METHODS: This was a retrospective study involving archived data sets of women seen between November 2013 and May 2014. All underwent a clinical interview, POPQ examination, and 4D translabial ultrasound (TLUS). The main outcome measure was organ descent on clinical examination and TLUS. Offline analysis for organ descent was undertaken blinded against all other data.
RESULTS: A total of 224 women were assessed. Mean age was 57 (23-84) years. Median parity was 3 (0-7). Ninety-three percent (n=208) were vaginally parous. Fifty-eight percent (n=129) complained of symptoms of prolapse: 49% (n=110) of a vaginal lump, 27% (n=61) of a dragging sensation. Clinically, mean point B anterior (Ba) was -0.86 (-3 to +7.5) cm, mean cervical station (C) was -4.1 (-9 to +8) cm, mean point B posterior (Bp) was -1.1 (-3 to +5) cm. On imaging, mean bladder, uterine, and rectal descent were -8.3 (-68.0 to 34) mm, +18.6 (-56.4 to 46.3) mm, and -5.3 (-39.8 to 36) mm respectively. On univariate analysis, both symptoms were strongly associated with objective prolapse clinically and on TLUS, with "vaginal lump" consistently the stronger predictor.
CONCLUSIONS: The symptom of a "vaginal lump or bulge" was consistently a stronger predictor of objective POP than "dragging sensation." This finding was insensitive to adjustments for potential confounders. However, a "dragging sensation" is clearly a symptom of prolapse.
METHODS: This was a retrospective study of women seen at a tertiary urogynecological unit. All women had undergone a standardized interview, clinical examination including Modified Oxford Scale (MOS) grading, urodynamic testing and four-dimensional translabial ultrasound (TLUS). Cranioventral shift of the bladder neck (BN) and reduction in the hiatal anteroposterior (AP) diameter were measured using ultrasound volumes acquired on maximal PFM contraction, blinded against all clinical data.
RESULTS: Data from 726 women with a mean age of 56 ± 13.7 (range, 18-88) years and a mean body mass index of 29 ± 6.1 (range, 17-55) kg/m(2) were analyzed. Stress (SI) and urge (UI) urinary incontinence were reported by 73% and 72%, respectively, and 13% had AI. Mean MOS grade was 2.4 ± 1.1 (range, 0-5). Mean cranioventral BN shift on TLUS was 7.1 ± 4.4 (range, 0.3-25.3) mm; mean reduction in AP hiatal diameter was 8.6 ± 4.8 (range, 0.3-31.3) mm. On univariate analysis, neither MOS nor TLUS measures were strongly associated with symptoms of urinary incontinence or AI; associations were non-significant except for BN displacement/SI (7.3 mm vs 6.5 mm; P = 0.028), BN displacement/UI (6.85 vs 7.75; P = 0.019), hiatal AP diameter/AI (9.6 mm vs 8.5 mm; P = 0.047) and MOS/SI (2.42 vs 2.19; P = 0.013).
CONCLUSIONS: In this large retrospective study we did not find any strong associations between sonographic or palpatory measures of PFM function and symptoms of urinary incontinence or AI. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
METHODS: We analysed data from 726 women with a mean age of 56 (SD 13.7, range 18-88) years, seen for symptoms of pelvic floor dysfunction between August 2011 and April 2013. The examination included a standardised interview and clinical assessment of FPOP with Pelvic Organ Prolapse Quantification (POP-Q) measurements, Modified Oxford Scale (MOS) grading and 4D TLUS.
RESULTS: Symptoms of prolapse were reported in 51.4% (373 out of 726) with a mean bother score of 5.8 (SD 2.91, range 0-10). A clinically significant POP (Incontinence Society [ICS]-POP-Q stage ≥ 2) in any compartment was diagnosed in 77.1%. Mean MOS was 2.4 (SD 1.1, range 0-5). Significant POP on TLUS was seen in 54.6% (389 out of 712). TLUS volumes at rest and on maximal PFM contraction were analysed on a desktop PC, to assess the degree of bladder neck (BN) cranioventral shift and levator antero-posterior (AP) diameter reduction, blinded against other data. Mean cranioventral BN shift was 7.11 (SD 4.36, range 0.32-25.32) mm and mean levator AP diameter reduction was 8.6 (SD 4.8, range 0.3-31.3) mm. MOS was strongly associated with subjective and objective POP (P ≤ 0.001), whereas this was not true for TLUS measurements of tissue displacement.
CONCLUSION: The MOS seems to be a more valid measure of PFM function than sonographically determined BN displacement or reduction of hiatal AP diameter observed on PFM contraction.
METHODS: This was a retrospective study on women attending a tertiary urogynecological unit. The assessment included an interview, POPQ assessment, Modified Oxford Scale (MOS) score, and 4D translabial ultrasound (US) on PFM contraction (PMFC). Hormonal status and details on hormone replacement therapy (HRT) were recorded. Corrected menopausal age was defined as the duration of systemic estrogen deprivation. Offline analysis of stored US volumes was performed to measure the reduction in anteroposterior hiatal diameter and bladder neck elevation on PFMC at a later date.
RESULTS: Seven hundred thirty-nine women were seen during the study period. Fifty-three were excluded for missing data, leaving 686. Mean age was 56 (17-89, SD 13.3) years; average BMI was 29 (16-66, SD 6.6) kg/m²; 60.6% (n = 416) were menopausal at a mean duration of 16 (1-56, SD 10.2) years. Forty-nine (7.1%) were currently on systemic HRT, while 104 (15.2%) had used it previously. Mean corrected menopausal age (menopausal age - systemic HRT duration) was 7.4 (0-56, SD 10.0) years. Current local estrogen use ≥ 3 months was reported by 31 (4.5%). Mean PFM contractility measured by MOS was 2 (0-5, SD 1.1,). On multivariate analysis there was no association between menopausal age and PFM contractility.
CONCLUSIONS: Estrogen deprivation may not be an independent predictor of pelvic floor muscle contractility.
METHODS: This is a retrospective observational study utilising 187 archived data sets of women presenting with lower urinary tract symptoms and/or pelvic organ prolapse between August 2012 and November 2013. Evaluation included a standardised interview, ICS-POPQ, rectal examination and 4D translabial ultrasound. The main outcome measure was the diagnosis of rectocele by digital rectal palpation on Valsalva manoeuvre. This diagnosis correlated with the sonographic diagnosis of rectocele to determine agreement between digital examination and ultrasound findings.
RESULTS: Complete data sets were available for 180 participants. On imaging, the mean position of the rectal ampulla was 11.07 (-36.3 to 44.3) mm below the symphysis pubis; 42.8% (77) had a rectocele of a depth of ≥10 mm. On palpation, a rectocele was detected in 60 women (33%). Agreement between palpation and imaging was observed in 77%; the kappa was 0.52 (CI 0.39-0.65). On receiver operator characteristic analysis, the area under the curve was 0.854 for the relationship between rectocele pocket depth and the detection of rectocele on palpation.
CONCLUSION: Moderate agreement was found between digital rectal examination for rectocele and translabial ultrasound findings of a "true rectocele". Digital rectal examination may be used to identify these defects in clinical practice. Extending the clinical examination of prolapse to include rectal examination to palpate defects in the rectovaginal septum may reduce the need for defecatory proctograms for the assessment of obstructive defecation and may help triage patients in the management of posterior compartment prolapse.
METHODS: This was a retrospective observational study at a tertiary urogynecological unit. A total of 337 patients were seen for a standardized interview, clinical examination (ICS POP-Q) and 4D translabial ultrasonography. Stored imaging data were analyzed offline to evaluate functional pelvic floor anatomy and investigate associations with symptoms and other findings.
RESULTS: Of the 337 women seen during the study period, 13 were excluded due to missing data, leaving 324. Vaginal laxity was reported by 24% with a mean bother of 5.7. In a univariate analysis, this symptom was associated with younger age, vaginal parity, POP symptoms and bother, clinically and sonographically determined POP and hiatal area on Valsalva maneuver.
CONCLUSIONS: Vaginal laxity or 'looseness' is common in our urogynecology service at a prevalence of 24%. The associated bother is almost as high as the bother associated with conventional prolapse symptoms. It is associated with younger age, vaginal parity, symptoms of prolapse, prolapse bother and objective prolapse on POP-Q examination and imaging, suggesting that vaginal laxity may be considered a symptom of prolapse. The strongest associations were found with gh + pb and hiatal area on Valsalva maneuver, suggesting that vaginal laxity is a manifestation of levator ani hyperdistensibility.
Methods: This was a prospective observational study of women who delivered vaginally in Universiti Kebangsaan Malaysia Medical Centre from March 2017 to September 2017. Those who were able to void within 6 hours after delivery, the voided volume measurements were taken at their second void followed by measurement of residual urine using a transabdominal ultrasound scan. For those unable to void at 6 hours postpartum, the bladder volume was measured. If the bladder volume was 500 ml or more, an indwelling catheter would be inserted and kept for 24 hours.
Results: A total of 155 patients who fulfilled the inclusion were recruited. There were 143 (92.3%) patients who had residual urine volume of less than 150 ml at second void. Out of these 143 patients, 138 (96.5%) had residual urine volume of less than 100 ml, and among the 138 patients, 119 (86.2%) had residual urine volume of less than 50 ml. The median residual urine volume was 10 ml (2, 42). The overall rate of postpartum urinary retention (PPUR) was 7.7%; 6 (3.85%) had overt retention and 6 (3.85%) had covert retention. Primiparity, duration of active phase of labour, duration of second stage of labour, epidural analgesia, episiotomy, instrumental delivery, and perineal pain score were independent risk factors associated with postpartum urinary retention.
Conclusion: Postpartum urinary retention complicates approximately 7.7% of vaginal deliveries. Majority (86.2%) of them had residual urine volume less than 50 ml. Obstetrics factors independently associated with PPUR include primiparity, duration of active phase of labour, duration of second stage of labour, epidural analgesia, episiotomy, instrumental delivery, and degree of perineal pain.
METHODS: An observational cross-sectional study of 964 archived datasets of women seen for symptoms and signs of lower urinary tract and pelvic organ dysfunction between September 2011 and February 2014 at a tertiary urogynaecology centre in Australia was carried out. An in-house standardised interview, the International Continence Society Pelvic Organ Prolapse Quantification (ICS POP-Q) and 4-D translabial ultrasound, followed by analysis of ultrasound volumes for pelvic organ descent and hiatal area on Valsalva, were performed, blinded against other data.
RESULTS: There is a positive association between BMI and posterior compartment prolapse on clinical examination and ultrasound imaging, but not for the anterior and central compartments. There was no association with prolapse symptom bother and a negative association with symptoms of prolapse.
CONCLUSIONS: In this observational study, we found a strong association between all tested measures of posterior compartment descent and BMI, both clinical and on imaging.
METHODS: This retrospective observational study involved 1296 women seen in a urogynaecological centre. All had undergone an interview, clinical examination and 4D ultrasound (US) imaging supine and after voiding. Offline analysis of volume data was undertaken blinded against other data. Rectal ampulla position and rectocele depth were measured on Valsalva. A pocket depth of 10 mm was used as a cutoff to define rectocele on imaging.
RESULTS: Most women presented with prolapse (53%, n = 686); 810 (63%) complained of obstructed defecation (OD). Clinically, 53% (n = 690) had posterior-compartment prolapse with a mean Bp of -1 [standard deviation (SD)1.5; -3 to 9 cm]. Mean descent of the rectal ampulla was 10 mm below the symphysis (SD 15.8; -50 to 41). A rectocele on imaging was found in 48% (n = 618). On univariate analysis, OD symptoms were strongly associated with rectal descent, rectocele depth and rectocele on imaging (all P
METHODS: A randomized controlled trial was conducted from 2008 to 2020 at the Obstetrics and Gynaecology Clinic of the Universiti Kebangsaan Malaysia Medical Centre. Primigravida mothers diagnosed with DRA were selected and randomly assigned to the intervention (n=21) or control (n=20) group. The intervention group underwent a home-based STEP consisting of three phases of nine abdominal exercises. DRA size was assessed at baseline and at 8 weeks postpartum using two-dimensional ultrasound.
RESULTS: The mean age of the participants was 28 years (standard deviation, 3.6), with the majority of Malay ethnicity (87.8%) and working mothers (78%). After 8 weeks, the intervention group showed a significant reduction in DRA size of up to 27% (mean difference, 6.17 mm; 95% confidence interval, 3.7-8.7; P<0.001). No significant intergroup DRA changes were observed after 8 weeks of follow-up.
CONCLUSION: Early postpartum screening for DRA should be advocated to allow early STEP intervention to ensure favorable outcomes. STEP intervention is an effective postnatal training program for managing DRA.
METHODS: A total of 271 patients were analysed in a retrospective study utilising archived ultrasound volume datasets. Symptoms of obstructed defecation (straining at stool, incomplete bowel emptying, perineal, vaginal and anal digitation) were ascertained on interview. Postprocessing of stored 3D/4D translabial ultrasound datasets obtained on maximal Valsalva was used to diagnose descent of the rectal ampulla, rectocoele, enterocoele and rectal intussusception at a later date, blinded to all clinical data.
RESULTS: Digitation was reported by 39 % of our population. The position of the rectal ampulla on Valsalva was associated with perineal (p = 0.02) and vaginal (p = 0.02) digitation. The presence of a true rectocoele was significantly associated with perineal (p = 0.04) and anal (p = 0.03) digitation. Rectocoele depth was associated with all three forms of digitation (P = 0.005-0.02). The bother of symptoms of obstructed defecation was strongly associated with digitation (all P
METHODS: This is a retrospective observational study involving 58 pregnancies from 1st January 2013 to 31st December 2019. Inclusion criteria were previous mid-trimester miscarriage and/or preterm birth, previous cervical surgery or short cervical length on routine sonogram. The demographic data, characteristics of each pregnancy and details of outcomes and management were described.
RESULTS: The majority of women were Malay with mean age and body mass index of 32.9 ± 4.2 years and 27.1 ± 6.3 kg/m2 respectively. The most frequent indications for Arabin pessary insertion were previous mid-trimester miscarriage (46.4%) and early preterm birth (17.2%). A total of 73.4% of these women had the pessary inserted electively at a mean cervical length of 31.6 ± 9.1 mm at median gestation of 15.0 weeks. They were managed as outpatient (56.9%), inpatient (24.1%) or mixed (19.0%) with combination of progestogen (81.0%) and 53.4% received antenatal corticosteroids. Spontaneous preterm birth at or more than 34 weeks gestation occurred in 74.1% with birthweight at or more than 2000 g (82.4%). Despite cervical funneling in 12 women (20.7%), 66.7% delivered at or later than 34 weeks gestation and 2 (16.7%) resulted in miscarriage.
CONCLUSIONS: Insertion of the Arabin pessary is beneficial to prevent spontaneous preterm birth in pregnant women who are at high risk. In particular, early insertion and close monitoring allows the best possible outcomes.
TRIAL REGISTRATION: This study was retrospectively registered with ClinicalTrials.gov ( NCT04638023 ) on 20/11/2020.
METHODS: This was a cross-sectional study involving 195 women enrolled in a longitudinal cohort study and seen 20 years after an index birth. All had a standardized patient-administered questionnaire, the International Continence Society Pelvic Organ Prolapse Quantification assessment and 4D translabial ultrasound. Main outcome measures were objective POP clinically and on translabial ultrasound. Postimaging assessment of levator integrity and sonographically determined pelvic organ descent was done blinded against other data.
RESULTS: Of 195 women who were seen a mean of 23 (range, 19.4-46.2) years after their first birth, one declined ultrasound assessment and was excluded, leaving 194. Mean age was 50.2 (range 36.9-66.5) years with a mean body mass index (BMI) of 27.6 (range, 18.3-54.3) kg/m2 . Median parity was 3 (range 1-14). Ninety-one percent (n = 176) had delivered vaginally. Eighteen percent (n = 34) were symptomatic of prolapse. Clinically, 36% (n = 69) had significant POP. Levator avulsion was diagnosed in 16% (n = 31). Mean levator avulsion defect score was 2.2 (range, 0-12). On univariate analysis, levator avulsion and levator avulsion defect score were associated with clinically and sonographically significant POP, that is, odds ratio 2.6 (1.2-5.7), P = .01; and odds ratio 3.3 (1.4-7.7); P = .003, respectively; Ba (P
METHODS: This is a retrospective review using archived data sets of women seen in the context of two prospective perinatal imaging studies. All subjects had undergone a standardised interview, a clinical examination and 4D translabial ultrasound, 3 months and 2-5 years post-partum. Main outcome measures were pelvic organ descent and hiatal area at maximum Valsalva manoeuvre. Means at the two time points were compared using paired Student's t test. Predictors of change over time in continuous variables were explored using linear modelling methods.
RESULTS: A total of 300 women had at least two postnatal follow-ups. They were first seen on average 0.39 (SD 0.2, range 0.2-2.1) years and again 3.1 (SD 1.5, range 1.4-8) years after the index delivery, with a mean interval of 2.71 (SD 1.5, range 0.7-7.7) years, providing a total of 813 (300 × 2.71) woman-years of observation. On univariate analysis, there was a significant decrease in mobility over time of the bladder neck, bladder, and rectal ampulla (P = < 0.004) and hiatal area (P = 0.012). The degree of improvement was less marked in women with levator avulsion.
CONCLUSIONS: A significant reduction in pelvic organ descent and hiatal area was noted over a mean of 2.7 years after a first birth.
AIMS: Our objective was to investigate long-term association between delivery mode, LAM avulsion and obstetric anal sphincter injuries (OASIS) in women at least 20 years after their first birth.
METHODS: All women recruited at 'index birth' of the Dunedin (New Zealand) arm of ProLong (PROlapse and incontinence LONG-term research) Study, were invited to have translabial and transperineal ultrasound assessment of LAM and anal sphincters. Post-processing analysis of imaging data was performed blinded against delivery data. Statistical analysis was performed using the χ2 test and results are expressed as odds ratios (OR).
RESULTS: Of the initial 1250 participants, 196 women returned for examination. Mean age was 50.8 years with a mean body mass index of 27.6 and median parity was three. They were seen on average 23 years after their first delivery. Four data sets were unavailable and one declined ultrasound assessment, leaving 191 for analysis. LAM avulsion was diagnosed in 29 (15.2%), and 24 women (12.6%) had significant anal sphincter defect. LAM avulsion was associated with forceps delivery (OR 2.45, 95% CI 1.04-5.80, P = 0.041). Forceps conveyed a greater risk of OASIS (21%) compared to a spontaneous vaginal delivery (11%) but did not reach statistical significance.
CONCLUSIONS: Forceps delivery is associated with long-term injurious effect on pelvic floor structures. Discussions of the long-term negative impact of pelvic floor structures and their functions are necessary to achieve an informed consent toward an operative vaginal delivery.
METHODS: The P-QOL questionnaire was translated into the Malay language and subsequently back-translated to English. Test-retest reliability and internal consistency were tested. All patients who visited the gynecology outpatient clinic of UKMMC, UMMC and IIUM between January 2016 and May 2017 completed the P-QOL questionnaires and were assessed for POP-Q staging.
RESULTS: One hundred twenty patients with symptomatic pelvic organ prolapse and 180 asymptomatic patients were included. The Cronbach's alpha for each domain was > 0.70, which confirmed that there was a highly acceptable internal consistency. The value varied between 0.88 (role limitation) and 0.912 (sleep/energy). Test-retest reliability showed a significant correlation between the total scores for each domain (p
METHODS: This was a retrospective study of 3980 singletons, term pregnancy, spontaneous labouring women between 2015 and 2019 comparing outcomes between those with cervical dilation of 4 versus 6 cm at diagnosis of the active phase of labour.
RESULTS: A total of 3403 (85.5%) women had cervical dilatation of 4 cm, and 577 (14.5%) at 6 cm upon diagnosis of the active phase of labour. Women in 4 cm group were significantly heavier at delivery (p = 0.015) but significantly more multiparous women were in 6 cm group (p