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.

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 cm(2) (SD 9.4 cm(2) ). 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).

METHODS: This is a retrospective study on 750 women seen at a tertiary urogynecological unit who had undergone a standardized interview, clinical examination, and 4D TPUS. Univariate and multivariate logistic regression analyses were undertaken to study the association between examination findings and symptoms of OD. This study was approved by the local human research ethics committee (Nepean Blue Mountains Local Health District Human Research Ethics Committee, IRB approval no. 13-16).

METHODS: This was a retrospective study utilizing records of patients referred to a tertiary urogynecological service between November 2012 and March 2013. Patients underwent a standardized interview, clinical assessment using the POP quantification system of the International Continence Society and four-dimensional translabial ultrasound. The craniocaudal difference in the location of minimal distances in mid-sagittal and coronal planes was determined by offline analysis of ultrasound volumes, and provided a numerical measure of warping. We tested potential predictors, such as demographic factors, signs and symptoms of prolapse, levator avulsion and levator distensibility, for an association with warping.

STUDY DESIGN: This was a retrospective observational study involving vaginally nulliparous women who presented to a tertiary urogynaecology unit with symptoms and signs of pelvic floor dysfunction between 2006 and 2014. Nulliparous women were compared with those who delivered exclusively by Caesarean Section (CS). All had undergone a standardised clinical interview, ICS POP-Q assessment and 3D/4D translabial pelvic floor ultrasound. Main outcome measures included sonographically determined pelvic organ position and hiatal dimensions on Valsalva and pelvic floor muscle contraction (PFMC).

RESULTS: Of 2930 women seen during the study period, 242 had never given birth vaginally. One hundred and twenty-nine (53 %) were nulliparous, and 113 (47 %) were delivered by CS only. The CS group demonstrated significantly higher pelvic organ mobility in the anterior compartment (all P < 0.05) and a larger hiatal area on Valsalva (P = 0.004). All sonographic measures of pelvic floor muscle function demonstrated greater tissue displacement on PFMC in the CS group (all P < 0.05).

MATERIAL AND METHODS: In this retrospective observational study the records of patients attending a tertiary urogynecological unit between January 2012 and December 2014 were analyzed. POP assessment included a standardized interview, clinical examination using Pelvic Organ Prolapse Quantification and four-dimensional translabial ultrasound. Puborectalis muscle trauma was assessed with tomographic ultrasound imaging using two continuous scoring systems and a previously established discrete system. Receiver operating characteristics and adjusted odds ratios were used for comparison of scoring systems in predicting symptoms and signs of POP.

RESULTS: Of 1258 women analyzed, 52.6% complained of prolapse symptoms. On ultrasound imaging, 65.7% of women had sonographically significant POP. Complete avulsion was diagnosed in 25.3% of women, being unilateral in 13.9% and bilateral in 11.4%. A maximum score in the 6-point and the 12-point tomographic ultrasound imaging scale increased the odds for a diagnosis of any significant POP on ultrasound by 4.4 and 4.8 times, respectively, compared with 4.6 times for the discrete diagnosis of bilateral avulsion. For all avulsion scoring systems the relation was strongest for cystocele and uterine prolapse.

METHODS: This is an observational, cross-sectional analysis of 486 women who presented to a tertiary urogynecological center between May 2013 and August 2014. They underwent a standardized interview and an examination that involved 3-dimensional/4-dimensional TPUS. The SMIS and VAS were administered if they answered positively to a question on AI. The association between defects of the EAS and symptoms of AI was evaluated using bivariate tests, as well as adjusting for pertinent covariates using multiple linear regression modeling.

RESULTS: Of the included patients, 17.1% reported AI, and 15.2% had significant EAS defects (≥4 slices) on TPUS imaging. A significant sonographic defect was diagnosed in 23% of women with AI versus 14% of those without (P = 0.033). Women with symptoms of AI were more likely to have a significant defect on TPUS (odds ratio, 1.878; 95% confidence interval, 1.05-3.37). No significant findings were seen when analyzing SMIS, its components, and VAS against sonographic EAS defects.

METHODS: This work was a retrospective study of 175 women seen in a tertiary urogynecologic center for symptoms of lower urinary tract and pelvic floor dysfunction. All underwent a standardized interview, POP quantification prolapse assessment, and 4-dimensional translabial US examination in supine and standing positions. Offline measurement of organ descent on the Valsalva maneuver was undertaken at a later date and was blinded against all other data.

METHODS: This study was a retrospective analysis using data sets of nulliparous women seen antenatally. All women had a 4-dimensional TLUS examination at a mean gestational age ± SD of 36 ± 0.7 (range, 32.9-37.3) weeks. Anal sphincter biometry, including external anal sphincter (EAS) length and thickness, EAS proximal rotational asymmetry, and internal anal sphincter thickness, was assessed blinded against other data.

METHODS: A retrospective observational study involving postmenopausal women with pelvic floor dysfunction attending a tertiary urogynecology center between January 2012 and March 2015. All underwent a clinical examination including International Continence Society Pelvic Organ Prolapse Quantification and 4D translabial ultrasound imaging. Information on current or former use of systemic HT and current local estrogen use was collected. Main outcome measure was pelvic organ support.

RESULTS: One thousand four hundred forty-three women were seen during the study period. On univariate analysis, current HT was significantly associated with sonographically determined descent of the rectal ampulla (β [95% confidence interval] 3.4 mm [0.4-6.5], P = 0.03) and Gh + Pb (-0.45 mm [-0.8 to -0.1], P = 0.005). Past HT use, duration of HT use, or current vaginal estrogen use was not associated with pelvic organ support. On multivariate analysis controlling for age, parity, body mass index, history of forceps delivery, and avulsion, the association between current HT on the one hand and Gh + Pb as well as increased descent of the rectal ampulla on ultrasound, remained significant (P = 0.008 and P = 0.012, respectively).

OBJECTIVE: In this study we use transperineal ultrasound to identify how many women will achieve a normal vaginal delivery without substantial damage to the levator ani or anal sphincter muscles, and to create a model to predict patient characteristics associated with successful atraumatic normal vaginal delivery.

STUDY DESIGN: This is a retrospective, secondary analysis of data sets gathered in the context of an interventional perinatal imaging study. A total of 660 primiparas, carrying an uncomplicated singleton pregnancy, underwent an antepartum and postpartum interview, vaginal exam (Pelvic Organ Prolapse Quantification), and 4-dimensional translabial ultrasound. Ultrasound data were analyzed for levator trauma and/or overdistention and residual sphincter defects. Postprocessing analysis of ultrasound volumes was performed blinded against clinical data and analyzed against obstetric data retrieved from the local maternity database. Levator avulsion was diagnosed if the muscle insertion at the inferior pubic ramus at the plane of minimal hiatal dimensions and within 5 mm above this plane on tomographic ultrasound imaging was abnormal, ie the muscle was disconnected from the inferior pubic ramus. Hiatal overdistensibility (microtrauma) was diagnosed if there was a peripartum increase in hiatal area on Valsalva by >20% with the resultant area ≥25 cm2. A sphincter defect was diagnosed if a gap of >30 degrees was seen in ≥4 of 6 tomographic ultrasound imaging slices bracketing the external anal sphincter. Two models were tested: a first model that defines severe pelvic floor trauma as either obstetric anal sphincter injury or levator avulsion, and a second, more conservative model, that also included microtrauma.

RESULTS: A total of 504/660 women (76%) returned for postpartum follow-up as described previously. In all, 21 patients were excluded due to inadequate data or intercurrent pregnancy, leaving 483 women for analysis. Model 1 defined nontraumatic vaginal delivery as excluding operative delivery, obstetric anal sphincter injuries, and sonographic evidence of levator avulsion or residual sphincter defect. Model 2 also excluded microtrauma. Of 483 women, 112 (23%) had a cesarean delivery, 103 (21%) had an operative vaginal delivery, and 17 (4%) had a third-/fourth-degree tear, leaving 251 women who could be said to have had a normal vaginal delivery. On ultrasound, in model 1, 27 women (6%) had an avulsion and 31 (6%) had a residual defect, leaving 193/483 (40%) who met the criteria for atraumatic normal vaginal delivery. In model 2, an additional 33 women (7%) had microtrauma, leaving only 160/483 (33%) women who met the criteria for atraumatic normal vaginal delivery. On multivariate analysis, younger age and earlier gestation at time of delivery remained highly significant as predictors of atraumatic normal vaginal delivery in both models, with increased hiatal area on Valsalva also significant in model 2 (all P ≤ .035).

MATERIAL AND METHODS: A retrospective observational study utilizing data from two studies with identical inclusion criteria and assessment protocols between 2005 and 2014. A total of 1148 primiparae with an uncomplicated singleton pregnancy were recruited and assessed with translabial ultrasound at 36 weeks antepartum and 871 (76%) returned for reassessment 3-6 months postpartum. The ultrasound data of vaginally parous women were analyzed for levator avulsion and microtrauma. The former was diagnosed if the muscle insertion at the inferior pubic ramus in the plane of minimal hiatal dimensions and within 5 mm above were abnormal on tomographic ultrasound imaging. Microtrauma was diagnosed in women with an intact levator and if there was a postpartum increase in hiatal area on Valsalva by >20% with the resultant area ≥25 cm2 .

RESULTS: The complete datasets of 844 women were analyzed. Among them, 609 delivered vaginally: by normal vaginal delivery in 452 (54%), a vacuum birth in 102 (12%) and a forceps delivery in 55 (6%). Levator avulsion was diagnosed in 98 and microtrauma in 97. On multivariate analysis, increasing maternal age, lower body mass index and lower bladder neck descent were associated with avulsion. Increased bladder neck descent and a family history of cesarean section (CS) were associcated with microtrauma.

METHODS: This is a retrospective study involving 416 women who presented to a tertiary urogynecology unit with symptoms of pelvic floor dysfunction. Genital hiatus and Pb were measured at rest and on maximal Valsalva. The strength of association between binary markers of POP and measurements of Gh/Pb was estimated using logistic regression analysis. Receiver operator characteristic statistics were used to compare predictive values of Gh and Pb measurements obtained at rest and on Valsalva.

RESULTS: A total of 451 women were seen during the study period. Thirty-five were excluded owing to missing data, leaving 416. Fifty-four percent (n = 223) complained of POP symptoms. On examination, 80% (n = 332) had significant POP (stage 2+ in anterior or posterior compartments or stage 1+ in the central compartment). On imaging, significant POP was diagnosed in 66% (n = 275). Mean hiatal area was 22 cm (SD, 7; range, 5-49 cm) at rest and 30 cm (SD, 10; range, 11-69 cm) on Valsalva. Genital hiatus and Pb measured on Valsalva were consistently stronger predictors of prolapse symptoms and objective prolapse (by clinician examination and by ultrasound) than at Gh and Pb measured at rest. The corresponding area under the curve values were significantly larger for Gh/Pb measures on Valsalva after adjusting for multiple confounders.

METHODS: This was a retrospective ancillary analysis involving 660 nulliparous women carrying an uncomplicated singleton term pregnancy in a prospective perinatal intervention trial at two Australian tertiary obstetric units. They had been seen antenatally and at 3-6 months postpartum for a standardized clinical assessment between 2007 and 2014. Primary outcome measures were sonographically diagnosed LAM and external anal sphincter (EAS) trauma.

METHODS: A cross-sectional study, incorporating 195 women involved in a longitudinal cohort study. Palpation for levator integrity was performed, followed by a four-dimensional translabial ultrasound. LAM avulsion defects were diagnosed in the presence of puborectalis muscle detachment from its insertion. Post-processing analysis of ultrasound volumes for LAM integrity on TUI was performed blinded against palpation findings. Agreement between methods was assessed using Cohen's κ.

RESULTS: In all, 388 paired assessments of LAM bilaterally, were available. Sixteen (8.2%) unilateral avulsion defects were detected on palpation. Sonographically, 31 (16%) were diagnosed with avulsions: 4.6% bilateral and 11.3% unilateral. An overall agreement of 91% was observed between digital palpation and TUI, yielding a Cohen's κ of 0.32 (95% confidence interval 0.15-0.48) demonstrating "fair agreement": and implying 25% sensitivity, 98% specificity, 63% positive predictive value, and 92% negative predictive value. Analysis of the first and last 20 palpations showed no change in performance during the 13-day study period.

METHODS: This was a cross-sectional study involving 195 women, participants of the Dunedin arm of the ProLong study (PROlapse and incontinence LONG-term research study) seen 20 years after their index birth. Assessment included a standardized questionnaire, ICS POP-Q and 4D translabial ultrasound. Post-imaging analysis of LAM and EAS integrity was undertaken blinded against other data. Statistical analysis was performed using Fisher's exact test and results were expressed as odds ratios (OR).

RESULTS: LAM avulsion and EAS defects were diagnosed in 31 (16%) and 24 (12.4%) women respectively. No significant difference in the prevalence of levator avulsion and EAS defects between primiparous (VP1) and multiparous (VP2+) women who had delivered vaginally (OR 1.9, 95% CI 0.72-5.01, p = 0.26) and (OR 1.2, 95% CI 0.4-3.8, p = 0.76) respectively.