Topics: Animals; Humans; Muscle, Skeletal; Pelvic Floor; Perineum; Urinary Bladder; Urinary Tract
PubMed: 26209089
DOI: 10.1016/j.autneu.2015.06.003 -
The Journal of Maternal-fetal &... Dec 2022This was an observational study on cervical length and head perineum distance and the prediction of time of delivery. One-hundred and twenty-five nulliparous women with... (Observational Study)
Observational Study
OBJECTIVES
This was an observational study on cervical length and head perineum distance and the prediction of time of delivery. One-hundred and twenty-five nulliparous women with uncomplicated, term, singleton pregnancy were recruited when they presented to the labor ward with show or infrequent painful uterine contractions (less than three contractions in ten minutes on a 30 min cardiotocogram). Apart from digital vaginal examination to assess cervical length and dilatation, sonographic cervical length and head perineum distance were measured by two-dimensional ultrasound. We compared women who delivered within 72 h of presentation of labor symptoms, with women who did not. After excluding ten women whose labor was induced and delivered within 72 h of presentation, one hundred and fifteen women were included for final data analysis.
MAIN FINDINGS
Forty-nine women (42.6%) delivered while sixty-six women (57.4%) remained undelivered at 72 h of presentation of symptoms of labor. There was no statistically significant difference between the two groups on age, presence of show, contractions, fetal head station and presentation and mode of delivery. For the group who had delivered within 72 h of presentation of labor symptoms, the mean sonographic cervical length was 1.87 cm ± 0.62 cm, while the head perineum distance was 6.01 cm ± 1.15 cm. For the other group, the mean sonographic cervical length was 2.10 cm ± 0.83 cm; head perineum distance was 6.03 cm ± 1.18 cm. There was no statistically significant difference between the groups for both sonographic cervical length ( = .90); and head perineum distance ( = .08). We also compared the cervical length measured by digital vaginal examination versus sonography. The median sonographic measurements were 1.47 cm, 2.11 cm and 2.79 cm at "1 cm," "2 cm" and "3 cm" digital vaginal measurement, respectively. However, there was extensive overlap between digitally and sonographically measured cervical length. Prediction accuracy of cervical length and head perineum distance was poor. The area under curve (AUC) of receiver operating characteristic (ROC) curve were 0.433 for sonographic cervical length and 0.501 for HPD.
CONCLUSION
Transperineal sonographical assessment of cervical length and head perineum distance before labor was not useful in predicting the time of delivery. However, it can be explored as an alternative assessment method when digital vaginal examination is not preferred.
Topics: Pregnancy; Female; Humans; Perineum; Delivery, Obstetric; Ultrasonography, Prenatal; Prospective Studies; Labor, Obstetric; Labor Presentation
PubMed: 33455498
DOI: 10.1080/14767058.2021.1873264 -
International Urogynecology Journal Oct 2015In this systematic review we aimed to assess if the Epi-No birth trainer used during antepartum could prevent perineal trauma in nulliparous women. (Review)
Review
INTRODUCTION AND HYPOTHESIS
In this systematic review we aimed to assess if the Epi-No birth trainer used during antepartum could prevent perineal trauma in nulliparous women.
METHODS
We searched CENTRAL, MEDLINE, EMBASE, Scielo, and Conference abstracts, looking for randomized controlled studies (RCT). High heterogeneity (i(2) > 50 %) was corrected with random models. All studies were analyzed according to their quality and risk of bias. Nulliparous women or women whose previous pregnancy ended before 21 weeks' gestation were included and the main outcome measures were: episiotomy rates, perineal tears, severe (3rd/4th) perineal tears, and intact perineum.
RESULTS
Five studies were included (1,369 participants) for systematic review and two of them (932 participants) were eligible for meta-analysis. Epi-No did not reduce episiotomy rates (RR 0.92 [95%CI 0.75-1.13], n = 710, p =0.44; two studies; fixed model) and second stage of labor (MD -12.50 [95%CI -29.62, -4.62], n = 162, p = 0.54; one study; fixed model), and did not increase intact perineum (RR 1.15 [95 % CI 0.81-1.64], n = 705, p = 0.43; two studies; random model). No influence of Epi-No on reducing all perineal tears (RR 0.99 [95%CI 0.84-1.17], n = 705, p = 0.93, two studies; fixed model) or severe (3rd/4th) perineal tears (RR 1.31 [95%CI 0.72-2.37], n = 705, p = 0.38, two studies; fixed model). Mean birthweight of the Epi-No group was higher than that of the control group in both studies, with no statistical significance.
CONCLUSION
Epi-No birth trainer is a device that did not reduce episiotomy rates and had no influence on reducing perineal tears.
Topics: Dilatation; Episiotomy; Female; Humans; Obstetric Labor Complications; Perineum; Pregnancy; Vagina
PubMed: 25851585
DOI: 10.1007/s00192-015-2687-8 -
International Urogynecology Journal Jun 2022Obstetric anal sphincter injuries (OASIs) that are missed at delivery can have long-term consequences. OASIs that are under-classified at delivery are likely to be...
INTRODUCTION AND HYPOSTHESIS
Obstetric anal sphincter injuries (OASIs) that are missed at delivery can have long-term consequences. OASIs that are under-classified at delivery are likely to be inadequately repaired, resulting in a persistent anal sphincter defect. We aimed to identify women who have persistent defects on endoanal ultrasound, inconsistent with the original diagnosis, and compare the effect on St Mark's incontinence scores (SMIS). We also aimed to look for changes in numbers of under-classification over time.
METHODS
Records of women attending a perineal clinic who had endoanal ultrasound from 2012 to 2020 were reviewed. Women who had a modified Starck score implying a defect greater than the classification [indicated by the depth of external anal sphincter or internal anal sphincter (IAS) defect] at delivery were identified.
RESULTS
A total of 1056 women with a diagnosis of 3a or 3b tears were included. Of these, 120 (11.36%) were found to have a defect greater than the original diagnosis and therefore were incorrectly classified at delivery. Women who had a 3b tear diagnosed at delivery, but had an IAS defect, had a significantly higher SMIS (p < 0.01). When comparing two 4-year periods, there was a significant improvement in the diagnosis of IAS tears.
CONCLUSION
Some women with OASIs that have under-classified OASIs are associated with worse anorectal symptoms. This is likely because of an incomplete repair. Some improvement in diagnosis of IAS tears has been noted. We propose improved training in OASIs can help reduce the number of incorrectly classified tears and improve repair.
Topics: Anal Canal; Delivery, Obstetric; Fecal Incontinence; Female; Humans; Lacerations; Obstetric Labor Complications; Perineum; Pregnancy; Rupture; Ultrasonography
PubMed: 35150290
DOI: 10.1007/s00192-021-05051-y -
International Journal of Gynaecology... Sep 2023Numerous interventions to reduce perineal trauma during childbirth have been studied in recent years, including perineal massage. (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Numerous interventions to reduce perineal trauma during childbirth have been studied in recent years, including perineal massage.
OBJECTIVE
To determine the efficacy of perineal massage during the second stage of labor to prevent perineal damage.
SEARCH STRATEGY
Systematic search in PubMed, Pedro, Scopus, Web of Science, ScienceDirect, BioMed, SpringerLink, EBSCOhost, CINAHL, and MEDLINE with the terms Massage, Second labor stage, Obstetric delivery, and Parturition.
SELECTION CRITERIA
The articles must have been published in the last 10 years; the perineal massage was administered to the study sample; and the experimental design consisted of randomized controlled trial.
DATA COLLECTION AND ANALYSIS
Tables were used to describe both the studies' characteristics and the extracted data. The PEDro and Jadad scales were used to assess the quality of studies.
MAIN RESULTS
Of the 1172 total results identified, nine were selected. Seven studies were included in the meta-analysis and indicated a statistically significant decreased number of episiotomies in perineal massage.
CONCLUSIONS
Massage during the second stage of labor appears to be effective in preventing episiotomies and reducing the duration of the second stage of labor. However, it does not appear to be effective in reducing the incidence and severity of perineal tears.
Topics: Humans; Female; Pregnancy; Lacerations; Labor Stage, Second; Massage; Delivery, Obstetric; Parturition; Perineum; Obstetric Labor Complications
PubMed: 36808391
DOI: 10.1002/ijgo.14723 -
Archives of Gynecology and Obstetrics Apr 2024
Topics: Female; Pregnancy; Humans; Epidermal Cyst; Perineum; Vulva
PubMed: 37573272
DOI: 10.1007/s00404-023-07188-1 -
Ginekologia Polska Aug 2014Damage to the perineum, vulva, anal sphincters, rectal wall and the fascial structures of the pelvic floor may be caused by obstetric trauma. Emergency surgical... (Review)
Review
Damage to the perineum, vulva, anal sphincters, rectal wall and the fascial structures of the pelvic floor may be caused by obstetric trauma. Emergency surgical treatment aims at control of the bleeding, anatomical reconstruction of the disrupted tissues and minimization of the risk of infection. Suturing of the rectal wall and mucosa of the anal canal is followed by reconstruction of the perineal body internal and external anal sphincters, vulva and the perineum. Delayed surgery is undertaken after the complete healing of the obstetric tear. All cicatricial fibers must be saved to reinforce sphincters and perineal body muscles suturing. Anal levators and perineal transvers muscles suturing is used for the rectovaginal septum and pelvic floor reconstruction. Anal sphincters are reconstructed by the 'overlapping' technique. X en Z suturing is used for a perineal skin plasty.
Topics: Anal Canal; Female; Humans; Infant, Newborn; Obstetric Labor Complications; Pelvic Floor; Perineum; Postoperative Complications; Pregnancy; Rupture; Suture Techniques; Wound Healing
PubMed: 25219145
DOI: 10.17772/gp/1783 -
Acta Chirurgica Belgica Oct 2021Conventional abdominoperineal resection (APR) has a high rate of local recurrence. Extralevator abdominoperineal excision (ELAPE) can potentially diminish the rate of...
INTRODUCTION
Conventional abdominoperineal resection (APR) has a high rate of local recurrence. Extralevator abdominoperineal excision (ELAPE) can potentially diminish the rate of intraoperative tumour perforation (IOTP) and can provide wider circumferential resection margins (CRM) but at the price of higher perineal complication rate. The aim of our study was to compare the short term results of conventional APR to ELAPE.
MATERIALS AND METHODS
Thirty-five consecutively operated APRs compared to 38 also consecutively operated ELAPEs. Prospectively collected short-term outcome data were analysed retrospectively.
RESULTS
There was no difference in demographics, disease stage or tumour location between groups. IOTP rate and CRM positivity rates were similar between the two groups ( = .608). No difference was found in major (Clavien-Dindo III-V) complications, but we found statistically significant difference in minor (Clavien-Dindo I-II) complications ( = .01) in favour of the ELAPE group. Frequency of perineal SSI was lower in ELAPE group, but the difference was not significant ( = .320). Intraoperative iatrogenic complications occurred at significantly lower rate in ELAPE group ( = .035). Also, postoperative morbidity connected with the dissection in the perineal phase (e.g. urine incontinence, urinary retention) was significantly lower ( = .018) after ELAPE.
DISCUSSION AND CONCLUSIONS
In our experience ELAPE operations may diminish the rate of Clavien-Dindo I-II complications compared to conventional APR. This effect is ensuing from the decrease of intraoperative iatrogenic complications and from the decrease of minor postoperative complications.
Topics: Digestive System Surgical Procedures; Humans; Neoplasm Recurrence, Local; Perineum; Proctectomy; Rectal Neoplasms; Retrospective Studies; Treatment Outcome
PubMed: 32496868
DOI: 10.1080/00015458.2020.1778265 -
American Journal of Obstetrics &... Nov 2021This review presents the available data on the diagnosis of obstetrical anal sphincter injury by postnatal ultrasound imaging. There is increasing evidence that anal... (Review)
Review
This review presents the available data on the diagnosis of obstetrical anal sphincter injury by postnatal ultrasound imaging. There is increasing evidence that anal sphincter tears are often missed after childbirth and, even when diagnosed, often suboptimally repaired, with a high rate of residual defects after reconstruction. Even after postpartum diagnosis and primary repair, 25% to 50% of patients will have persistent anal incontinence. As clinical diagnosis may fail in the detection and classification of obstetrical anal sphincter injury, the use of imaging has been proposed to improve the detection and treatment of these lacerations. Notably, 3-dimensional endoanal ultrasound is considered the gold standard in the detection of obstetrical anal sphincter injury, and recently, 4-dimensional transperineal ultrasound, commonly available in obstetrical and gynecologic settings, has proven to be effective as well. Avoidance of forceps delivery when possible, performance of a rectal examination after vaginal delivery and before repair of any severe perineal tear, and offering sonographic follow-up at 10 to 12 weeks after vaginal delivery in high-risk women (maternal age of ≥35 years, vaginal birth after cesarean delivery, forceps, prolonged second stage of labor, overt obstetrical anal sphincter injury, shoulder dystocia, and macrosomia) may help reduce morbidity arising from anal sphincter tears.
Topics: Adult; Anal Canal; Female; Humans; Lacerations; Perineum; Postpartum Period; Pregnancy; Ultrasonography
PubMed: 34129995
DOI: 10.1016/j.ajogmf.2021.100421 -
Anatomical Sciences Education Sep 2020Progressive curricular changes in medical education over the past two decades have resulted in the diaspora of gross anatomy content into integrated curricula while...
Progressive curricular changes in medical education over the past two decades have resulted in the diaspora of gross anatomy content into integrated curricula while significantly reducing total contact hours. Despite the development of a wide range of alternative teaching modalities, gross dissection remains a critical component of medical education. The challenge posed to modern anatomists is how to maximize and integrate the time spent dissecting under the current curricular changes. In this study, an alternative approach to the dissection of the pelvis and perineum is presented in an effort to improve content delivery and student satisfaction. The approach involves removal of the perineum en bloc from the cadaver followed by excision of the pubic symphysis, removal and examination of the bladder and associated structures, examination and bisection of the midline pelvic organs in situ, and midsagittal hemisection of the pelvis for identification of the neurovasculature. Results indicate that this novel dissecting approach increases the number of structures identified by 46% ± 14% over current dissecting methods. Survey results indicate that students were better able to integrate lecture and laboratory concepts, understand the concepts, and successfully identify more structures using the new approach (P < 0.05). The concept of anatomic efficiency is introduced and proposed as a standard quantitative measure of gross dissection proficiency across programs and institutions. These findings provide evidence that innovative solutions to anatomy education can be found that help to maintain critical content and student satisfaction in a modern medical curriculum.
Topics: Anatomy; Dissection; Female; Humans; Male; Pelvis; Perineum; Young Adult
PubMed: 31758729
DOI: 10.1002/ase.1932