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International Urogynecology Journal Feb 2023The failure of the levator hiatus (LH) and urogenital hiatus (UGH) to remain closed is not only associated with pelvic floor disorders, but also contributes to... (Review)
Review
INTRODUCTION AND HYPOTHESIS
The failure of the levator hiatus (LH) and urogenital hiatus (UGH) to remain closed is not only associated with pelvic floor disorders, but also contributes to recurrence after surgical repair. Pregnancy and vaginal birth are key events affecting this closure. An understanding of normal and failed hiatal closure is necessary to understand, manage, and prevent pelvic floor disorders.
METHODS
This narrative review was conducted by applying the keywords "levator hiatus" OR "genital hiatus" OR "urogenital hiatus" in PubMed. Articles that reported hiatal size related to pelvic floor disorders and pregnancy were chosen. Weighted averages for hiatal size were calculated for each clinical situation.
RESULTS
Women with prolapse have a 22% and 30% larger LH area measured by ultrasound at rest and during Valsalva than parous women with normal support. Women with persistently enlarged UGH have 2-3 times higher postoperative failure rates after surgery for prolapse. During pregnancy, the LH area at Valsalva increases by 29% from the first to the third trimester in preparation for childbirth. The enlarged postpartum hiatus recovers over time, but does not return to nulliparous size after vaginal birth. Levator muscle injury during vaginal birth, especially forceps-assisted, is associated with increases in hiatal size; however, it only explains a portion of hiatus variation-the rest can be explained by pelvic muscle function and possibly injury to other level III structures.
CONCLUSIONS
Failed hiatal closure is strongly related to pelvic floor disorders. Vaginal birth and levator injury are primary factors affecting this important mechanism.
Topics: Pregnancy; Female; Humans; Pelvic Floor Disorders; Pelvic Floor; Parturition; Postpartum Period; Ultrasonography; Prolapse; Imaging, Three-Dimensional
PubMed: 36129480
DOI: 10.1007/s00192-022-05354-8 -
International Urogynecology Journal May 2017The paravaginal defect has been a topic of active discussion concerning what it is, how to diagnose it, its role in anterior vaginal wall prolapse, and if and how to... (Review)
Review
INTRODUCTION AND HYPOTHESIS
The paravaginal defect has been a topic of active discussion concerning what it is, how to diagnose it, its role in anterior vaginal wall prolapse, and if and how to repair it. The aim of this article was to review the existing literature on paravaginal defect and discuss its role in the anterior vaginal wall support system, with an emphasis on anatomy and imaging.
METHODS
Articles related to paravaginal defects were identified through a PubMed search ending 1 July 2015.
RESULTS
Support of the anterior vaginal wall is a complex system involving levator ani muscle, arcus tendineus fascia pelvis (ATFP), pubocervical fascia, and uterosacral/cardinal ligaments. Studies conclude that physical examination is inconsistent in detecting paravaginal defects. Ultrasound (US) and magnetic resonance imaging (MRI) have been used to describe patterns in the appearance of the vagina and bladder when a paravaginal defect is suspected. Different terms have been used (e.g., sagging of bladder base, loss of tenting), which all represent changes in pelvic floor support but that could be due to both paravaginal and levator ani defects.
CONCLUSION
Paravaginal support plays a role in supporting the anterior vaginal wall, but we still do not know the degree to which it contributes to the development of prolapse. Both MRI and US are useful in the diagnosis of paravaginal defects, but further studies are needed to evaluate their use.
Topics: Female; Humans; Magnetic Resonance Imaging; Pelvic Floor; Pelvic Organ Prolapse; Ultrasonography; Urinary Bladder; Vagina
PubMed: 27640064
DOI: 10.1007/s00192-016-3096-3 -
Urologia Internationalis 2010The human pelvic floor is a complex structure and pelvic floor dysfunction is seen frequently in females. (Review)
Review
INTRODUCTION
The human pelvic floor is a complex structure and pelvic floor dysfunction is seen frequently in females.
MATERIALS AND METHODS
This review focuses on the surgical reconstruction of the pelvic floor employing recent findings on functional anatomy. A selective literature research was performed by the authors.
RESULTS
Pelvic floor activity is regulated by 3 main muscular forces that are responsible for vaginal tension and suspension of the pelvic floor organs, bladder and rectum. A variety of symptoms can derive from pelvic floor dysfunctions, such as urinary urge and stress incontinence, abnormal bladder emptying, fecal incontinence, obstructive bowel disease syndrome and pelvic pain. These symptoms mainly derive, for different reasons, from laxity in the vagina or its supporting ligaments as a result of altered connective tissue. Pelvic floor reconstruction is nowadays driven by the concept that in case of pelvic floor symptoms, restoration of the anatomy will translate into restoration of the physiology and ultimately improve patients' symptoms.
CONCLUSION
The surgical reconstruction of the anatomy is almost exclusively focused on the restoration of the lax pelvic floor ligaments. Exact preoperative identification of the anatomical lesions is necessary to allow for exact anatomical reconstruction with respect to the muscular forces of the pelvic floor.
Topics: Female; Humans; Models, Anatomic; Muscle, Skeletal; Pelvic Floor; Pelvic Pain; Plastic Surgery Procedures; Surveys and Questionnaires; Urinary Bladder; Urinary Incontinence; Urology
PubMed: 20173361
DOI: 10.1159/000273458 -
International Journal of Environmental... Feb 2023The purpose of the study was to investigate 1: overall knowledge of pelvic organ prolapse (POP) and urinary incontinence (UI) as well as knowledge, attitudes, and...
The purpose of the study was to investigate 1: overall knowledge of pelvic organ prolapse (POP) and urinary incontinence (UI) as well as knowledge, attitudes, and practice of pelvic floor muscle exercise (PFME); and 2: the association of these factors with parity in pregnant women in Gondar, Ethiopia. A facility-based cross-sectional study was performed in the Central Gondar zone, northwest Ethiopia between February and April 2021. The associations between parity and knowledge of POP and UI, and knowledge, attitude, and practice towards PFME were estimated using logistics regression models and presented as crude and adjusted odds ratios with 95% confidence intervals. Nulliparous women were used as the reference. Adjustments were made for maternal age, antenatal care visits, and level of education. The study sample comprised 502 pregnant women: 133 nulliparous, and 369 multiparous. We found no association between parity and knowledge of POP, UI, or knowledge, attitude, and practice toward PFME. The sum score indicated poor knowledge about both POP, UI, and PFME in the study population, and poor attitude and practice of PFME. Despite a high attendance in antenatal care services, knowledge, attitude, and practice were poor, indicating a need for quality improvement of the services.
Topics: Female; Pregnancy; Humans; Pelvic Floor Disorders; Pregnant Women; Pelvic Floor; Cross-Sectional Studies; Health Knowledge, Attitudes, Practice; Ethiopia; Urinary Incontinence; Surveys and Questionnaires
PubMed: 36901212
DOI: 10.3390/ijerph20054201 -
Acta Obstetricia Et Gynecologica... Oct 2022Hysterectomy is one of the most common major surgical procedures in women. The effects of hysterectomy on pelvic floor and sexual function are uncertain. Our objective...
INTRODUCTION
Hysterectomy is one of the most common major surgical procedures in women. The effects of hysterectomy on pelvic floor and sexual function are uncertain. Our objective was to investigate the effects of hysterectomy for benign indications on pelvic floor and sexual function and to compare different modes of surgery.
MATERIAL AND METHODS
We performed a prospective clinical cohort study. In all, 260 women scheduled for hysterectomy answered validated questionnaires (Pelvic Floor Impact Questionnaire, Pelvic Floor Distress Inventory and Female Sexual Function Index). Participants were followed 6 months and 1 year after surgery. Data were analyzed using nonparametric statistics and mixed effect models.
RESULTS
Women with subtotal hysterectomy, vaginal hysterectomy, laparoscopic assisted vaginal hysterectomy, and previous prolapse/incontinence surgery were excluded from further analysis, leaving the remaining cohort to 242 patients. The response rate at 6 months and 1 year follow-up was 180/242 (74.3%) and 169/242 (69.8%), respectively. There was an improvement of pelvic floor function at both follow-ups; mean score of Pelvic Floor Impact Questionnaire at baseline was 42.5 (51.7), at 6 months 19.9 (42.2) and at 1 year 23.7 (50.3) (p < 0.001). The mean score of Pelvic Floor Distress Inventory at baseline was 69.6 (51.1), at 6 months 49 (43.2) and at 1 year 49 (43.2) (p < 0.001). There was an improvement of sexual function after 6 months (mean score of Female Sexual Function Index at baseline 17.9 [SD 11.7] and at 6 months 21.0 [SD 11.7]) (p < 0.001). There was no difference in pelvic floor or sexual function when comparing surgical techniques.
CONCLUSIONS
Robotic assisted laparoscopic hysterectomy, laparoscopic hysterectomy and abdominal hysterectomy improve pelvic floor function to the same extent at 6 months and 1 year after surgery. There was an overall improvement of sexual function 6 months after hysterectomy, but this did not persist after 1 year.
Topics: Cohort Studies; Female; Humans; Hysterectomy; Pelvic Floor; Pelvic Organ Prolapse; Prospective Studies; Quality of Life; Surveys and Questionnaires; Treatment Outcome
PubMed: 36004493
DOI: 10.1111/aogs.14437 -
Scientific Reports May 2021Pelvic floor muscle stretch injury during pregnancy and birth is associated with the incidence of stress urinary incontinence (SUI), a condition that affects 30-60% of...
Pelvic floor muscle stretch injury during pregnancy and birth is associated with the incidence of stress urinary incontinence (SUI), a condition that affects 30-60% of the female population and is characterized by involuntary urine leakage during physical activity, further exacerbated by aging. Aging and multiparous rabbits suffer pelvic nerve and muscle damage, resulting in alterations in pelvic floor muscular contraction and low urethral pressure, resembling SUI. However, the extent of nerve injury is not fully understood. Here, we used electron microscopy analysis of pelvic and perineal nerves in multiparous rabbits to describe the extent of stretch nerve injury based on axon count, axon size, myelin-to-axon ratio, and elliptical ratio. Compared to young nulliparous controls, mid-age multiparous animals showed an increase in the density of unmyelinated axons and in myelin thickness in both nerves, albeit more significant in the bulbospongiosus nerve. This revealed a partial but sustained damage to these nerves, and the presence of some regenerated axons. Additionally, we tested whether electrical stimulation of the bulbospongiosus nerve would induce muscle contraction and urethral closure. Using a miniature wireless stimulator implanted on this perineal nerve in young nulliparous and middle age multiparous female rabbits, we confirmed that these partially damaged nerves can be acutely depolarized, either at low (2-5 Hz) or medium (10-20 Hz) frequencies, to induce a proportional increase in urethral pressure. Evaluation of micturition volume in the mid-age multiparous animals after perineal nerve stimulation, effectively reversed a baseline deficit, increasing it 2-fold (p = 0.02). These results support the notion that selective neuromodulation of pelvic floor muscles might serve as a potential treatment for SUI.
Topics: Aging; Animals; Axons; Electric Stimulation; Female; Nerve Regeneration; Nerve Tissue; Parity; Pelvic Floor; Pregnancy; Pressure; Rabbits; Urinary Incontinence, Stress; Urodynamics
PubMed: 34011938
DOI: 10.1038/s41598-021-90088-8 -
Scientific Reports Oct 2023Urinary incontinence (UI) is defined as any uncontrolled urine leakage. Pelvic floor muscles (PFM) appear to be a crucial aspect of trunk and lumbo-pelvic stability, and...
Urinary incontinence (UI) is defined as any uncontrolled urine leakage. Pelvic floor muscles (PFM) appear to be a crucial aspect of trunk and lumbo-pelvic stability, and UI is one indication of pelvic floor dysfunction. The evaluation of pelvic tilt and lumbar angle is critical in assessing the alignment and posture of the spine in the lower back region and pelvis, and both of these variables are directly related to female dysfunction in the pelvic floor. UI affects a significant number of women worldwide and can have a major impact on their quality of life. However, traditional methods of assessing these parameters involve manual measurements, which are time-consuming and prone to variability. The rehabilitation programs for pelvic floor dysfunction (FSD) in physical therapy often focus on pelvic floor muscles (PFMs), while other core muscles are overlooked. Therefore, this study aimed to predict the activity of various core muscles in multiparous women with FSD using multiple scales instead of relying on Ultrasound imaging. Decision tree, SVM, random forest, and AdaBoost models were applied to predict pelvic tilt and lumbar angle using the train set. Performance was evaluated on the test set using MSE, RMSE, MAE, and R. Pelvic tilt prediction achieved R values > 0.9, with AdaBoost (R = 0.944) performing best. Lumbar angle prediction performed slightly lower with decision tree achieving the highest R of 0.976. Developing a machine learning model to predict pelvic tilt and lumbar angle has the potential to revolutionize the assessment and management of this condition, providing faster, more accurate, and more objective assessments than traditional methods.
Topics: Female; Humans; Quality of Life; Urinary Incontinence; Pelvic Floor; Physical Therapy Modalities; Muscular Diseases; Posture
PubMed: 37863988
DOI: 10.1038/s41598-023-44964-0 -
Medicine Jan 2021The pelvic floor muscle (PFM) is associated with respiratory function. We investigated the effects of PFM training by pelvic floor electrical stimulation (PFES) on PFM... (Randomized Controlled Trial)
Randomized Controlled Trial
Effect of pelvic floor electrical stimulation on diaphragm excursion and rib cage movement during tidal and forceful breathing and coughing in women with stress urinary incontinence: A randomized controlled trial.
BACKGROUND
The pelvic floor muscle (PFM) is associated with respiratory function. We investigated the effects of PFM training by pelvic floor electrical stimulation (PFES) on PFM strength, diaphragm excursion, and upper rib cage movement during tidal and forceful breathing and coughing in women with stress urinary incontinence (SUI).
METHODS
In total, 33 participants with SUI were divided into PFES and control groups. The two groups were measured pre- and post-8 weeks of training. Diaphragm excursion and upper rib cage movement during tidal and forceful breathing and coughing and PFM strength were measured using sonography, electromagnetic sensors, and perineometry.
RESULTS
There were significant difference of main effect between pre- and post-training and between groups in PFM strength (between groups: P = .001, between time: P < .001) and diaphragm excursion during forceful breathing (between groups: P = .015, between time: P = .026) and coughing (between groups: P = .035, between time: P = .006). There were significant differences in diaphragm excursion during tidal (P = .002) and forceful breathing (P = .005) and coughing (P < .001) between pre- and post-training in the PFES group. Elevation of the upper rib cage during tidal (P < .001) and forceful breathing (P = .001) was significantly decreased after 8 weeks of training in the PFES group. Widening in the horizontal plane in the upper rib cage during forceful breathing (P < .001) was significantly increased after 8 weeks of training in the PFES group. PFM strength (P < .001) was significantly increased after 8 weeks of training in the PFES group.
CONCLUSIONS
Pelvic floor muscles training by electrical stimulation can improve diaphragm excursion and breathing patterns in women with SUI.
Topics: Adult; Cough; Diaphragm; Electric Stimulation; Female; Humans; Middle Aged; Pelvic Floor; Republic of Korea; Rib Cage; Tidal Volume; Treatment Outcome; Ultrasonography; Urinary Incontinence, Stress
PubMed: 33429797
DOI: 10.1097/MD.0000000000024158 -
Ultrasound in Obstetrics & Gynecology :... Nov 2018To describe morphometry of the pelvic floor in a large population of nulliparous women, comparing those with and those without pelvic pain. We also aimed to assess its...
OBJECTIVES
To describe morphometry of the pelvic floor in a large population of nulliparous women, comparing those with and those without pelvic pain. We also aimed to assess its association with characteristics such as age and body mass index (BMI).
METHODS
This was a prospective study performed between January 2013 and November 2015 in non-pregnant nulliparous women attending a general gynecology clinic. Following collection of demographic data, women were examined using translabial four-dimensional (4D) ultrasound. Dynamic volumes of pelvic floor muscle were obtained at rest, on maximal contraction and on Valsalva maneuver, and analyzed at a later date by an assessor blinded to demographic details. Standard measurements for each volume included levator hiatal area and anteroposterior and transverse diameters, and pubovisceral muscle length and width. Subanalysis was performed comparing women with and those without pelvic pain. Linear regression analysis was performed to assess the association between characteristics, including age and BMI, and levator hiatal area at rest.
RESULTS
Three hundred and sixty eight nulliparous women were examined using translabial 4D ultrasound. Median levator hiatal area was 10.62 cm at rest, 11.95 cm on Valsalva maneuver and 8.18 cm on maximal contraction. There was no difference between women with and those without pelvic pain when comparing biometric measurements of the pelvic floor musculature, except for in pubovisceral muscle width during the contraction phase. Regression analysis demonstrated that higher age and BMI were associated with increased levator hiatal area measurement.
CONCLUSIONS
Pelvic floor morphometry in nulliparous women is unchanged by pelvic pain, but levator hiatal area is increased in women with higher BMI and age. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
Topics: Adult; Age Factors; Body Mass Index; Female; Humans; Muscle Contraction; Pelvic Floor; Pelvic Pain; Ultrasonography; Valsalva Maneuver; Young Adult
PubMed: 29700879
DOI: 10.1002/uog.19075 -
Radiologie (Heidelberg, Germany) Nov 2023Pelvic floor dysfunction is common in women. (Review)
Review
BACKGROUND
Pelvic floor dysfunction is common in women.
OBJECTIVES
To describe the role of ultrasound in the urogynecological examination and imaging of the pelvic floor.
MATERIALS AND METHODS
Analysis and summary of current recommendations and literature on the role of pelvic floor ultrasound.
RESULTS
Pelvic floor ultrasound is a dynamic and real-time imaging modality. It is readily available, allows for a realistic assessment of anatomy and morphology, and poses minimal patient burden.
CONCLUSIONS
Pelvic floor ultrasound is of great value in preoperative diagnostics as well as in the postoperative management of complications.
Topics: Female; Humans; Pelvic Floor; Pelvic Organ Prolapse; Ultrasonography; Pelvic Floor Disorders; Postoperative Period
PubMed: 37789193
DOI: 10.1007/s00117-023-01215-7