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The Association Between Levator-Urethra Gap Measurements and Symptoms and Signs of Female Pelvic Organ Prolapse

Kamisan Atan I, Shek KL, Furtado GI, Caudwell-Hall J, Dietz HP

Female Pelvic Med Reconstr Surg, 2016 Nov-Dec;22(6):442-446.
PMID: 27465815

OBJECTIVES: Levator avulsion is associated with pelvic organ prolapse in women. It is diagnosed clinically by a widened gap on palpation between the insertion of the puborectalis muscle on the inferior pubic ramus and the urethra. This gap can also be assessed on imaging. This study aimed to determine the association between sonographically determined levator-urethral gap (LUG) measurements and symptoms and signs of prolapse.

METHODS: This is a retrospective study on 450 women seen in a tertiary urogynecological center for symptoms of pelvic floor dysfunction between January 2013 and February 2014. All had a standardized interview, International Continence Society Pelvic Organ Prolapse Quantification assessment and 4-dimensional translabial ultrasound. Post-imaging analysis of archived ultrasound volumes for LUG measurement was undertaken on tomographic slices at the plane of minimal hiatal dimensions and within 5-mm cranial to this plane, bilaterally at an interslice interval of 2.5 mm, blinded against all clinical data. A LUG of 25 mm or greater was considered abnormal.

RESULTS: Mean LUG and maximum LUG in individuals were 22.5 mm (SD, 4.6) and 26.4 mm (SD, 6.0), respectively, with at least 1 abnormal LUG in 51% (n = 222). An abnormal LUG in all 3 slices involving the plane of minimal hiatal dimensions and within 5 mm cranial to this plane on at least 1 side was fulfilled in 24% (n = 103). The LUG measurements were strongly associated with bother, symptoms and signs of prolapse (P < 0.001 to 0.002). This remained significant on multivariate analysis controlling for potential confounding factors.

CONCLUSIONS: Sonographically determined LUG is strongly associated with symptoms, symptom bother, and pelvic organ prolapse on clinical examination and imaging.
Can Anal Sphincter Defects Be Identified by Palpation?

Shek KL, Atan IK, Dietz HP

Female Pelvic Med Reconstr Surg, 2016 Nov-Dec;22(6):472-475.
PMID: 27682743

OBJECTIVES: The aim of this study was to correlate clinical findings of anal sphincter defects and function with a sonographic diagnosis of significant sphincter defects.

METHODS: This is an observational cross-sectional study on women seen 6 to 10 weeks after primary repair of obstetric anal sphincter injuries (OASIs). All patients underwent a standardized interview including the St Mark incontinence score, a digital rectal examination, and 3-/4-dimensional transperineal ultrasound imaging.

RESULTS: Two hundred forty-five patients were seen after primary repair of OASIs. Mean age was 29 (17-43) years. They were assessed at a median of 58 (15-278) days postpartum. One hundred fifty-seven (64%) delivered normal vaginally, 72 (29%) delivered by vacuum, and 16 (7%) delivered by forceps. A comparison of external anal sphincter (EAS) and internal anal sphincter ultrasound volume data and palpation was possible in 220 and 212 cases, respectively. Sphincter defects at rest and on contraction were both detected clinically in 17 patients. Significant abnormalities of the EAS were diagnosed on tomographic ultrasound imaging in 99 cases (45%), and significant abnormalities of the internal anal sphincter were diagnosed in 113 cases (53%). Agreement between digital and sonographic findings of sphincter defect was poor (k = 0.03-0.08). Women with significant EAS defects on ultrasound were found to have a lower resistance to digital insertion (P = 0.018) and maximum anal squeeze (P = 0.009) on a 6-point scale. The difference was however small.

CONCLUSIONS: Digital rectal examination does not seem to be sufficiently sensitive to diagnose residual sphincter defects after primary repair of OASIs. Imaging is required for the evaluation of sphincter anatomy after repair.
Relationship of Anatomy and Function: External Anal Sphincter on Transperineal Ultrasound and Anal Incontinence

Paka C, Kamisan Atan I, Rios R, Dietz HP

Female Pelvic Med Reconstr Surg, 2016 10 27;23(4):238-243.
PMID: 27782978 DOI: 10.1097/SPV.0000000000000350

OBJECTIVE: The aim of this study was to investigate the association of the anatomic integrity of the external anal sphincter (EAS) detected on transperineal ultrasound (TPUS) with symptoms of anal incontinence (AI) as measured by St Mark's Incontinence Score (SMIS) and the visual analog scale (VAS).
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.
CONCLUSIONS: The symptom of AI is associated with significant EAS defects detected on TPUS. However, this study failed to show an association between significant EAS defects and the SMIS and VAS.
Should Genital Hiatus/Perineal Body Be Measured at Rest or on Valsalva?

Ow LL, Subramaniam N, Kamisan Atan I, Friedman T, Martin A, Dietz HP

Female Pelvic Med Reconstr Surg, 2018 7 7;25(6):415-418.
PMID: 29979358 DOI: 10.1097/SPV.0000000000000608

OBJECTIVE: Genital hiatus (Gh) and perineal body (Pb) are part of the Pelvic Organ Prolapse Quantification assessment system, but it is unclear whether measurements should be taken at rest or on Valsalva. This study was designed to assess the predictive value of Gh and Pb measurements obtained at rest and on Valsalva for signs and symptoms of pelvic organ prolapse (POP).
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.
CONCLUSIONS: Genital hiatus/Pb measured on maximal Valsalva is a superior predictor of symptoms and signs of POP compared with Gh/Pb at rest.