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Gravante G, De Simone V, Sorge R, La Torre M, D'Andrea V, Romano S, Gallo G. Assessment of long-term outcomes following Milligan-Morgan hemorrhoidectomy with Doppler transperineal ultrasound and endoscopy: a pilot study. Int J Colorectal Dis 2025; 40:104. [PMID: 40310510 PMCID: PMC12045805 DOI: 10.1007/s00384-025-04894-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/14/2025] [Indexed: 05/02/2025]
Abstract
PURPOSE Hemorrhoidectomy remains the gold-standard treatment for advanced hemorrhoidal disease, but long-term outcomes vary depending on the surgical technique and assessment method. This study aims to show the long-term results achieved using a combination of transperineal ultrasound (TPUS) and endoscopy in patients who underwent Milligan-Morgan hemorrhoidectomy (MM). METHODS A consecutive series of MM patients treated between February 2020 and December 2023 were contacted and underwent a clinical proctological evaluation, a Doppler TPUS, and an endoscopic check of the anal canal. All investigations were performed using the ESAOTE MyLab XPRO80. TPUS anatomy, including Doppler views, was assessed on the axial, sagittal, and coronal planes. Outcome measures consisted of the description of Doppler TPUS modifications following MM, and their relationship with clinical and endoscopic findings. RESULTS: Twenty-three patients were available for the analysis at 26 months of follow-up (range 14-48). Fifteen patients had a Doppler vascular pattern (65.2%), eight patients a scattered pattern (34.8%). No correlation was present between residual symptoms and the Doppler vascular pattern (p = 0.089). The vascular pattern was associated with endoscopic signs of recurrences (p = 0.003), and its absence was able to predict the lack of internal recurrences in all patients (100%). CONCLUSION Doppler TPUS could help in the long-term assessment of patients presenting residual symptoms after MM. If confirmed in larger future cohort studies, the 100% negative predictive value of the vascular pattern could be used to exclude internal recurrences during postoperative follow-up.
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Affiliation(s)
- Gianpiero Gravante
- Department of General Surgery, Azienda Sanitaria Locale ASL Lecce, Casarano, Italy
| | - Veronica De Simone
- Proctology and Pelvic Floor Surgery Unit, Ospedale Isola Tiberina-Gemelli Isola, 00186, Rome, Italy
| | - Roberto Sorge
- Department of Human Physiology, Laboratory of Biometry, University of Tor Vergata in Rome, Rome, Italy
| | | | - Vito D'Andrea
- Department of Surgery, "Sapienza" University of Rome, Rome, Italy
| | - Stefania Romano
- Department of General Surgery, Azienda Sanitaria Locale ASL Lecce, Casarano, Italy
| | - Gaetano Gallo
- Department of Surgery, "Sapienza" University of Rome, Rome, Italy.
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Borycka K, Młyńczak M, Rosoł M, Korzeniewski K, Iwanowski P, Heřman H, Janku P, Uchman-Musielak M, Dosedla E, Diaz EG, Sudoł-Szopińska I, Mik M, Ratto C, Spinelli A. Detection of obstetric anal sphincter injuries using machine learning-assisted impedance spectroscopy: a prospective, comparative, multicentre clinical study. Sci Rep 2025; 15:7522. [PMID: 40033085 PMCID: PMC11876446 DOI: 10.1038/s41598-025-92392-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2024] [Accepted: 02/27/2025] [Indexed: 03/05/2025] Open
Abstract
To evaluate the clinical performance and safety of the ONIRY system for obstetric anal sphincter injuries (OASI) detection versus three-dimensional endoanal ultrasound (EAUS). A prospective, comparative, multicentre, international study. Poland, Czechia, Slovakia, and Spain. 152 women between the first moments up to 8 weeks after vaginal delivery. Participants underwent EAUS and were allocated to groups based on OASIS classification: A (no perineal tear), B (1st or 2nd degree tear), or C (3rd or 4th degree, anal sphincters affected). Electric impedance was measured in the anal canal using the ONIRY system. The primary endpoint was the diagnostic outcome of impedance spectroscopy versus EAUS. Adverse events were collected. Part II involved in silico modelling and 10-time 10-fold cross-validation for automated analysis. Accuracy, sensitivity, and specificity. 30 women were allocated to group A, 61 to group B, and 61 to group C. The diagnostic outcome was determined for 147 participants. The accuracy, sensitivity, and specificity of the ML-assisted impedance spectroscopy were 87.0 ± 0.5%, 90.6 ± 2.0%, and 84.6 ± 1.9%, respectively, compared with EAUS. After data cleaning, the performance metrics of the proposed final ML model for ONIRY were: 90.0 ± 0.4%, 90.0 ± 1.2%, and 90.0 ± 0.7%, respectively. No adverse device effects or deficiencies were observed. By enabling early identification of sphincter injuries, ML-assisted impedance spectroscopy facilitates timely diagnosis and intervention, potentially reducing long-term complications such as faecal incontinence. Its rapid, bedside application in obstetric settings supports immediate postpartum care, complementing digital rectal examination and optimizing clinical decision-making.
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Affiliation(s)
- Katarzyna Borycka
- OASIS Diagnostics, R&D of Medical Technology, Warsaw, Poland.
- Department of General Surgery, Faculty of Medicine, Lazarski University, Warsaw, Poland.
| | - Marcel Młyńczak
- OASIS Diagnostics, R&D of Medical Technology, Warsaw, Poland
- Faculty of Mechatronics, Institute of Metrology and Biomedical Engineering, Warsaw University of Technology, Warsaw, Poland
| | - Maciej Rosoł
- OASIS Diagnostics, R&D of Medical Technology, Warsaw, Poland
- Faculty of Mechatronics, Institute of Metrology and Biomedical Engineering, Warsaw University of Technology, Warsaw, Poland
| | - Kacper Korzeniewski
- OASIS Diagnostics, R&D of Medical Technology, Warsaw, Poland
- Faculty of Mechatronics, Institute of Metrology and Biomedical Engineering, Warsaw University of Technology, Warsaw, Poland
| | - Piotr Iwanowski
- OASIS Diagnostics, R&D of Medical Technology, Warsaw, Poland
| | - Hynek Heřman
- Institute for the Care of Mother and Child, Prague, Czech Republic
- 3rd Medical Faculty, Charles University, Prague, Czech Republic
| | - Petr Janku
- Department of Obstetrics and Gynaecology, University Hospital Brno and Medical Faculty, Masaryk University, Brno, Czech Republic
- Department of Health Sciences, Medical Faculty, Masaryk University, Brno, Czech Republic
| | | | - Erik Dosedla
- Department of Gynaecology and Obstetrics, Faculty of Medicine, Univerzita Pavla Jozefa Šafárika, Košice, Slovakia
| | - Enrique Gonzalez Diaz
- Department of Obstetrics and Gynaecology, Complejo Asistencial Universitario de Leon, León, Spain
| | - Iwona Sudoł-Szopińska
- Department of Radiology, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
- Ultrasound Department, Warsaw Medical University, Warsaw, Poland
| | - Michał Mik
- Department of General and Colorectal Surgery, Medical University of Lodz, Lodz, Poland
| | - Carlo Ratto
- Proctology and Pelvic Floor Surgery Unit, Isola Tiberina Hospital, Gemelli Isola, Catholic University, Rome, Italy
| | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy
- IRCCS Humanitas Research Hospital, via Manzoni 56, 20089, Rozzano, Milan, Italy
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Ralston C, Reena M, Solanki D, Morris S, Schizas AMP, Williams AB, Hainsworth AJ. Can we use integrated total pelvic floor ultrasound as a screening tool in defaecatory pelvic floor dysfunction? A prospective evaluation of the accuracy of integrated total pelvic floor ultrasound compared with defaecation proctography. Colorectal Dis 2025; 27:e17274. [PMID: 39948825 DOI: 10.1111/codi.17274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 09/26/2024] [Accepted: 10/22/2024] [Indexed: 05/09/2025]
Abstract
AIM Pelvic floor dysfunction is common and includes symptoms such as urinary incontinence, pelvic pain, faecal incontinence, obstructive defaecation syndrome symptoms and pelvic organ prolapse. It is investigated with defaecation proctography (DP) and integrated total pelvic floor ultrasound (TPFUS). Whilst DP is currently the gold standard, TPFUS is efficient and less invasive, offering additional sphincter function assessment. This study aimed to compare TPFUS accuracy to DP in the evaluation of pelvic floor dysfunction. METHODS From 2015 to 2016, a prospective observational study was conducted at Guy's and St Thomas's Foundation Trust. Symptomatic women with incomplete evacuation were consecutively invited to participate. Patients underwent three scans using both TPFUS and DP. Reports were independently verified by a blinded consultant. Sensitivity, specificity and agreement were calculated for anatomical (rectocele, intussusception, enterocele, cystocele) and functional (coordination, evacuation) features. RESULTS A total of 216 patients were included. Moderate agreement was seen between DP and TPFUS in prediction of rectoceles (positive predictive value 85%, negative predictive value 67%, Cohen's kappa 0.46) and on the evaluation of dimensions of rectoceles (R coefficient 0.55) (P < 0.0001). Fair agreement was seen in the assessment of propulsion (positive predictive value 76%, negative predictive value 50%, Cohen's kappa 0.25). Poor agreement was observed on other anatomical and functional objectives. CONCLUSION This is the most extensive prospective comparison of these imaging modalities. While there is limited correlation between DP and TPFUS in exploring anatomical and functional aspects of pelvic floor disorders, TPFUS proves to be an effective screening tool. With enhanced expertise and confidence in its use, TPFUS could potentially guide surgical planning rather than solely identifying those needing DP.
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Affiliation(s)
| | - Max Reena
- Guy's and St Thomas's NHS Foundation Trust, London, UK
| | - Deepa Solanki
- Guy's and St Thomas's NHS Foundation Trust, London, UK
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Lyu X, Zhu L, Zhang W, Chen H. Epidural Anesthesia and Pelvic Floor Outcomes in Primiparas: A Retrospective Transperineal Ultrasound Study. Int Urogynecol J 2025; 36:163-171. [PMID: 39621064 DOI: 10.1007/s00192-024-06000-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2024] [Accepted: 10/31/2024] [Indexed: 02/01/2025]
Abstract
PURPOSE This study evaluated pelvic organ positions in primiparas with painful and painless deliveries using transperineal ultrasound (TPU) and assessed the effects of epidural anesthesia on pelvic floor function. METHODS From January 2022 to March 2023, 512 primiparas with vaginal deliveries at our hospital underwent pelvic floor ultrasound examinations 42 days postpartum. The study included 138 women with painful deliveries and 375 with painless deliveries. Measurements included the urethral tilt angle (UTA), retrovesical angle at rest (RVA-R), bladder neck-symphysis pubis distance (BSD) at rest, retrovesical angle at Valsalva maneuver (RVA-V), urethral rotation angle (URA), bladder neck descent (BND), rectal ampulla distance, and levator hiatal area (LHa) at maximum Valsalva maneuver. Statistical analysis was performed using SPSS 26.0. RESULTS No significant differences were found between the painful and painless delivery groups in terms of age, gestational age, newborn birth weight, BMI, UTA, RVA-R, RVA-V, URA, and BND (P > 0.05). Although the second stage and total duration of labor were significantly longer in the painless delivery group, there were no significant differences in the incidences of cystocele, internal urethral orifice opening, uterine prolapse, rectocele, and LHa expansion between the groups (P > 0.05). CONCLUSION Transperineal ultrasound showed no significant difference in pelvic floor dysfunction incidence between primiparas with painful and painless deliveries. Epidural anesthesia did not significantly affect pelvic floor function in the early postpartum period.
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Affiliation(s)
- Xiaoyun Lyu
- Department of Obstetrics, HangZhou First People's Hospital of China, ZheJiang University, No.261, Huansha Road, Hangzhou, P. R. China.
| | - Libo Zhu
- Department of Obstetrics, HangZhou First People's Hospital of China, ZheJiang University, No.261, Huansha Road, Hangzhou, P. R. China
| | - Wei Zhang
- Department of Obstetrics, HangZhou First People's Hospital of China, ZheJiang University, No.261, Huansha Road, Hangzhou, P. R. China
| | - Haiping Chen
- Department of Ultrasonography, HangZhou First People's Hospital of China, ZheJiang University, Hangzhou, P. R. China
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Wójtowicz H, Wlaźlak E, Kociszewski J, Wlaźlak W, Krakowiak J, Fijołek-Więcławek W, Wróbel A, Surkont G. Correlation analysis of selected anatomical and functional parameters of the urethra, assessed through ultrasound and urodynamic examinations. J Ultrason 2024; 24:1-7. [PMID: 39839502 PMCID: PMC11748197 DOI: 10.15557/jou.2024.0039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Accepted: 07/30/2024] [Indexed: 01/23/2025] Open
Abstract
Aim This study aimed to examine the correlations between specific urethral function parameters observed in urodynamic testing and selected urethral characteristics evaluated by pelvic floor ultrasonography. Additionally, the presence of urethral funneling during straining was evaluated in female patients referred for surgical treatment of stress urinary incontinence. Material and methods A retrospective study was conducted on 192 female patients referred for surgical treatment of stress urinary incontinence with the use of retropubic tension-free vaginal tape. Maximum urethral closure pressure and functional urethral length were evaluated urodynamically during resting profilometry. Ultrasound measurements, along with the assessment of funneling, were performed as part of the pelvic floor examination, following the technique described by Kociszewski. Patients with clinically significant pelvic organ prolapse, a history of anterior compartment surgery, prior radiotherapy, or symptoms of overactive bladder were excluded from the analysis. Results The values obtained from urodynamic and ultrasound examinations were evaluated statistically. No correlation was identified between the analyzed urodynamic and ultrasound parameters. Long urethral funneling was confirmed in all patients with stress urinary incontinence assessed as eligible for the placement of tension-free vaginal tape. Conclusions The results indicate that urodynamic and ultrasound examinations assess distinct aspects of urethral anatomy and function, and therefore their findings cannot be used interchangeably. Long urethral funneling assessed during pelvic floor ultrasonography was noted in all patients with clinically and urodynamically confirmed stress urinary incontinence.
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Affiliation(s)
- Hubert Wójtowicz
- Gynecology, Independent Public Health Care Complex, Pruszków, Poland
| | - Edyta Wlaźlak
- Department of Operative Gynecology and Gynecologic Oncology, 1st Chair of Obstetrics and Gynecology, Medical University of Lodz, Łódź, Poland
| | | | - Wiktor Wlaźlak
- Department of Operative Gynecology and Gynecologic Oncology, 1st Chair of Obstetrics and Gynecology, Medical University of Lodz, Łódź, Poland
| | - Jan Krakowiak
- Department of Social Medicine, Chair of Social and Preventive Medicine, Medical University of Lodz, Lodz, Poland
| | - Wojciech Fijołek-Więcławek
- Department of Operative Gynecology and Gynecologic Oncology, 1st Chair of Obstetrics and Gynecology, Medical University of Lodz, Łódź, Poland
| | - Andrzej Wróbel
- 2nd Chair and Department of Gynecology, Medical University of Lublin, Lublin, Poland
| | - Grzegorz Surkont
- Department of Operative Gynecology and Gynecologic Oncology, 1st Chair of Obstetrics and Gynecology, Medical University of Lodz, Łódź, Poland
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Pietrus M, Pityński K, Gawron I, Socha MW, Nowosielski K, Biskupski-Brawura-Samaha R, Waligóra M. Diagnostic utility of translabial ultrasound in pelvic organ prolapse: a prospective observational study. J OBSTET GYNAECOL 2024; 44:2386975. [PMID: 39105256 DOI: 10.1080/01443615.2024.2386975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Accepted: 07/26/2024] [Indexed: 08/07/2024]
Abstract
BACKGROUND The increasing awareness of women's health issues, specifically pelvic organ prolapse (POP) and urinary incontinence (UI), has spurred a surge in patients seeking specialised advice for these conditions, necessitating modern diagnostic approaches for such issues. This study explored the diagnostic utility of translabial ultrasound for POP, emphasising its correlation with clinical assessments based on International Continence Society (ICS) criteria. METHODS Seventy-one patients with POP Quantification System (POP-Q) stage 0-IV with or without UI were prospectively enrolled at Jagiellonian University Medical College between 2014 and 2016. The study objectives included evaluating diagnostic accuracy and concordance across pelvic compartments, correlating the diagnoses with patient-reported symptoms, and identifying variables contributing to diagnostic discrepancies. RESULTS Translabial ultrasound identified POP in 74.5% of the patients, aligning closely with clinical evaluations. Concordance was the highest in assessments performed in the medial compartment (85.8%), while assessments performed in the anterior (29.6%) and posterior (29.6%) compartments showed higher rates of discrepancies. Correlation analyses showed varying associations, with the posterior compartment exhibiting the least pronounced correlation (R = 0.72, p < 0.0001). Self-perceive POP showed no discernible differences in relation to ultrasonographic and clinical assessments. Among the respondents, 55.9% reported experiencing the sensation of POP. Mean POP levels determined using the two approaches precisely matched in 46.5% of these cases. Discrepancies involved variables such as self-perceived POP, number of deliveries, child weight at birth, UI, and sexual activity. CONCLUSIONS Translabial ultrasound showed robust correlation with clinical assessments for evaluating POP, especially for defining defects and facilitating treatment-related decision-making. Our findings highlight the reliability of this method, particularly for assessments in the medial compartment. The evidence did not indicate the superiority of either method in detecting POP disorders for symptomatic versus asymptomatic patients. Significantly, a higher POP-Q measurement in clinical examination was correlated with greater sexual activity.
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Affiliation(s)
- Milosz Pietrus
- Faculty of Medicine, Department of Gynecology and Obstetrics, Clinic of Gynecology and Oncology, Jagiellonian University Medical College, Kraków, Poland
| | - Kazimierz Pityński
- Faculty of Medicine, Department of Gynecology and Obstetrics, Clinic of Gynecology and Oncology, Jagiellonian University Medical College, Kraków, Poland
| | - Iwona Gawron
- Jagiellonian University Medical College, Faculty of Medicine, Department of Gynecology and Obstetrics, Clinic of Gynecological Endocrinology, Kraków, Poland
| | - Maciej W Socha
- Department of Perinatology, Gynecology and Gynecologic Oncology, Faculty of Health Sciences, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Krzysztof Nowosielski
- Department of Obstetrics and Gynecology, University Clinical Center, Faculty of Medical Sciences, Medical University of Silesia, Katowice, Poland
| | | | - Marcin Waligóra
- Pulmonary Circulation Centre, Department of Cardiac and Vascular Diseases, Faculty of Medicine, Jagiellonian University Medical College, John Paul II Hospital in Kraków, Kraków, Poland
- Center for Innovative Medical Education, Department of Medical Education, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland
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AIUM Practice Parameter for the Performance of Ultrasound of the Female Pelvis, 2024 Revision. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2024; 43:E56-E64. [PMID: 39158217 DOI: 10.1002/jum.16556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2024] [Accepted: 08/07/2024] [Indexed: 08/20/2024]
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Jeong HY, Hyun K, Lee JK. Anal canal coronal-sagittal ratio: a novel parameter for diagnosing pelvic floor injury in 2-dimensional transanal ultrasound. Ann Coloproctol 2024; 40:459-466. [PMID: 36353815 PMCID: PMC11532386 DOI: 10.3393/ac.2022.00129.0018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 04/29/2022] [Accepted: 05/21/2022] [Indexed: 11/12/2022] Open
Abstract
PURPOSE Pelvic floor injury diagnosis using 3-dimensional (3D) pelvic floor ultrasound or magnetic resonance imaging is unfeasible in many clinics. We assessed the efficacy of a novel diagnostic parameter, the anal canal coronal-sagittal (CS) ratio, for pelvic floor injury on 2D transanal ultrasound. METHODS This retrospective study analyzed the data of 126 female patients who underwent 3D pelvic floor ultrasound (including 2D transanal ultrasound) at a pelvic floor center between August and December 2020. The anal canal CS ratio on 2D transanal ultrasound and pelvic floor avulsion injury measurements were recorded for all patients. RESULTS A cutoff anal canal CS ratio of 1.15 was obtained using receiver operating characteristic analysis (sensitivity, 0.820; specificity, 0.763; and area under the curve, 0.838). Patients were categorized into the anal canal CS ratio ≥1.15 and the anal canal CS ratio <1.15 groups. Bilateral pelvic floor avulsion was more common in the anal canal CS ratio ≥1.15 group (n=35, 56.5%), and the incidence of pelvic floor avulsion was significantly different between the 2 groups (P=0.001). Existing parameters of pelvic floor injury, including minimal levator hiatus (P=0.001), levator plate descent angle (P=0.001), and levator ani deficiency score (P=0.001), were statistically different between the 2 groups. CONCLUSION The anal canal CS ratio was an efficient novel parameter that indirectly detected pelvic floor injury in 2D transanal ultrasound. It is a potential alternative indicator for pelvic floor injury on the widely popular 2D transanal ultrasound.
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Affiliation(s)
| | - Keehoon Hyun
- Department of Surgery, Seoul Song Do Hospital, Seoul, Korea
| | - Jong Kyun Lee
- Department of Surgery, Seoul Song Do Hospital, Seoul, Korea
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Barba M, Cola A, De Vicari D, Costa C, Volontè S, Frigerio M. How Old Is Too Old? Outcomes of Prolapse Native-Tissue Repair through Uterosacral Suspension in Octogenarians. Life (Basel) 2024; 14:433. [PMID: 38672705 PMCID: PMC11050946 DOI: 10.3390/life14040433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 03/20/2024] [Accepted: 03/21/2024] [Indexed: 04/28/2024] Open
Abstract
INTRODUCTION Medical advancements are expected to lead to a substantial increase in the population of women aged 80 and older by 2050. Consequently, a significant number of individuals undergoing corrective prolapse surgery will fall into the elderly-patient category. The research indicates a notable rise in complications associated with prolapse surgery in patients older than 80, irrespective of frailty and other risk factors. Despite these challenges, the vaginal approach has been identified as the safest surgical method for pelvic organ prolapse (POP) repair in the elderly population. For this reason, we aimed to investigate the efficacy, complication rate, and functional outcomes associated with vaginal hysterectomy and an apical suspension/high uterosacral ligaments suspension as a primary technique for prolapse repair, both within a cohort of elderly patients. METHODS We retrospectively analyzed patients who underwent transvaginal hysterectomy plus an apical suspension procedure for stage ≥ II and symptomatic genital prolapse between January 2006 and December 2013. Anatomical and functional outcomes were evaluated. The Patient Global Impression of Improvement (PGI-I) score was used to evaluate subjective satisfaction after surgery. RESULTS Sixty-five patients were included in the analysis. The median age was 81.3 years. All individuals exhibited an anterior compartment prolapse stage II or higher, and the majority also a central prolapse stage II or higher. Notably, all participants reported symptoms of vaginal bulging. Over half of the population (58.6%) complained of incomplete bladder emptying. The intervention for all participants involved a vaginal hysterectomy with an apical suspension. Sixty-three patients (96.9%) and forty-four patients (67.6%) underwent a simultaneous anterior or posterior repair, respectively. Long-term complications (>30 days from surgery) were observed during follow-up, with a median duration of 23 ± 20 months. Seven (10.7%) anatomical recurrences were recorded, five (7.69%) concerning the anterior compartment, one (1.5%) the central, and three (4.6%) the posterior. Nevertheless, none of them necessitated further surgical intervention due to symptoms. Significant anatomical improvements for the anterior, central, and posterior compartments were noticed, compared to preoperative assessment (p < 0.001 for Aa and Ba, p < 0.001 for Ap and Bp, and p < 0.001 for C). PGI-I values established that 100% of patients were satisfied (PGI-I ≥ 2), with a median score of 1.12. Consequently, objective and subjective cure rates were 89.5% and 100%, respectively. CONCLUSION Vaginal hysterectomy combined with apical suspension, particularly high uterosacral ligaments suspension, is a safe and effective primary surgical approach, even in elderly patients.
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Affiliation(s)
| | | | | | | | | | - Matteo Frigerio
- Department of Gynecology, IRCCS San Gerardo dei Tintori, University of Milano-Bicocca, 20900 Monza, Italy; (M.B.); (D.D.V.); (C.C.); (S.V.)
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Jaekel AK, Zöhrer PI, Kirschner-Hermanns R, Knüpfer SC. [Imaging of the pelvic floor : The urological perspective]. RADIOLOGIE (HEIDELBERG, GERMANY) 2023; 63:814-820. [PMID: 37792032 DOI: 10.1007/s00117-023-01224-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/22/2023] [Indexed: 10/05/2023]
Abstract
BACKGROUND Physiological pelvic floor function is essential for maintaining the appropriate storage and voiding function of the lower urinary tract. Disorders of pelvic floor function can consist of both hypofunction and hyperfunction and can result in urge symptoms, urinary incontinence, disorders of the micturition process, urinary retention, and chronic pelvic floor pain, as well as endangering the upper urinary tract. Thus, these disorders can be complex in their cause and effect. An exact diagnosis and initiation of a target-specific therapy of the respective functional disorder can only be achieved by the interaction of functional and imaging diagnostics. OBJECTIVES The aim of this article is therefore to present these special imaging techniques from the perspective of functional urology and neuro-urology. METHODS This paper presents the available imaging techniques in the diagnosis of pelvic floor dysfunction and places them in the diagnostic context of lower urinary tract dysfunction.
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Affiliation(s)
- Anke K Jaekel
- Sektion Neuro-Urologie, Klinik und Poliklinik für Urologie und Kinderurologie, Universitätsklinik Bonn, Venusberg-Campus 1, 53127, Bonn, Deutschland.
- Abteilung Neuro-Urologie, Johanniter Rehabilitationszentrum Godeshöhe GmbH, 53177, Bonn, Deutschland.
| | - Pirmin I Zöhrer
- Sektion Neuro-Urologie, Klinik und Poliklinik für Urologie und Kinderurologie, Universitätsklinik Bonn, Venusberg-Campus 1, 53127, Bonn, Deutschland
| | - Ruth Kirschner-Hermanns
- Sektion Neuro-Urologie, Klinik und Poliklinik für Urologie und Kinderurologie, Universitätsklinik Bonn, Venusberg-Campus 1, 53127, Bonn, Deutschland
- Abteilung Neuro-Urologie, Johanniter Rehabilitationszentrum Godeshöhe GmbH, 53177, Bonn, Deutschland
| | - Stephanie C Knüpfer
- Sektion Neuro-Urologie, Klinik und Poliklinik für Urologie und Kinderurologie, Universitätsklinik Bonn, Venusberg-Campus 1, 53127, Bonn, Deutschland
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Hainsworth A, Solanki D, Ferrari L, Igbedioh C, Johnston L, Morris SJ, Igualada-Martinez P, Schizas AMP, Williams AB. The association between levator plate integrity and pelvic floor defaecatory dysfunction. Neurourol Urodyn 2023; 42:690-698. [PMID: 36692383 DOI: 10.1002/nau.25119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 12/01/2022] [Accepted: 12/09/2022] [Indexed: 01/25/2023]
Abstract
AIMS Levator ani deficiency has been implicated in anterior pelvic floor pathology but its association with pelvic floor defaecatory dysfunction is less clear. The aim was to examine the relationship of levator ani deficiency with anatomical abnormalities (rectocoele, intussusception, enterocoele, perineal descent) and patient symptoms (bowel, vagina) in patients with pelvic floor defaecatory dysfunction. METHODS The prospective observational case series of 223 women presenting to a tertiary colorectal pelvic floor unit with defaecatory dysfunction. Each underwent assessment with symptom severity and quality of life (QoL) scores, integrated total pelvic floor ultrasound (PFUS) (transvaginal, transperineal) and defaecation proctography (DP). Rectocoele, intussusception, enterocoele and perineal descent were assessed on both. Levator ani deficiency was scored using endovaginal ultrasound (score 0-18; mild [0-6], moderate [>6-12], severe [>12-18]). RESULTS The proportion of patients with rectocoele, enterocoele, and intussusception increased with increasing levator ani damage (mild, moderate, severe). There was a weakly positive correlation between size of rectocoele and levator ani deficiency. On PFUS, there was a weakly positive correlation between severity of intussusception and enterocoele with levator ani deficiency. On DP, there was a weakly positive correlation between perineal descent and levator ani deficiency. There was no association between bowel symptom and QoL scores and levator ani deficiency. Vaginal symptoms were associated with levator ani deficiency. CONCLUSIONS Anatomical abnormalities which are implicated in pelvic floor defaecatory dysfunction (rectocoele, intussusception, enterocoele, perineal descent) were associated with worsening levator ani deficiency. There was no association between bowel symptoms and levator ani deficiency. Vaginal symptoms were associated with levator ani deficiency.
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Affiliation(s)
- Alison Hainsworth
- The Pelvic Floor Unit, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Deepa Solanki
- The Pelvic Floor Unit, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Linda Ferrari
- The Pelvic Floor Unit, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Carlene Igbedioh
- The Pelvic Floor Unit, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Liam Johnston
- The Pelvic Floor Unit, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Samantha J Morris
- The Pelvic Floor Unit, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Alexis M P Schizas
- The Pelvic Floor Unit, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Andrew B Williams
- The Pelvic Floor Unit, Guy's and St Thomas' NHS Foundation Trust, London, UK
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12
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Santoro GA. Ultrasound Imaging of Pelvic Floor Disorders: Still a Subject of Debate? Dis Colon Rectum 2023; 66:169-171. [PMID: 36259694 DOI: 10.1097/dcr.0000000000002652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- Giulio A Santoro
- Tertiary Referral Pelvic Floor Center, II° Division of Surgery, AULSS2 Marca Trevigiana, University of Padua, Treviso, Italy
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13
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Badri H, Fowler G, Lane S. The role of anal manometry in the follow-up of women with obstetric anal sphincter injuries (OASI). Int Urogynecol J 2023; 34:399-404. [PMID: 36278987 DOI: 10.1007/s00192-022-05380-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 09/17/2022] [Indexed: 01/26/2023]
Abstract
INTRODUCTION AND HYPOTHESIS Mode of birth (MOB) following OASI is determined by choice, symptoms and anorectal study results in asymptomatic women. Endoanal ultrasound (EAUS) is the gold-standard imaging modality. EAUS use in MOB counselling is supported by strong evidence. Less is understood about how anal manometry (AM) influences MOB counselling. METHODS A retrospective observational study was conducted from 2007 to 2020. Women underwent symptom assessment using validated ePAQ and St Mark's incontinence score (SMIS). Anorectal studies using EAUS and AM were performed. The case group was the normal ultrasound group and the control group was the abnormal ultrasound group. Both groups were compared with normal and abnormal AM result groups. RESULTS A total of 1348 women were included over 13 years. Among these, 454 women were symptomatic, 894 were asymptomatic; 274 (31%) asymptomatic women had isolated abnormal AM results, 313 (35%) had two abnormal anorectal results and 221 (24.7%) had normal anorectal results. Eighty-six asymptomatic women (10.4%) had isolated abnormal EAUS results, 138 (30.4%) symptomatic women had isolated abnormal AM, 221 (48.7%) had two abnormal anorectal results and 57 (12.6%) had normal anorectal results. Thirty-eight symptomatic women (8.4%) had an isolated abnormal EAUS result. CONCLUSIONS AM identifies more women with sphincter function impairment than EAUS alone. Without AM, almost one third of asymptomatic women would not have been identified and could have been inadequately counselled. Performing AM and EAUS together captured most women with compromised anal sphincter function. We conclude that AM should be performed in all women with OASI alongside EAUS to enable accurate MOB counselling.
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Affiliation(s)
- Hawra Badri
- Liverpool Women's NHS Foundation Trust, Liverpool, UK.
| | | | - Steven Lane
- Department of Biostatistics, University of Liverpool, Liverpool, UK
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14
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Barakat B, Gauger U, Rehme C, Hadaschik B, Wolff I, Hijazi S. Diagnosis of female urethral diverticulum using pelvic floor ultrasound and comparison with voiding cystourethrogram (imaging study). Int Urogynecol J 2023; 34:563-569. [PMID: 36098788 DOI: 10.1007/s00192-022-05340-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 08/05/2022] [Indexed: 01/26/2023]
Abstract
INTRODUCTION AND HYPOTHESIS The purpose of this study was to evaluate the sensitivity and specificity of pelvic floor ultrasound (PFUS) in the diagnostic work-up of female urethral diverticulum (UD) and to compare results of PFUS with voiding cystourethrogram (VCUG). METHODS We retrospectively reviewed our database of patients, who received VCUG and PFUS for the diagnosis of UD. A total of 196 consecutive female patients with a minimum of one symptom, such as a lower urinary tract symptom (LUTS), postmicturition dribble, dyspareunia and recurrent urinary tract infection (UTI) who underwent initial diagnostics with VCUG and PFUS were selected. Diagnostic performance of both procedures, which included size, complexity, echogenicity. and content were compared. RESULTS Recurrent UTI and LUTS were the most common symptoms, which were present in 165 (84%) and 163 patients (83%) respectively. Final diagnosis of UD was based on PFUS and VCUG findings in 69 (35%) and 58 (30%) cases respectively. Based on our study cohort, the sensitivity of PFUS in detecting UD was significantly higher than that of VCUG: 94% (IQR: 89-97) versus 78% (IQR: 73-85, p<0.01), with a trend toward higher specificity: 100% (IQR: 94-100) versus 84% (IQR: 78-84, p=0.05). Enabling direct UD visualisation, PFUS was associated with a positive predictive value (PPV) of 100% (IQR: 97-100) and a negative predictive value (NPV) of 88% (IQR: 78-95), whereas VCUG had an inferior accuracy with a PPV of 84 (IQR: 80-84) and a NPV of 68 (IQR: 62-79). CONCLUSIONS In clinical practice, VCUG has a lower sensitivity than PFUS. Based on these results, we recommend the usage of dynamic PFUS as part of a non-invasive work-up.
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Affiliation(s)
- Bara Barakat
- Department of Urology and Pediatric Urology, Hospital Viersen, Hoserkirchweg 63, 41747, Viersen, Germany.
| | | | - Christian Rehme
- Department of Urology and Pediatric Urology, University Hospital Essen, Essen, Germany
| | - Boris Hadaschik
- Department of Urology and Pediatric Urology, University Hospital Essen, Essen, Germany
| | - Ingmar Wolff
- Department of Urology, University Medicine Greifswald, Greifswald, Germany
| | - Sameh Hijazi
- Department of Urology, Hospital Ibbenbüren, Ibbenbüren, Germany
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15
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Alshiek J, Wei Q, Javadian P, Quiroz LH, Baumfeld Y, Shobeiri SA. The Correlation Between the Sonographic Course of Transobturator Slings and Sling-Related Pain. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2023; 42:125-133. [PMID: 35388919 DOI: 10.1002/jum.15982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 03/16/2022] [Accepted: 03/17/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVES To determine whether transobturator slings follow a consistent path and whether there is an association between ultrasonographically visualized sling pattern or position with sling-related pain. METHODS This was a cross-sectional retrospective pilot study. We evaluated women who were presented to our clinic for pain or other urogynecologic symptoms following transobturator sling placement between 2009 and 2014. Patients had undergone a 3-dimensional endovaginal pelvic floor ultrasound, assessing minimal levator hiatus, antero-posterior diameter, left-right diameter, and the hiatal shape. The mesh patterns were categorized as seagull patterns (normal), lopsided, flat, and convoluted. RESULTS A total of 68 cases were reviewed. Fifty patients reported pain, and 18 did not. There were wide variations in the course of the slings. The sling center- minimal levator hiatus position ranged 14.8 mm below and 17.9 mm above the minimal levator hiatus. The lateral arm insertion points ranged between 17.1 mm below and 16.6 mm above the minimal levator hiatus. The right arm insertion points ranged between 9.6 mm below and 18.8 mm above the minimal levator hiatus. Thirty-five of 68 (70%) patients with pain and 13 of 18 (72.2%) without had abnormal sling patterns. The abnormal sling shape was not correlated with pain (P = 1). The levator shape trended toward a statistical significant correlation with sling shape abnormality (P = .084). CONCLUSIONS This population of women with transobturator sling complications demonstrated wide variations in anatomic paths. Neither the abnormal sling shape nor the distance of the center of the tape from the minimal levator hiatus level were correlated with pain.
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Affiliation(s)
- Jonia Alshiek
- Department of Obstetrics & Gynecology, INOVA Women's Hospital, Falls Church, Virginia, USA
- Department of Bioengineering, George Mason University, Fairfax, Virginia, USA
| | - Qi Wei
- Department of Bioengineering, George Mason University, Fairfax, Virginia, USA
| | - Pouya Javadian
- Department of Obstetrics & Gynecology, the University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Lieschen H Quiroz
- Department of Obstetrics & Gynecology, the University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Yael Baumfeld
- Department of Obstetrics & Gynecology, INOVA Women's Hospital, Falls Church, Virginia, USA
| | - S Abbas Shobeiri
- Department of Obstetrics & Gynecology, INOVA Women's Hospital, Falls Church, Virginia, USA
- Department of Bioengineering, George Mason University, Fairfax, Virginia, USA
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16
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Thorsen AJ. Management of Rectocele with and without Obstructed Defecation. SEMINARS IN COLON AND RECTAL SURGERY 2022. [DOI: 10.1016/j.scrs.2022.100937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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17
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Caramazza D, Campagna G, Moro F, Vacca L, Marturano M, Pizzacalla S, Trivellizzi IN, Panico G, Scambia G, Ercoli A, Testa AC. Transobturator tape versus single incision sling: how are they different? Clinical outcomes and ultrasonographic features of two mid-urethral slings. World J Urol 2022; 40:2521-2528. [PMID: 35982168 DOI: 10.1007/s00345-022-04109-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 07/17/2022] [Indexed: 11/29/2022] Open
Abstract
PURPOSE Stress urinary incontinence (SUI) is usually treated with mid-urethral slings. The best approach is still debated and the relationship between slings and pelvic structures is not completely understood. The aim of this study is to identify any difference between trans-obturator tape (TOT) and single incision sling (minisling). METHODS Patients submitted to TOT or minisling were included in the study. Q-tip and stress test, ICIQ-SF questionnaire, PGI-I validated score, and 2D/3D transvaginal ultrasound parameters were collected at 1- and 6-month follow-up. Correlations between ultrasound parameters and clinical outcomes, PGI-I and ICIq-SF, were performed. RESULTS 61 patients were included in the study. PGI-I score was significantly lower in the minisling group than in TOT group at 1-month (p = 0.016) and 6-month follow-up (p = 0.076). The median distance between the sling and the lumen of urethra was significantly higher and the angle between the branches of the sling was significantly narrower in the minisling group. There were significant differences in distances between the sling and the bladder neck at 1-month and 6-month follow-up. An inverse correlation between angle of the branches and the Q-tip test was observed (p = 0.059 Pearson's Rho - 0.578). PGI-I correlated also with angle of the branches (p = 0.009, Pearson's Rho 0.503). CONCLUSION Patients undergoing TOT or minisling are similarly satisfied but show differences at ultrasound exam at 1- and 6-month follow-up. Pelvic floor ultrasound could be used in a short-term follow-up to visualize the sling position and to plan the most appropriate follow-up strategy.
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Affiliation(s)
- Daniela Caramazza
- Dipartimento di Scienze della Salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli-IRCCS, UOC Uroginecologia e Medicina e Chirurgia Ricostruttiva Pelvica Femminile, Rome, Italy
| | - Giuseppe Campagna
- Dipartimento di Scienze della Salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli-IRCCS, UOC Uroginecologia e Medicina e Chirurgia Ricostruttiva Pelvica Femminile, Rome, Italy
| | - Francesca Moro
- Dipartimento di Scienze della Salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli-IRCCS, UOC di Ginecologia Oncologica, Rome, Italy.
| | - Lorenzo Vacca
- Dipartimento di Scienze della Salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli-IRCCS, UOC Uroginecologia e Medicina e Chirurgia Ricostruttiva Pelvica Femminile, Rome, Italy
| | - Monia Marturano
- Dipartimento di Scienze della Salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli-IRCCS, UOC Uroginecologia e Medicina e Chirurgia Ricostruttiva Pelvica Femminile, Rome, Italy
| | - Sara Pizzacalla
- Dipartimento di Scienze della Salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli-IRCCS, UOC Uroginecologia e Medicina e Chirurgia Ricostruttiva Pelvica Femminile, Rome, Italy
| | | | - Giovanni Panico
- Dipartimento di Scienze della Salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli-IRCCS, UOC Uroginecologia e Medicina e Chirurgia Ricostruttiva Pelvica Femminile, Rome, Italy
| | - Giovanni Scambia
- Dipartimento di Scienze della Salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli-IRCCS, UOC di Ginecologia Oncologica, Rome, Italy
| | - Alfredo Ercoli
- PID Ginecologia Oncologica e Chirurgia Ginecologica Mininvasiva, Università degli Studi di Messina, Policlinico G. Martino, Messina, Italy
| | - Antonia Carla Testa
- Dipartimento di Scienze della Salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli-IRCCS, UOC di Ginecologia Oncologica, Rome, Italy.,Dipartimento di Scienze della Vita e di Sanità Pubblica, Università Cattolica del Sacro Cuore, Rome, Italy
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18
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Dawoud C, Argeny S, Harpain F, Riss S. Obstruktives Defäkationssyndrom. COLOPROCTOLOGY 2022; 44:277-286. [DOI: 10.1007/s00053-022-00630-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/20/2022] [Indexed: 01/05/2025]
Abstract
ZusammenfassungDas obstruktive Defäkationssyndrom (ODS) ist eine Form der Verstopfung, die mit einer Stuhlentleerungsstörung verbunden ist. Das Krankheitsbild ist noch nicht vollständig verstanden, dementsprechend ist die Evidenz zur Pathogenese und Therapie limitiert. Prinzipiell werden funktionelle Ursachen, wie der Anismus oder das Puborektalissyndrom, von anatomischen Ursachen unterschieden. Häufige mechanische Hindernisse sind die Rektozele oder eine Intussuszeption, die zu einer erschwerten Defäkation führen können. Zur Auswahl der passenden Therapie ist entscheidend, die kausale Ursache festzustellen. Konservative Behandlungsversuche sollten primär angewendet werden und umfassen unter anderem das Beckenbodentraining, die Biofeedbacktherapie, den Einsatz von Laxanzien oder die anale Irrigation. Es gibt eine große Zahl chirurgischer Therapieoptionen mit unterschiedlichen Vor- und Nachteilen. Gute Fachkenntnis und Erfahrung sind entscheidend, um die geeignete Therapie für den Betroffenen auszuwählen.
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19
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Khatri G, Bhosale PR, Robbins JB, Akin EA, Ascher SM, Brook OR, Dassel M, Glanc P, Henrichsen TL, Learman LA, Sadowski EA, Saphier CJ, Wasnik AP, Maturen KE. ACR Appropriateness Criteria® Pelvic Floor Dysfunction in Females. J Am Coll Radiol 2022; 19:S137-S155. [PMID: 35550798 DOI: 10.1016/j.jacr.2022.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 02/19/2022] [Indexed: 10/18/2022]
Abstract
Pelvic floor disorders including pelvic organ prolapse (POP), urinary dysfunction, defecatory dysfunction, and complications after pelvic floor surgery are relatively common in the female population. Imaging tests are obtained when the initial clinical evaluation is thought to be incomplete or inconclusive or demonstrates findings that are discordant with patients' symptoms. An integrated imaging approach is optimal to evaluate the complex anatomy and dynamic functionality of the pelvic floor. Fluoroscopic cystocolpoproctography (CCP) and MR defecography are considered the initial imaging tests of choice for evaluation of POP. Fluoroscopic voiding cystourethrography is considered the initial imaging test for patients with urinary dysfunction. Fluoroscopic CCP and MR defecography are considered the initial imaging test for patients with defecatory dysfunction, whereas ultrasound pelvis transrectal is a complementary test in patients requiring evaluation for anal sphincter defects. MRI pelvis without and with intravenous contrast, MRI pelvis with dynamic maneuvers, and MR defecography are considered the initial imaging tests in patients with suspected complications of prior pelvic floor surgical repair. Transperineal ultrasound is emerging as an important imaging tool, in particular for screening of pelvic floor dysfunction and for evaluation of midurethral slings, vaginal mesh, and complications related to prior pelvic floor surgical repair. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
- Gaurav Khatri
- Division Chief, Body MRI; Associate Division Chief, Abdominal Imaging, UT Southwestern Medical Center, Dallas, Texas; Program Director, Body MRI Fellowship.
| | | | | | - Esma A Akin
- George Washington University Hospital, Washington, District of Columbia
| | - Susan M Ascher
- Georgetown University Hospital, Washington, District of Columbia
| | - Olga R Brook
- Section Chief of Abdominal Radiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Mark Dassel
- Director Endometriosis and Chronic Pelvic Pain, Cleveland Clinic, Cleveland, Ohio; American College of Obstetricians and Gynecologists
| | - Phyllis Glanc
- University of Toronto and Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | - Lee A Learman
- Dean, Virginia Tech Carilion School of Medicine, Roanoke, Virginia; American College of Obstetricians and Gynecologists
| | - Elizabeth A Sadowski
- University of Wisconsin, Madison, Wisconsin; and ACR O-RADS MRI Education Subcommittee Chair
| | - Carl J Saphier
- Women's Ultrasound, LLC, Englewood, New Jersey; American College of Obstetricians and Gynecologists
| | - Ashish P Wasnik
- Division Chief, Abdominal Radiology, University of Michigan, Ann Arbor, Michigan
| | - Katherine E Maturen
- Associate Chair for Ambulatory Care and Specialty Chair, University of Michigan, Ann Arbor, Michigan
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20
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Alshiek J, Wei Q, Shobeiri SA. Correlation between pelvic floor ultrasound parameters and vaginal pressures in nulliparous women: a subanalysis of the SUM-AN study. Int Urogynecol J 2022; 33:1481-1487. [PMID: 35230482 DOI: 10.1007/s00192-022-05117-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 01/15/2022] [Indexed: 10/19/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Pelvic floor ultrasound is used as a validated technique for measuring levator ani dimensions. Vaginal manometry has been used in the past as a method to assess levator ani muscle (LAM) strength. Whether the combination of both methods can contribute to our understanding of pelvic floor pathophysiology has not yet been described. We hypothesized that as female pelvic floor muscular hiatus increases, the vaginal pressure and strength decrease. METHODS We recruited 20 asymptomatic nulliparous women ages 18-85 years. Minimal levator hiatus (MLH) area, anteroposterior/left-right (AP/LR) diameter ratio, the distance between levator plate and the pubic symphysis (LP-PS) while at rest and squeeze were measured using endovaginal ultrasound (US). Vaginal pressure at rest, squeeze (Kegel) and Valsalva were measured using 3D manometry. Logistic and linear regression analysis was performed to assess correlations. RESULTS MLH area was negatively correlated with the sum of all the squeeze pressures produced on the four walls of the vagina (p = 0.049, R2 = 0.197). There was also a borderline negative correlation between MLH and the sum of rest pressures (p = 0.09, R2 = 0.15). AP/LR ratio was negatively correlated with the sum of squeeze pressures (p = 0.056, R2 = 0.197). LP-PS distances, both while at rest and during squeeze, were negatively correlated with the vaginal squeeze pressure (p = 0.046, R2 = 0.21; p = 0.011, R2 = 0.31, respectively). LP-V distance, both at rest and during squeeze, was negatively correlated with the sum of squeeze pressures on four vaginal walls (p = 0.02, R2 = 0.25; p = 0.005, R2 = 0.36, respectively). CONCLUSIONS Stronger levator ani muscles, smaller MLH area and a more oval shape of pelvic floor hiatus as assessed by pelvic floor ultrasound are associated with higher squeeze vaginal pressures as assessed by 3D manometry.
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Affiliation(s)
- Jonia Alshiek
- Department of Obstetrics & Gynecology, INOVA Women's Hospital, 3300 Gallows Road, Second floor South tower, Falls Church, VA, 22042-3307, USA.,Bioengineering, George Mason University, Fairfax, VA, USA
| | - Qi Wei
- Bioengineering, George Mason University, Fairfax, VA, USA
| | - S Abbas Shobeiri
- Department of Obstetrics & Gynecology, INOVA Women's Hospital, 3300 Gallows Road, Second floor South tower, Falls Church, VA, 22042-3307, USA. .,Bioengineering, George Mason University, Fairfax, VA, USA.
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21
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Liu LN, Liu XN, Liu C, Yao MY, Xu HX. Transperineal pelvic floor ultrasound for analyzing the outcomes of pelvic floor surgery for the treatment of anterior compartment prolapse: A comparative study of transvaginal mesh and native-tissue repair. Low Urin Tract Symptoms 2021; 13:456-462. [PMID: 34101374 DOI: 10.1111/luts.12392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 04/27/2021] [Accepted: 05/13/2021] [Indexed: 12/07/2022]
Abstract
OBJECTIVE To compare the outcomes of transvaginal mesh (TVM) and native-tissue repair (NTR) for the repair of anterior compartment prolapse. METHODS This retrospective study involved 90 patients with anterior compartment prolapse who underwent pelvic organ prolapse surgery between January 2018 and October 2020. A TVM was used to treat 53 patients and 37 underwent NTR. All patients underwent a standardized interview, clinical examination, and four-dimensional pelvic floor ultrasound (PFUS) before and after the surgery. The primary outcome was anatomic recurrence evaluated by ultrasonic parameters. The secondary outcomes were subjective recurrence and complications. RESULTS Subjective recurrence was 9.43% (5/53) for TVM and 16.22% (6/37) for NTR (P = .522). Significant recurrence of prolapse on ultrasound occurred in five patients (9.43%) after TVM and 12 (32.43%) after NTR; there was a significant difference between the TVM and NTR groups (P = .006). In the TVM group, the mesh was visible on ultrasound in each patient. The mesh exposure rate was 1.89% (1/53). The postoperative hiatal area reduction in the TVM group, compared with the NTR group, was statistically significant (5.55 ± 4.71 cm2 vs 3.09 ± 5.61 cm2 , P = .027). The incidence of de novo stress urinary incontinence was higher in the TVM group (20.75% vs 2.70%, P = .03). After surgery, there were significant differences between the two groups based on bladder descent (12.02 ± 8.64 mm vs 22.41 ± 13.95 mm, P = .000) and urethral rotation angle (25.26 ± 13.92° vs 40.27 ± 23.72°, P = .001). CONCLUSION PFUS is effective for evaluating postoperative outcomes. TVM facilitates a better anatomic cure than NTR for anterior compartment prolapse.
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Affiliation(s)
- Lin-Na Liu
- Department of Medical Ultrasound, Shanghai Tenth People's Hospital, Ultrasound Research and Education Institute, Tongji University Cancer Center, Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, Tongji University School of Medicine, Shanghai, China
| | - Xiu-Ni Liu
- Department of Obstetrics and Gynecology, Shanghai Tenth People's Hospital, Shanghai, China
| | - Chang Liu
- Department of Medical Ultrasound, Shanghai Tenth People's Hospital, Ultrasound Research and Education Institute, Tongji University Cancer Center, Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, Tongji University School of Medicine, Shanghai, China
| | - Meng-Yan Yao
- Department of Medical Ultrasound, Shanghai Tenth People's Hospital, Ultrasound Research and Education Institute, Tongji University Cancer Center, Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, Tongji University School of Medicine, Shanghai, China
| | - Hui-Xiong Xu
- Department of Medical Ultrasound, Shanghai Tenth People's Hospital, Ultrasound Research and Education Institute, Tongji University Cancer Center, Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, Tongji University School of Medicine, Shanghai, China
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van Gruting IM, Stankiewicz A, Thakar R, Santoro GA, IntHout J, Sultan AH. Imaging modalities for the detection of posterior pelvic floor disorders in women with obstructed defaecation syndrome. Cochrane Database Syst Rev 2021; 9:CD011482. [PMID: 34553773 PMCID: PMC8459393 DOI: 10.1002/14651858.cd011482.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Obstructed defaecation syndrome (ODS) is difficulty in evacuating stools, requiring straining efforts at defaecation, having the sensation of incomplete evacuation, or the need to manually assist defaecation. This is due to a physical blockage of the faecal stream during defaecation attempts, caused by rectocele, enterocele, intussusception, anismus or pelvic floor descent. Evacuation proctography (EP) is the most common imaging technique for diagnosis of posterior pelvic floor disorders. It has been regarded as the reference standard because of extensive experience, although it has been proven not to have perfect accuracy. Moreover, EP is invasive, embarrassing and uses ionising radiation. Alternative imaging techniques addressing these issues have been developed and assessed for their accuracy. Because of varying results, leading to a lack of consensus, a systematic review and meta-analysis of the literature are required. OBJECTIVES To determine the diagnostic test accuracy of EP, dynamic magnetic resonance imaging (MRI) and pelvic floor ultrasound for the detection of posterior pelvic floor disorders in women with ODS, using latent class analysis in the absence of a reference standard, and to assess whether MRI or ultrasound could replace EP. The secondary objective was to investigate differences in diagnostic test accuracy in relation to the use of rectal contrast, evacuation phase, patient position and cut-off values, which could influence test outcome. SEARCH METHODS We ran an electronic search on 18 December 2019 in the Cochrane Library, MEDLINE, Embase, SCI, CINAHL and CPCI. Reference list, Google scholar. We also searched WHO ICTRP and clinicaltrials.gov for eligible articles. Two review authors conducted title and abstract screening and full-text assessment, resolving disagreements with a third review author. SELECTION CRITERIA Diagnostic test accuracy and cohort studies were eligible for inclusion if they evaluated the test accuracy of EP, and MRI or pelvic floor ultrasound, or both, for the detection of posterior pelvic floor disorders in women with ODS. We excluded case-control studies. If studies partially met the inclusion criteria, we contacted the authors for additional information. DATA COLLECTION AND ANALYSIS Two review authors performed data extraction, including study characteristics, 'Risk-of-bias' assessment, sources of heterogeneity and test accuracy results. We excluded studies if test accuracy data could not be retrieved despite all efforts. We performed meta-analysis using Bayesian hierarchical latent class analysis. For the index test to qualify as a replacement test for EP, both sensitivity and specificity should be similar or higher than the historic reference standard (EP), and for a triage test either specificity or sensitivity should be similar or higher. We conducted heterogeneity analysis assessing the effect of different test conditions on test accuracy. We ran sensitivity analyses by excluding studies with high risk of bias, with concerns about applicability, or those published before 2010. We assessed the overall quality of evidence (QoE) according to GRADE. MAIN RESULTS Thirty-nine studies covering 2483 participants were included into the meta-analyses. We produced pooled estimates of sensitivity and specificity for all index tests for each target condition. Findings of the sensitivity analyses were consistent with the main analysis. Sensitivity of EP for diagnosis of rectocele was 98% (credible interval (CrI)94%-99%), enterocele 91%(CrI 83%-97%), intussusception 89%(CrI 79%-96%) and pelvic floor descent 98%(CrI 93%-100%); specificity for enterocele was 96%(CrI 93%-99%), intussusception 92%(CrI 86%-97%) and anismus 97%(CrI 94%-99%), all with high QoE. Moderate to low QoE showed a sensitivity for anismus of 80%(CrI 63%-94%), and specificity for rectocele of 78%(CrI 63%-90%) and pelvic floor descent 83%(CrI 59%-96%). Specificity of MRI for diagnosis of rectocele was 90% (CrI 79%-97%), enterocele 99% (CrI 96%-100%) and intussusception 97% (CrI 88%-100%), meeting the criteria for a triage test with high QoE. MRI did not meet the criteria to replace EP. Heterogeneity analysis showed that sensitivity of MRI performed with evacuation phase was higher than without for rectocele (94%, CrI 87%-98%) versus 65%, CrI 52% to 89%, and enterocele (87%, CrI 74%-95% versus 62%, CrI 51%-88%), and sensitivity of MRI without evacuation phase was significantly lower than EP. Specificity of transperineal ultrasound (TPUS) for diagnosis of rectocele was 89% (CrI 81%-96%), enterocele 98% (CrI 95%-100%) and intussusception 96% (CrI 91%-99%); sensitivity for anismus was 92% (CrI 72%-98%), meeting the criteria for a triage test with high QoE. TPUS did not meet the criteria to replace EP. Heterogeneity analysis showed that sensitivity of TPUS performed with rectal contrast was not significantly higher than without for rectocele(92%, CrI 69%-99% versus 81%, CrI 58%-95%), enterocele (90%, CrI 71%-99% versus 67%, CrI 51%-90%) and intussusception (90%, CrI 69%-98% versus 61%, CrI 51%-86%), and was lower than EP. Specificity of endovaginal ultrasound (EVUS) for diagnosis of rectocele was 76% (CrI 54%-93%), enterocele 97% (CrI 80%-99%) and intussusception 93% (CrI 72%-99%); sensitivity for anismus was 84% (CrI 59%-96%), meeting the criteria for a triage test with very low to moderate QoE. EVUS did not meet the criteria to replace EP. Specificity of dynamic anal endosonography (DAE) for diagnosis of rectocele was 88% (CrI 62%-99%), enterocele 97% (CrI 75%-100%) and intussusception 93% (CrI 65%-99%), meeting the criteria for a triage test with very low to moderate QoE. DAE did not meet the criteria to replace EP. Echodefaecography (EDF) had a sensitivity of 89% (CrI 65%-98%) and specificity of 92% (CrI 72%-99%) for intussusception, meeting the criteria to replace EP but with very low QoE. Specificity of EDF for diagnosis of rectocele was 89% (CrI 60%-99%) and for enterocele 97% (CrI 87%-100%); sensitivity for anismus was 87% (CrI 72%-96%), meeting the criteria for a triage test with low to very low QoE. AUTHORS' CONCLUSIONS In a population of women with symptoms of ODS, none of the imaging techniques met the criteria to replace EP. MRI and TPUS met the criteria of a triage test, as a positive test confirms diagnosis of rectocele, enterocele and intussusception, and a negative test rules out diagnosis of anismus. An evacuation phase increased sensitivity of MRI. Rectal contrast did not increase sensitivity of TPUS. QoE of EVUS, DAE and EDF was too low to draw conclusions. More well-designed studies are required to define their role in the diagnostic pathway of ODS.
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Affiliation(s)
- Isabelle Ma van Gruting
- Department of Obstetrics and Gynaecology, Croydon University Hospital NHS Trust, Croydon, Netherlands
| | | | - Ranee Thakar
- Department of Obstetrics and Gynaecology, Croydon University Hospital NHS Trust, Croydon, UK
| | - Giulio A Santoro
- Section of Anal Physiology and Ultrasound, Department of Surgery, Regional Hospital, Treviso, Italy
| | - Joanna IntHout
- Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, Netherlands
| | - Abdul H Sultan
- Department of Obstetrics and Gynaecology, Croydon University Hospital NHS Trust, Croydon, UK
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Jeong HY, Park DH, Lee JK. Levator plate descent angle in pelvic floor disorders. Tech Coloproctol 2021; 25:1011-1018. [PMID: 34297244 DOI: 10.1007/s10151-021-02458-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 05/04/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND The levator plate descent angle (LPDA) quantifies the levator plate position with reference to the pubic bone and perineal body at rest. Unfortunately, research on this notable new parameter is lacking, but it is clear that levator ani deficiency (LAD) will undermine the fundamental role of the levator ani muscle (LAM) in organ support. The aim of this study was to establish the relationship between the LPDA and LAD in patients with pelvic floor disorders. METHODS This retrospective study was conducted at Seoul Songdo Hospital, Korea between August 2019 and August 2020 on women with symptoms of pelvic floor disorder such as urinary incontinence, constipation, and fecal incontinence. In all cases, three-dimensional pelvic floor ultrasound was performed for LAD scoring, minimal levator hiatus, and LPDA evaluation. We evaluated LAD using a scoring system that graded levator injury according to the insertion point of each subdivision scored unilaterally. For the entire LAM group, a cumulative LAD score that ranged between 0 and 18 was possible. Scores were categorized as mild (0-6 points), moderate (7-12 points), and severe (13-18 points) deficiency RESULTS: A total of 93 patients were included in the study (mean age 65.89 ± 11.12 [range, 34-86] years). Thirteen participants had mild LAD scores (14.0%), 42 had moderate LAD scores (45.2%), and 38 had severe LAD scores (40.9%). There was a significant difference in mean age (59.23 ± 12.55 years vs. 64.43 ± 10.03 vs. 69.79 ± 10.55 years, p = 0.005) and mean parity (1.85 ± 0.90 vs 2.48 ± 1.15 vs 2.76 ± 1.10, p = 0.038) of patients between groups. There was also a significant difference in the mean Wexner incontinence score (7.14 ± 3.63 vs 7.24 ± 5.76 vs 11.41 ± 5.54, p = 0.028) and in the mean fecal incontinence quality of life (FIQOL) score (12.91 ± 3.11 vs 14.10 ± 3.87 vs 10.41 ± 3.65, p = 0.014). The mean value of the LPDA in the group with mild LAD scores was 14.65° (SD ± 3.54) and in the group with moderate LAD scores was 9.66° (SD ± 3.36). In the group with severe LAD scores, the mean LPDA was 1.83° (SD ± 4.71). The mean value for minimal levator hiatus (MLH) area in the mild LAD score group was 14.16cm2 (SD ± 2.72), that in the moderate LAD score group was 15.82cm2 (SD ± 2.30), and that in the severe LAD score group was 17.99cm2 (SD ± 2.81). There were significant differences between the three groups both in decreasing LPDA (p < 0.001) and increasing MLH (p < 0.001). There was a negative correlation between the LAD score and LPDA and the Pearson correlation coefficient was -0.528 (moderate correlation). There was a positive correlation between the LAD score and MLH, and the Pearson correlation coefficient was 0.303 (weak correlation). CONCLUSIONS The LAD score and LPDA have a moderate negative correlation. In patients with severe pelvic floor symptoms and extensive LAM injury, high LAD scores and low LPDA results were confirmed. In the treatment of patients with pelvic floor disorders, the LPDA seems to be a very useful parameter in determining the severity of structural defects.
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Affiliation(s)
- Hong Yoon Jeong
- Department of Surgery, Seoul Song Do Hospital, 72, Dasan-ro, Jung-gu, Seoul, 04597, Korea
| | - Duk Hoon Park
- Department of Surgery, Seoul Song Do Hospital, 72, Dasan-ro, Jung-gu, Seoul, 04597, Korea.
| | - Jong Kyun Lee
- Department of Surgery, Seoul Song Do Hospital, 72, Dasan-ro, Jung-gu, Seoul, 04597, Korea
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Krutova VA, Nadtochy AV, Naumova NV, Boldovskaya EA. [Usage evaluation of the biofeedback and electrical impulse stimulation of the pelvic floor muscles in patients after surgical correction of genital prolapse by the method of multi-parametric ultrasound]. VOPROSY KURORTOLOGII, FIZIOTERAPII, I LECHEBNOĬ FIZICHESKOĬ KULTURY 2021; 98:29-38. [PMID: 34223752 DOI: 10.17116/kurort20219803129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Pelvic floor surgery is currently recognized as the only effective method for treating genital prolapse but it is not able to restore fully the qualitative characteristics of perineal tissues. The risk of recurrence of the pathological process in the long-term period remains a serious negative aspect. Optimization of pelvic floor rehabilitation after surgical correction of perineal ptosis remains an urgent problem in the female population. The validated method of questioning is a priority in assessing the dynamics of clinical manifestations of failure of the anatomical and functional structures of the pelvic floor, their impact on the life quality of patients before and after the biofeedback method (BFB therapy) and electrical impulse stimulation (EIS) of muscles. Multi-parametric ultrasound diagnostics of perineal tissues can confirm the improvement of the echo-structure of the anatomical and functional elements of the pelvic floor after the complex application of physiotherapeutic effects using modern high-tech hardware systems through an external feedback channel by means of acoustic, visual and tactile perception. OBJECTIVE To evaluate the effectiveness of biofeedback therapy and EIS of the neuromuscular apparatus of the pelvic floor in patients operated on for stage III, IV of genital prolapse using mesh implants by means of validated questionnaire survey and measuring the parameters of perineal tissues by the method of multi-parametric ultrasound. MATERIAL AND METHODS The study included 187 women after surgical correction of stage III and IV genital prolapse according to POP-Q using mesh technologies. The 149 women underwent the observation program; 36 patients of the control group were recommended to modify their lifestyle; 113 patients of the main group - biofeedback therapy and EIS. The indicators of validated questionnaires (determination of the of perineal structures failure influence index on the life quality, ILQ) and ultrasound multi-parametric examination were assessed at baseline, 6 months and 1 year after the program of observation and rehabilitation. RESULTS The clinical effectiveness of biofeedback therapy and EIS was confirmed by validated questionnaire: after 1 year, the ILQ in the control group decreased by 7.7%, in the main group - by 43.3% (p<0.05). Multi-parametric ultrasound assessment of perineal tissues after surgical correction of stages III and IV of genital prolapse showed a positive effect of conservative rehabilitation on the anatomical and functional structures of the pelvic floor. The diagnostic advantage of endo-anal sonography in the analysis of the echo-structure of the pelvic floor elements, detection of pathologies that cannot be scanned endo-vaginally and trans-perineally has been established. There were 2 (5.5%) cases of recurrence of genital prolapse in the control group; there were no relapsesamong the patients of the main group. CONCLUSION The validated questioning for the ILQ and ultrasound multi-parametric study by measuring the parameters of perineal tissues confirmed the effectiveness of biofeedback therapy and EIS after surgical correction of stage III and IV genital prolapse using mesh technologies. Endo-anal sonography is essential in the examination of gynecological patients. The adherence to the monitoring and rehabilitation program was 79.6%.
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Affiliation(s)
- V A Krutova
- Kuban State Medical University, Krasnodar, Russia
| | - A V Nadtochy
- Kuban State Medical University, Krasnodar, Russia
| | - N V Naumova
- Kuban State Medical University, Krasnodar, Russia
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Jaekel AK, Kirschner-Hermanns R, Knüpfer SC. [Diagnostic testing of female urinary incontinence: dos and dont's]. Aktuelle Urol 2021; 52:237-244. [PMID: 34020505 DOI: 10.1055/a-1492-5287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Urinary incontinence causes significant limitations in quality of life and reduces mental and physical health. It is a widespread and chronic disease. About 200 million people are affected by urinary incontinence worldwide. Females are more often affected than males. For the therapy of female urinary incontinence various conservative and surgical treatment measures are available. A comprehensive diagnostic work-up is crucial for effective and successful use of those therapeutical measures. The current paper gives a review of diagnostic options for female urinary incontinence: from non-invasive up to invasive investigations. It presents potential pitfalls and possibilities for improving the diagnostic work-up.
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Affiliation(s)
- Anke K. Jaekel
- Universitätsklinikum Bonn, Klinik und Poliklinik für Urologie und Kinderurologie, Abteilung Neuro-Urologie, Bonn
| | - Ruth Kirschner-Hermanns
- Universitätsklinikum Bonn, Klinik und Poliklinik für Urologie und Kinderurologie, Abteilung Neuro-Urologie, Bonn
| | - Stephanie C. Knüpfer
- Universitätsklinikum Bonn, Klinik und Poliklinik für Urologie und Kinderurologie, Abteilung Neuro-Urologie, Bonn
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Denson LE, Terrell DR, Vesely SK, Peck JD, Quiroz LH, Shobeiri SA. The Prevalence of Pelvic Floor Hematoma After Vaginal Delivery. Female Pelvic Med Reconstr Surg 2021; 27:393-397. [PMID: 32541297 PMCID: PMC7938706 DOI: 10.1097/spv.0000000000000895] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The goal of this study was to evaluate differences in levator ani hematoma formation within 3 days of delivery between adult women after their first vaginal delivery and adult women who have had multiple vaginal deliveries. METHODS This was a cross-sectional study at a single institution from 2013 to 2015 using a high-resolution endovaginal ultrasound transducer to identify postvaginal delivery hematoma formation. Logistic regression was used to examine the association between hematoma formation and vaginal parity while considering potential confounders including induction, vaginal operative delivery, vaginal birth after cesarean, fetal weight, fetal head circumference, race and ethnicity, body mass index, age at delivery, gestational age, and length of second-stage labor. RESULTS Ninety women (46 vaginal-primiparous; 44 vaginal-multiparous) were included in this study. After adjusting for oxytocin use, length of second-stage labor, and body mass index, the odds of pelvic floor hematoma of 1000 mm3 or greater were 2.93 (95% confidence interval, 0.78-10.91) times greater in women after their first vaginal delivery compared with women with a history of multiple vaginal deliveries. The adjusted odds of pelvic floor hematoma of 1500 mm3 or greater were 6.02 (95% confidence interval, 1.09-33.24) times greater in vaginal-primiparous compared with vaginal-multiparous women. CONCLUSIONS Although the prevalence of pelvic floor hematoma was higher in vaginal-primiparous women than vaginal-multiparous women after vaginal delivery, hematomas were present in both groups. Future prospective studies are needed to evaluate the additive effect of multiple vaginal deliveries on the pelvic floor.
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Affiliation(s)
- Lindsay E. Denson
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, The University of Oklahoma Health Sciences Center, Oklahoma City, OK
- Department of Biostatistics and Epidemiology, The University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Deirdra R. Terrell
- Department of Biostatistics and Epidemiology, The University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Sara K. Vesely
- Department of Biostatistics and Epidemiology, The University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Jennifer D. Peck
- Department of Biostatistics and Epidemiology, The University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Lieschen H. Quiroz
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, The University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - S. Abbas Shobeiri
- Department of Obstetrics and Gynecology, INOVA Women’s Hospital, Annandale, VA
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Correlation between symptoms and imaging findings including pelvic floor ultrasound to improve the symptom-based diagnosis of female urethral diverticulum (CHECK-UD study). Int Urogynecol J 2021; 33:2267-2274. [PMID: 33871666 DOI: 10.1007/s00192-021-04770-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 03/16/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION AND HYPOTHESIS The objective was to establish a model to predict the presence of a female urethral diverticulum (UD) based on symptoms. METHODS A prospective CHECK-UD study (check of female urethral diverticulum) was conducted. Female patients presenting with symptoms such as lower urinary tract symptoms (LUTS), postmicturition dribble or urinary incontinence (UI), dyspareunia or pain in the pelvic area, and recurrent urinary tract infection (UTI) treated between 2015 and 2020 were included. The association between each symptom variable and the positive finding of UD was evaluated by multivariate logistic regression adjusting for age, body mass index (BMI), vaginal deliveries, previous surgery for SUI, previous pelvic surgery, and microscopic hematuria. A predictive model for the presence of UD was then created. RESULTS In total, 189 female patients with a minimum of one symptom were enrolled. Pelvic floor ultrasound revealed the presence of UD in 66 out of 189 (34.92%). Of the four symptoms, the combinations "LUTS + postmicturition dribble + UTI," "postmicturition dribble + LUTS," and "UTI + LUTS" were most significantly related to positive findings and had a higher positive prognostic value for the diagnosis of UD than each individual symptom alone (OR = 13.78 [95% CI: 6.95-16.35], p < 0.001; OR = 9.94 [95% CI: 4.60-12.2], p < 0.05; and OR = 5.78 [95% CI: 1.58-6.98] p = 0.05) respectively. CONCLUSION Based on our model, the combination "LUTS + postmicturition dribble + UTI" seems to be the most sensitive combination of clinical symptoms predicting the positive finding of UD. This model could be used for patient counseling and for the identification of patients with UD.
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García-Mejido J, Bonomi-Barby M, Armijo-Sánchez A, Borrero-Fernández C, Castro-Portillo L, Vargas-Broquetas M, Cañadas-Granados M, Sainz-Bueno J. Metodología para el estudio ecográfico transperineal del suelo pélvico. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2021. [DOI: 10.1016/j.gine.2020.09.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Taithongchai A, Pandeva I, Sultan AH, Thakar R. Association between 3D endovaginal and 2D perineal pelvic floor ultrasound findings and symptoms in women presenting with mid-urethral sling complications. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 57:639-646. [PMID: 32959432 DOI: 10.1002/uog.23130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 09/05/2020] [Accepted: 09/11/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES To present the characteristics of women attending a tertiary urogynecology pelvic floor scan clinic with mid-urethral sling (MUS) complications and examine the association between patient symptoms and findings on two-dimensional (2D) perineal and three-dimensional (3D) endovaginal ultrasound. METHODS This was a cross-sectional study of all women with MUS complications referred to a specialist pelvic floor ultrasound clinic between October 2016 and October 2018. Detailed history was obtained regarding their symptoms and time of onset. All patients underwent 2D perineal and 3D endovaginal ultrasound assessment. The association between patient symptoms and ultrasound findings was evaluated using logistic regression analysis. Only symptomatic women with a single MUS, without other pelvic floor mesh, prior mesh excision or bulking agents, were included in the regression analysis. RESULTS A total of 311 women with a history of MUS surgery were seen during the study period. Vaginal and/or non-vaginal pain was reported by 80% of patients and this was the primary presenting complaint in 59% of the patients. One-third of the patients reported symptoms starting within 4 weeks after surgery. The data of 172 patients were included in the regression analysis. MUS position within the rhabdosphincter was significantly associated with voiding dysfunction (odds ratio (OR), 10.6 (95% CI, 2.2-50.9); P = 0.003). Voiding dysfunction was highest in those with C-shaped MUS both at rest and on Valsalva maneuver (OR, 3.2 (95% CI, 1.3-7.6); P < 0.001). MUS position in the distal third of the urethra was significantly associated with a higher rate of recurrent urinary tract infection (OR, 2.9 (95% CI, 1.3-6.3); P = 0.01). CONCLUSIONS Pelvic floor ultrasound can provide insight into the position and shape of the MUS, which could explain some patient symptoms and guide management or surgical planning. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- A Taithongchai
- Croydon Urogynaecology and Pelvic Floor Reconstruction Unit, Croydon University Hospital, Croydon, London, UK
| | - I Pandeva
- Croydon Urogynaecology and Pelvic Floor Reconstruction Unit, Croydon University Hospital, Croydon, London, UK
| | - A H Sultan
- Croydon Urogynaecology and Pelvic Floor Reconstruction Unit, Croydon University Hospital, Croydon, London, UK
| | - R Thakar
- Croydon Urogynaecology and Pelvic Floor Reconstruction Unit, Croydon University Hospital, Croydon, London, UK
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Leombroni M, Buca D, Liberati M, Falò E, Rizzo G, Khalil A, Manzoli L, Flacco ME, Santarelli A, Makatsariya A, Frondaroli F, D'Antonio F. Post-partum pelvic floor dysfunction assessed on 3D rotational ultrasound: a prospective study on women with first- and second-degree perineal tears and episiotomy. J Matern Fetal Neonatal Med 2021; 34:445-455. [PMID: 31291792 DOI: 10.1080/14767058.2019.1609932] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 04/03/2019] [Accepted: 04/17/2019] [Indexed: 02/07/2023]
Abstract
Purpose: To evaluate the morphology and biometry of pelvic floor structures 3 months after birth in women experiencing first- or second-degree perineal tears or undergoing episiotomy during labor.Material and methods: Prospective observational study including nulliparous women delivering at term with a clinical diagnosis of first- or second-degree perineal tears after birth or undergoing episiotomy. The role of Kristeller maneuver during labor in affecting pelvic structure and function is also explored. All women underwent 2D trans-perineal and 3D endovaginal or endoanal ultrasound 3 months after birth.Results: 115 women assessed 3 months after delivery were enrolled in the study. Compared with controls, women who experienced first-degree perineal tears had higher bladder neck-symphysis (versus 20.9 ± 4.9 versus 16.1 ± 4.9 mm, p = .017), bladder wall-pubic symphysis (22.4 ± 7.4 versus 14.2 ± 9.5 mm, p = .02) and anorectal angle-symphysis distance (12.5 ± 4.7 versus 9.3 ± 4.3 mm, p = .018). Furthermore, they have thicker internal and external anal sphincter. The incidence of partial right and left pubo-rectalis muscle avulsion was higher in women experiencing first-degree vaginal tear during labor (16.2 versus 0%, p = .004 for both). In women affected by second-degree tears, the occurrence of partial avulsion of the right and left pubo-rectalis muscle was 16.2%, while Oasis was detected in 10.8% of the cases. Women receiving Kristeller maneuver during labor had a higher incidence of either right or left puborectalis muscle avulsion.Conclusion: Women who had either first- and second-degree perineal tears or episiotomy show signs of abnormal pelvic morphometry on 3D rotational ultrasound 3 months after birth.
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Affiliation(s)
- Martina Leombroni
- Department of Obstetrics and Gynaecology, University of Chieti, Chieti, Italy
| | - Danilo Buca
- Department of Obstetrics and Gynaecology, University of Chieti, Chieti, Italy
| | - Marco Liberati
- Department of Obstetrics and Gynaecology, University of Chieti, Chieti, Italy
| | - Eleonora Falò
- Department of Obstetrics and Gynaecology, University of Chieti, Chieti, Italy
| | - Giuseppe Rizzo
- Department of Maternal Fetal Medicine, Ospedale Cristo Re Roma, University of Roma Tor Vergata, Rome, Italy
- Department of Obstetrics and Gynaecology, The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
| | - Asma Khalil
- Fetal Medicine Unit, Division of Developmental Sciences, St. George's University of London, London, UK
| | - Lamberto Manzoli
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | | | | | - Alexander Makatsariya
- Department of Obstetrics and Gynaecology, The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
| | - Franco Frondaroli
- Department of Obstetrics and Gynaecology, University of Chieti, Chieti, Italy
| | - Francesco D'Antonio
- Women´s Health and Perinatology Research Group, Department of Clinical Medicine, Faculty of Sciences, Women'S Health and Perinatology Research Group, UiT - The Arctic University of Norway, Tromsø, Norway
- Department of Obstetrics and Gynaecology, University Hospital of Northern Norway, Tromsø, Norway
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Al Mulhim AA, Schulwolf SL, McFadden KM, Shokoohi H. Transperineal Ultrasound in the Diagnosis of Proctitis in the Emergency Department. J Emerg Med 2021; 60:e119-e124. [PMID: 33422374 DOI: 10.1016/j.jemermed.2020.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 11/10/2020] [Accepted: 11/22/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patients with anorectal complaints commonly present to the emergency department (ED). In patients with prior history of pelvic radiation and those with risk factors for sexually transmitted infections, proctitis is frequently on the differential diagnosis. Computed tomography (CT) scans are frequently done in patients with atypical presentations and those with broader differential diagnoses. Although in cases with suspected uncomplicated proctitis, conducting a point-of-care transperineal ultrasound (TPUS) may provide sufficient data to confirm the diagnosis and ascertain a safe plan for outpatient management, thus limiting the need for CT scan, a frequent flow-limiting step in the ED. CASE REPORT In this article, we present a brief case series of patients presenting to the ED with anorectal complaints in whom TPUS revealed circumferential symmetric rectal wall edema and pericolonic stranding suggestive of proctitis. History and subsequent imaging further supported these diagnoses; we also briefly detail the patients' clinical course and outcomes. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We propose the use of TPUS as the screening imaging for anorectal pathologies and those with suspected proctitis to increase its use among emergency physicians. We review the main sonographic features of proctitis alongside reports from clinical cases, as well as the potential advantages of TPUS as a first-line imaging modality as compared with CT or magnetic resonance imaging. Although the complexities of anorectal anatomy can make TPUS a more difficult ultrasound modality to master, integrating TPUS into clinical practice will prove beneficial to both physician and patient.
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Affiliation(s)
- Abdullah A Al Mulhim
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts; Center for Ultrasound Research and Education (CURE) at Massachusetts General Hospital, Boston, Massachusetts; Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Sara L Schulwolf
- Center for Ultrasound Research and Education (CURE) at Massachusetts General Hospital, Boston, Massachusetts
| | - Kathleen M McFadden
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts; Center for Ultrasound Research and Education (CURE) at Massachusetts General Hospital, Boston, Massachusetts; Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Hamid Shokoohi
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts; Center for Ultrasound Research and Education (CURE) at Massachusetts General Hospital, Boston, Massachusetts
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Hainsworth AJ, Solanki D, Morris SJ, Igbedioh C, Schizas AMP, Williams AB. Is there any association between symptoms and findings on imaging in pelvic floor defaecatory dysfunction? A prospective study. Colorectal Dis 2021; 23:237-245. [PMID: 33090672 DOI: 10.1111/codi.15396] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 08/29/2020] [Accepted: 09/15/2020] [Indexed: 12/20/2022]
Abstract
AIM To compare features on imaging (integrated total pelvic floor ultrasound (transperineal, transvaginal) and defaecation proctography) with bowel, bladder and vaginal symptoms in pelvic floor defaecatory dysfunction. METHOD A prospective observational case series of 216 symptomatic women who underwent symptom severity scoring (bowel, bladder and vaginal), integrated total pelvic floor ultrasound and defaecation proctography. Anatomical (rectocele, intussusception, enterocele, cystocele) and functional (co-ordination, evacuation) features were examined. RESULTS Irrespective of imaging modality, patients with a rectocele had higher International Consultation on Incontinence Modular Questionnaire - Vaginal Symptoms (ICIQ-VS) scores than patients without. On integrated total pelvic floor ultrasound, ICIQ-VS quality of life scores were higher in those with a rectocele. There was a higher International Consultation on Incontinence Modular Questionnaire - Bowel Symptoms (ICIQ-BS) bowel pattern score in those with a rectocele, and a lower ICIQ-BS bowel pattern and sexual impact score in those with intussusception. Poor co-ordination was associated with increased ICIQ-BS bowel control scores and obstructed defaecation symptom scores. On defaecation proctography, ICIQ-VS symptom scores were lower in patients with poor co-ordination. CONCLUSION Patients with a rectocele on either imaging modality may have qualitative vaginal symptoms on assessment. In patients with bowel symptoms but no vaginal symptoms, it is not possible to predict which anatomical abnormalities will be present on imaging.
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Affiliation(s)
| | - Deepa Solanki
- The Pelvic Floor Unit, Guy's and St Thomas, Hospital, London, UK
| | | | - Carlene Igbedioh
- The Pelvic Floor Unit, Guy's and St Thomas, Hospital, London, UK
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Duckett J, Thakar R, Shah V, Stephenson J, Balachandran A. The Use of Imaging for Synthetic Midurethral Slings. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2020; 39:1497-1506. [PMID: 32125008 DOI: 10.1002/jum.15254] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 01/29/2020] [Accepted: 02/03/2020] [Indexed: 06/10/2023]
Abstract
Ultrasound and magnetic resonance imaging can be used to image midurethral slings, which have may have complications such as pain. There is considerable misunderstanding regarding the utility of the different modalities. This article aims to review the current literature to identify the benefits and limitations of each imaging modality and identify the place that each should have for patients with midurethral sling complications. A literature search was performed, and all relevant articles were identified and reviewed. Different imaging modalities are complementary, but more research is required in this area.
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Affiliation(s)
- Jonathan Duckett
- Department of Obstetrics and Gynecology, Medway Maritime Hospital, Gillingham, Kent, England
| | - Ranee Thakar
- Croydon Urogynecology and Pelvic Floor Reconstruction Unit, Croydon University Hospital, Croydon, Surrey, England
| | - Vikas Shah
- Gastrointestinal Imaging Group, Glenfield General Hospital, University Hospitals of Leicester, Leicester, England
| | - James Stephenson
- Gastrointestinal Imaging Group, Glenfield General Hospital, University Hospitals of Leicester, Leicester, England
| | - Aswini Balachandran
- Croydon Urogynecology and Pelvic Floor Reconstruction Unit, Croydon University Hospital, Croydon, Surrey, England
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Brusciano L, Gambardella C, Roche B, Tolone S, Romano RM, Tuccillo F, Del Genio G, Terracciano G, Gualtieri G, Docimo L. Dynamic transperineal ultrasonography correlates with prolonged pudendal nerve latency in female with fecal incontinence. Updates Surg 2020; 72:1187-1194. [PMID: 32596803 DOI: 10.1007/s13304-020-00838-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 06/21/2020] [Indexed: 12/17/2022]
Abstract
The pelvic floor is a complex anatomical entity and its neuromuscular assessment is evaluated through debated neurophysiological tests. An innovative approach is the study of pelvic floor through dynamic transperineal ultrasound (DTU). The aim of this study is to evaluate DTU sensitivity in recognizing patients with fecal incontinence and to evaluate its concordance with the results of the motor latency studied via pudendal nerve terminal motor latency (PNTML). Female patients affected by FI addressed to our center of coloproctology were prospectively assessed. After a coloproctological evaluation, comprising the PNTML assessment to identify pudendal neuropathy, patients were addressed to DTU to determine anterior and posterior displacement of puborectalis muscle by a blinded coloproctologist. In order to compare the data, a cohort of female healthy volunteers was enrolled. Sixty-eight subjects (34 patients and 34 healthy volunteers) were enrolled. The sensitivities of anterior displacement, posterior displacement and either anterior or posterior displacement in determining the fecal incontinence were 82%, 67% and 91%, respectively. A further high correlation of either anterior or posterior displacement with PTNML was also noted (88%). DTU is an indirect, painless and reproducible method for the identification of the pelvic floor neuromuscular integrity. Its findings seem to highly correlate with FI symptoms and with PNTML results. In the near future, after larger comparative studies, DTU would be considered a potential reliable non-invasive and feasible indirect procedure in the identification of fecal incontinence by pudendal neuropathy. Trial registration number is NCT03933683.
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Affiliation(s)
- Luigi Brusciano
- Division of General, Mini-Invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli" Naples, via Luigi Pansini n° 5, 80131, Naples, Italy
| | - Claudio Gambardella
- Division of General, Mini-Invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli" Naples, via Luigi Pansini n° 5, 80131, Naples, Italy. .,Department of Cardiothoracic Sciences, School of Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy.
| | - Bruno Roche
- Proctology Unit, Division of Visceral Surgery, Department of Surgery, Geneva University Hospitals and Medical School, 4 Rue Gabrielle-Perret-Gentil, Geneva 14, 1211, Geneva, Switzerland
| | - Salvatore Tolone
- Division of General, Mini-Invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli" Naples, via Luigi Pansini n° 5, 80131, Naples, Italy
| | - Roberto Maria Romano
- Division of General, Mini-Invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli" Naples, via Luigi Pansini n° 5, 80131, Naples, Italy
| | - Francesco Tuccillo
- Division of General, Mini-Invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli" Naples, via Luigi Pansini n° 5, 80131, Naples, Italy
| | - Gianmattia Del Genio
- Division of General, Mini-Invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli" Naples, via Luigi Pansini n° 5, 80131, Naples, Italy
| | - Gianmattia Terracciano
- Division of General, Mini-Invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli" Naples, via Luigi Pansini n° 5, 80131, Naples, Italy
| | - Giorgia Gualtieri
- Division of General, Mini-Invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli" Naples, via Luigi Pansini n° 5, 80131, Naples, Italy
| | - Ludovico Docimo
- Division of General, Mini-Invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli" Naples, via Luigi Pansini n° 5, 80131, Naples, Italy
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Grossi U, Brusciano L, Tolone S, Del Genio G, Di Tanna GL, Gambardella C, Docimo L. Implantable Agents for Fecal Incontinence: An Age-Matched Retrospective Cohort Analysis of GateKeeper versus SphinKeeper. Surg Innov 2020; 27:608-613. [PMID: 32543984 DOI: 10.1177/1553350620934932] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background. We aim to evaluate morphofunctional changes of the sphincter complex after GateKeeper (GK) and SphinKeeper (SK) procedures and correlate these with symptom improvement. Methods. Ten consecutive females undergoing SK implant were age-matched with a cohort of 10 females who previously underwent the GK procedure. Patients in the SK and GK groups underwent implantation of 10 and 6 prostheses, respectively. Muscle tension (Tm), expressed in millinewtons per centimetre squared, mN (cm2)-1, was calculated using the equation Tm = P(ri)(tm)-1, where P is the average maximum squeeze pressure and ri and tm the inner radius and thickness of the external anal sphincter, respectively. The pre- and postimplant changes in Tm and Cleveland Clinic Fecal Incontinence Score (CCFIS) were tested by linear and Poisson regression models, respectively. Results. The CCFIS significantly improved in both groups at 12-month postimplantation. Although not reaching statistical significance, symptom improvement after SK was 33% above that observed after GK (P = .088). Compared to the baseline, a significant increase in Tm was observed in both groups at 12 months (GK, 508.1 [478.8-568.0] vs 864.4 [827.0-885.8] mN (cm2)-1; SK, 528.0 [472.7-564.0] vs 858.6 [828.0-919.6] mN (cm2)-1, P = .005). Compared to the GK group, Tm was significantly higher in patients after SK implant (158.3 mN (cm2)-1 [95% confidence interval, 109.6-207.0]; P < .001), after controlling for baseline values, at 12-month postimplantation. Conclusions. GK and SK are safe and effective treatments for FI with good short-term clinical outcomes. Comparative analysis showed superiority of SK over GK in terms of gain in Tm, with borderline significantly better improvement in symptoms. Larger studies are needed to confirm these findings.
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Affiliation(s)
- Ugo Grossi
- General, Mini-invasive and Obesity Surgery Unit, Department of Advanced Medical and Surgical Sciences, 18994University of Campania "Luigi Vanvitelli" Naples, Italy.,Colorectal and Pelvic Floor Unit, Regional Hospital Treviso, University of Padua, Italy
| | - Luigi Brusciano
- General, Mini-invasive and Obesity Surgery Unit, Department of Advanced Medical and Surgical Sciences, 18994University of Campania "Luigi Vanvitelli" Naples, Italy
| | - Salvatore Tolone
- General, Mini-invasive and Obesity Surgery Unit, Department of Advanced Medical and Surgical Sciences, 18994University of Campania "Luigi Vanvitelli" Naples, Italy
| | - Gianmattia Del Genio
- General, Mini-invasive and Obesity Surgery Unit, Department of Advanced Medical and Surgical Sciences, 18994University of Campania "Luigi Vanvitelli" Naples, Italy
| | - Gian Luca Di Tanna
- Statistics Division, 58453The George Institute for Global Health, Australia
| | - Claudio Gambardella
- General, Mini-invasive and Obesity Surgery Unit, Department of Advanced Medical and Surgical Sciences, 18994University of Campania "Luigi Vanvitelli" Naples, Italy
| | - Ludovico Docimo
- General, Mini-invasive and Obesity Surgery Unit, Department of Advanced Medical and Surgical Sciences, 18994University of Campania "Luigi Vanvitelli" Naples, Italy
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Capanna F, Haslinger C, Wisser J. Accuracy of clinical diagnosis of anal sphincter defect: clinical evaluation versus 3D-transperineal ultrasound. MINERVA GINECOLOGICA 2020; 72:187-194. [PMID: 32403913 DOI: 10.23736/s0026-4784.20.04562-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Obstetric anal sphincter injuries (OASIS) are common and an important factor in the etiology of anal incontinence. The objective of this study was to evaluate, classify and compare the agreement of clinically diagnosed third-degree sphincter tears with 3D-transperineal ultrasound (3D-TPUS) realized within 3-7 days post-delivery. METHODS This is a retrospective observational study were 119 patients with third-degree obstetric anal sphincter tears were diagnosed and treated, 85 of those underwent a 3D-TPUS examination 3-7 days postpartum. We compared the proportion of third-degree perineal tears, classified with the clinical examination as grade 3a+b and grade 3c, with the 3D-TPUS. RESULTS In 16 patients with clinically diagnosed third-degree perineal tears grade a and b, the ultrasound examination confirmed the lesion of the external anal sphincter (EAS) muscle, but in nine patients (56% of the cases) we found a lesion of the internal anal sphincter (IAS) muscle, missed by clinical examination. In the remaining 69 patients with the third-degree perineal tears grade c, the ultrasound examination confirmed both lesions (EAS and IAS muscles) in 56 women, but in 13 patients (19% of the cases) defects of the IAS muscle could not be confirmed by the ultrasound. CONCLUSIONS There was moderate agreement regarding diagnosis of grade 3a+b and grade c perineal tears between ultrasound and clinical examination, so a combined use of clinical and ultrasound knowledge can improve the possibility to find a gold standard in the diagnosis of OASIS.
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Affiliation(s)
- Federica Capanna
- Department of Obstetrics, Zurich University Hospital, Zurich, Switzerland - .,Department of Obstetrics, Geneva University Hospitals, Geneva, Switzerland -
| | | | - Josef Wisser
- Department of Obstetrics, Zurich University Hospital, Zurich, Switzerland
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AIUM Practice Parameter for the Performance of an Ultrasound Examination of the Female Pelvis. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2020; 39:E17-E23. [PMID: 32150295 DOI: 10.1002/jum.15205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
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Brusciano L, Tolone S, Del Genio G, Grossi U, Schiattarella A, Piccolo FP, Martellucci J, Schiano di Visconte M, Docimo L. Middle-term Outcomes of Gatekeeper Implantation for Fecal Incontinence. Dis Colon Rectum 2020; 63:514-519. [PMID: 31985515 DOI: 10.1097/dcr.0000000000001559] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Intersphincteric injectable bulking agents are one of the current treatment options for fecal incontinence, failing behavioral and medical therapy. Gatekeeper showed promising short-term results, but long-term outcomes are unknown. OBJECTIVE The purpose of this study was to clinically evaluate a prospective cohort of fecal incontinence patients up to 36 months after implantation of Gatekeeper. DESIGN This was a prospective clinical study. SETTINGS The study was conducted at a large university tertiary care hospital. PATIENTS Consecutive female patients were eligible if fecal incontinence onset was ≥6 months before the first visit and symptoms were refractory to standard conservative measures. INTERVENTIONS All of the patients underwent implantation of 4 or 6 Gatekeeper prostheses. Three-dimensional endoanal ultrasonography and high-resolution anorectal manometry were performed preoperatively and postoperatively at 2 and 3 months after implantation. MAIN OUTCOME MEASURES The Cleveland Clinic Fecal Incontinence score was calculated at baseline and 1, 3, 12, 24, and 36 months postoperatively. RESULTS Twenty patients (all women; median age, 59 y) were enrolled, and all implants were uneventful. Postoperative endoanal ultrasonography showed normal prosthesis localization in 16 patients (80%). At manometry, mean anal resting pressure significantly improved (57.8 ± 7.5 mm Hg; p = 0.0004). Mean preoperative Cleveland Clinic Fecal Incontinence score was 12.4 ± 1.8, with significant improvements initially documented at 3 months (4.9 ± 1.5; p < 0.0001) and sustained up to 36 months (4.9 ± 1.7; p < 0.0001). Patients receiving only 4 (compared with 6) prostheses and those experiencing pudendal neuropathy (compared with those who did not) showed significantly higher Cleveland Clinic Fecal Incontinence score values in the middle term. LIMITATIONS The study was limited by its small sample size and absence of quality-of-life data. CONCLUSIONS Initial improvements after Gatekeeper implantation for fecal incontinence are sustained in the middle term. Accurate preoperative evaluation of coexistent clinical conditions that may negatively affect outcomes is recommended for patient selection. See Video Abstract at http://links.lww.com/DCR/B109. RESULTADOS A MEDIANO PLAZO EN LA IMPLANTACIÓN DE GATEKEEPER PARA LA INCONTINENCIA FECAL: Los agentes de volumen inyectables interesfintéricos, son opciones actuales de tratamiento para la incontinencia fecal, ante fallas de terapias conductuales y médicas. Gatekeeper mostró resultados prometedores a corto plazo, pero resultados a largo plazo aún son desconocidos.Evaluar clínicamente una cohorte prospectiva de pacientes con incontinencia fecal, hasta 36 meses después de la implantación de Gatekeeper.Estudio clínico prospectivo.El estudio se realizó en un gran hospital universitario de atención terciaria.Fueron elegibles pacientes femeninas consecutivas, si el inicio de la incontinencia fecal, fue al menos 6 meses antes de la primera visita, y que los síntomas fueron refractarios a las medidas conservadoras estandarizadas.Todas las pacientes fueron sometidas a implantación de 4 o 6 prótesis Gatekeeper. Se realizó ecografía endoanal de 3D y manometría anorrectal de alta resolución, antes de la implantación y después a los 2 y 3 meses.Se calculó el puntaje de incontinencia fecal de la Cleveland Clinic al inicio, y a los 1, 3, 12, 24 y 36 meses después de la operación.Se inscribieron veinte pacientes (todas mujeres; con edad media de 59 años), y todos los implantes transcurrieron sin incidentes. La ecografía endoanal postoperatoria, mostró localización normal de la prótesis en 16 (80%) pacientes. A la manometría, la presión media de reposo anal, mejoró significativamente (57.8 ± 7.5 mmHg, p = 0.0004). La puntuación media preoperatoria de la incontinencia fecal de la Cleveland Clinic, fue de 12.35 ± 1.75, con mejoras significativas documentadas inicialmente a los 3 meses (4.9 ± 1.5, p <0.0001) y sostenidas hasta los 36 meses (4.9 ± 1.7, p <0.0001). Los pacientes que recibieron solo 4 prótesis (en comparación con 6) y que padecían neuropatía pudenda (en comparación con aquellas que no la padecían), mostraron valores de puntaje de Incontinencia Fecal de la Clínica Cleveland, significativamente más altos en el mediano plazo.El tamaño pequeño de la muestra y la ausencia de datos en calidad de vida.Las mejoras iniciales después de la implantación de Gatekeeper para la incontinencia fecal, se mantienen en el mediano plazo. Para la selección de pacientes, se recomienda una precisa evaluación preoperatoria de las condiciones clínicas coexistentes, que puedan afectar negativamente los resultados. Consulte Video Resumen en http://links.lww.com/DCR/B109.
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Affiliation(s)
- Luigi Brusciano
- Department of Medical, Surgical, Neurologic, Metabolic and Aging Sciences, General, Mini-invasive and Obesity Surgery Unit, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Salvatore Tolone
- Department of Medical, Surgical, Neurologic, Metabolic and Aging Sciences, General, Mini-invasive and Obesity Surgery Unit, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Gianmattia Del Genio
- Department of Medical, Surgical, Neurologic, Metabolic and Aging Sciences, General, Mini-invasive and Obesity Surgery Unit, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Ugo Grossi
- 4th Surgery Unit, Treviso Regional Hospital, University of Padua, Treviso, Italy
| | - Antonio Schiattarella
- Department of Medical, Surgical, Neurologic, Metabolic and Aging Sciences, General, Mini-invasive and Obesity Surgery Unit, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Francesco Pio Piccolo
- Department of Medical, Surgical, Neurologic, Metabolic and Aging Sciences, General, Mini-invasive and Obesity Surgery Unit, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Jacopo Martellucci
- General, Emergency and Mini-invasive Surgery, Careggi University Hospital, Florence, Italy
| | | | - Ludovico Docimo
- Department of Medical, Surgical, Neurologic, Metabolic and Aging Sciences, General, Mini-invasive and Obesity Surgery Unit, University of Campania "Luigi Vanvitelli," Naples, Italy
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Brusciano L, Gambardella C, Gualtieri G, Terracciano G, Tolone S, Schiano di Visconte M, Grossi U, Del Genio G, Docimo L. Effects of Extracorporeal Magnetic Stimulation in Fecal Incontinence. Open Med (Wars) 2020; 15:57-64. [PMID: 32064358 PMCID: PMC7005914 DOI: 10.1515/med-2020-0009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 11/28/2019] [Indexed: 12/20/2022] Open
Abstract
Background Fecal incontinence (FI) is a common condition that has devastating consequences for patients’ QOL. In some patients, the conventional functional pelvic floor electrical stimulation has been effective but is an invasive and embarrassing treatment. The object of the study was to evaluate the feasibility of functional extracorporeal magnetic stimulation (FMS) in strengthening the pelvic floor muscles without an anal plug and the embarrassment of undressing. Materials and Methods Thirty patients (26 female and 4 males) with FI were enrolled. All patients were assessed during a specialized coloproctology evaluation followed by endoanal ultrasonography and anorectal manometry. All patients underwent an FMS treatment once weekly for 8 weeks. Patients’ outcome was assessed by the Cleveland Clinic Fecal Incontinence Score (CCFIS) and by the fecal incontinence QOL questionnaire (FIQL). Results After 8 weeks, the number of solid and liquid stool leakage per week was significantly reduced (p<0.05) with a significant improvement of the CCFIS and of the FIQL (p<0.05). Moreover, the authors recorded a missed recruitment of the agonist and antagonists’ defecation muscles. Conclusion FMS is a safe, non-invasive and painless treatment for FI. It could be recommended for selected patients with non-surgical FI to ensure a rapid clinical improvement.
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Affiliation(s)
- Luigi Brusciano
- Division of General, Mininvasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli" Naples, via Luigi Pansini n° 5, 80131, Naples Italy
| | - Claudio Gambardella
- Division of General, Mini-invasive and Obesity Surgery- Master of Coloproctology and Master of Pelvi-Perineal Rehabilitation. University of Study of Campania "Luigi Vanvitelli" Naples, Italy.,Department of Cardiothoracic Sciences - University of Campania "Luigi Vanvitelli", School of Medicine, Naples, Italy
| | - Giorgia Gualtieri
- Division of General, Mini-invasive and Obesity Surgery- Master of Coloproctology and Master of Pelvi-Perineal Rehabilitation. University of Study of Campania "Luigi Vanvitelli" Naples, Italy
| | - Gianmattia Terracciano
- Division of General, Mini-invasive and Obesity Surgery- Master of Coloproctology and Master of Pelvi-Perineal Rehabilitation. University of Study of Campania "Luigi Vanvitelli" Naples, Italy
| | - Salvatore Tolone
- Division of General, Mini-invasive and Obesity Surgery- Master of Coloproctology and Master of Pelvi-Perineal Rehabilitation. University of Study of Campania "Luigi Vanvitelli" Naples, Italy
| | - Michele Schiano di Visconte
- Colorectal and Pelvic Floor Diseases Center, Department of General Surgery"S. Maria dei Battuti" Hospital Conegliano Italy
| | - Ugo Grossi
- Pelvic Floor Unit, I° Department of Surgery, Regional Hospital, Treviso, Italy
| | - Gianmattia Del Genio
- Division of General, Mini-invasive and Obesity Surgery- Master of Coloproctology and Master of Pelvi-Perineal Rehabilitation. University of Study of Campania "Luigi Vanvitelli" Naples, Italy
| | - Ludovico Docimo
- Division of General, Mini-invasive and Obesity Surgery- Master of Coloproctology and Master of Pelvi-Perineal Rehabilitation. University of Study of Campania "Luigi Vanvitelli" Naples, Italy
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Reliability and Diagnostic Accuracy of a New Vaginal Dynamometer to Measure Pelvic Floor Muscle Strength. Female Pelvic Med Reconstr Surg 2019; 26:514-519. [PMID: 31860565 DOI: 10.1097/spv.0000000000000796] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
AIMS Assess the intrarater and interrater reliabilities and diagnostic accuracy of a new vaginal dynamometer to measure pelvic floor muscle (PFM) strength in incontinent and continent women. METHODS A test-retest reliability study including 152 female patients. EXCLUSION CRITERIA history of urge urinary incontinence, prolapse of pelvic organ, pregnancy, previous urogynecological surgery, severe vaginal atrophy, or neurological conditions. The examination comprised digital assessment using the modified Oxford scale (MOS) and dynamometry measurements with a new prototype hand-held dynamometer. The MOS score ranges from 0 to 5: 0, no contraction; 1, flicker; 2, weak; 3, moderate; 4, good; 5, strong. Examinations were performed by a physiatrist, a physiotherapist and a midwife. The rest period between each rater measurement was 5 minutes. Assessment of intrarater and interrater reliability was calculated with the intraclass correlation coefficient. RESULTS One hundred twenty-two incontinent women and 30 continent women were included. Scores between 0 and 2 in MOS were recorded in 72% of incontinent women versus 20% in continent patients (P < 0.001). Intrarater reliability of the dynamometer was 0.942 (95% confidence interval [CI], 0.920-0.958) and the interrater reliability was 0.937 (95% CI, 0.913-0.954). The analysis of variance analysis showed significant differences in PFM strength across digital assessment categories. The post-hoc analysis showed statistical differences between adjacent categories of MOS 1-2 and 2-3. The diagnostic accuracy showed an area under the curve of 0.82 (95% C,: 0.75-0.89), 0.87 (95% CI, 0.81-0.92), and 0.83 (95% CI, 0.77-0.90) for the physiatrist, midwife, and physiotherapist, respectively. CONCLUSIONS The results obtained show a good reliability and validity of this new vaginal dynamometer to quantify PFM strength.
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Pelvic floor dysfunctions: how to image patients? Jpn J Radiol 2019; 38:47-63. [PMID: 31845071 DOI: 10.1007/s11604-019-00903-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Accepted: 11/21/2019] [Indexed: 12/13/2022]
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Xing Q, Chitnis P, Sikdar S, Alshiek J, Shobeiri SA, Wei Q. M3VR-A multi-stage, multi-resolution, and multi-volumes-of-interest volume registration method applied to 3D endovaginal ultrasound. PLoS One 2019; 14:e0224583. [PMID: 31751356 PMCID: PMC6872108 DOI: 10.1371/journal.pone.0224583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 10/16/2019] [Indexed: 11/24/2022] Open
Abstract
Heterogeneity of echo-texture and lack of sharply delineated tissue boundaries in diagnostic ultrasound images make three-dimensional (3D) registration challenging, especially when the volumes to be registered are considerably different due to local changes. We implemented a novel computational method that optimally registers volumetric ultrasound image data containing significant and local anatomical differences. It is A Multi-stage, Multi-resolution, and Multi-volumes-of-interest Volume Registration Method. A single region registration is optimized first for a close initial alignment to avoid convergence to a locally optimal solution. Multiple sub-volumes of interest can then be selected as target alignment regions to achieve confident consistency across the volume. Finally, a multi-resolution rigid registration is performed on these sub-volumes associated with different weights in the cost function. We applied the method on 3D endovaginal ultrasound image data acquired from patients during biopsy procedure of the pelvic floor muscle. Systematic assessment of our proposed method through cross validation demonstrated its accuracy and robustness. The algorithm can also be applied on medical imaging data of other modalities for which the traditional rigid registration methods would fail.
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Affiliation(s)
- Qi Xing
- Department of Computer Science, George Mason University, Fairfax, Virginia, United States of America
- The School of Information Science and Technology, Southwest Jiaotong University, Sichuan, China
| | - Parag Chitnis
- Department of Bioengineering, George Mason University, Fairfax, Virginia, United States of America
| | - Siddhartha Sikdar
- Department of Bioengineering, George Mason University, Fairfax, Virginia, United States of America
| | - Jonia Alshiek
- Department of Obstetrics & Gynecology, INOVA Health System, Falls Church, Virginia, United States of America
| | - S. Abbas Shobeiri
- Department of Bioengineering, George Mason University, Fairfax, Virginia, United States of America
- Department of Obstetrics & Gynecology, INOVA Health System, Falls Church, Virginia, United States of America
| | - Qi Wei
- Department of Bioengineering, George Mason University, Fairfax, Virginia, United States of America
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Shokoohi H, Pyle M, Frasure SE, Dimbil U, Pourmand A. Point-of-care Transperineal Ultrasound to Diagnose Abscess in the Emergency Department. Clin Pract Cases Emerg Med 2019; 3:349-353. [PMID: 31763585 PMCID: PMC6861055 DOI: 10.5811/cpcem.2019.6.43514] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 06/21/2019] [Accepted: 06/28/2019] [Indexed: 02/08/2023] Open
Abstract
Perineal and rectal pain are common presentations in the emergency department (ED). In the majority of cases, clinical examination is sufficient to detect local anorectal pathologies. However, perianal and rectal abscesses and fistulas are often the primary concerns prompting diagnostic imaging in the ED. Currently, computed tomography is the preferred imaging modality. Recently, transperineal ultrasound has emerged as an optimal imaging modality for the diagnosis of perineal and perianal abscesses. We present a case in which point-of-care ultrasound accurately detected an intersphincteric abscess, and review the appropriate ultrasound technique to evaluate patients with suspected perianal and rectal abscesses.
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Affiliation(s)
- Hamid Shokoohi
- Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts
- The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Matthew Pyle
- The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Sarah E. Frasure
- The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Ubah Dimbil
- The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Ali Pourmand
- The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
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El-Haieg DO, Madkour NM, Basha MAA, Ahmad RA, Sadek SM, Al-Molla RM, Tantwy EF, Almassry HN, Altaher KM, Mahmoud NEM, Aly SA. Magnetic resonance imaging and 3-dimensional transperineal ultrasound evaluation of pelvic floor dysfunction in symptomatic women: a prospective comparative study. Ultrasonography 2019; 38:355-364. [PMID: 31466142 PMCID: PMC6769195 DOI: 10.14366/usg.19007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 05/06/2019] [Indexed: 12/15/2022] Open
Abstract
Purpose The purpose of this study was to investigate magnetic resonance imaging (MRI) and 3-dimensional transperineal ultrasound (3D-TPUS) features of pelvic floor dysfunction (PFD) in symptomatic women in correlation with digital palpation and to define cut-offs for hiatal dimensions predictive of muscle dysfunction. Methods This prospective study included 73 women with symptoms suggesting PFD. 3D-TPUS, MRI, and digital palpation of the levator ani muscle were performed in all patients. Levator hiatal antero-posterior (LHap) diameter and area (LH area) were measured at rest and at maximum muscle contraction. Results The reduction in LHap diameter and LH area during contraction was significantly less in women with underactive pelvic floor muscle contraction (UpfmC) than in those who had normal pelvic floor muscle contraction by digital palpation (P<0.001). Statistically significant positive correlations (P<0.001) were found between the Modified Oxford Score and 3D-TPUS and MRI regarding the reduction in the LHap diameter (r=0.80 and r=0.82, respectively) and LH area (r=0.60 and r=0.70, respectively). A reduction in LHap of <6.5% on 3D-TPUS and <7.6% on MRI predicted UpfmC with sensitivities of 46.2% and 82.7%, respectively. A reduction in LH area of <3.4% on 3D-TPUS and <3.8% on MRI predicted UpfmC with sensitivities of 75.0% and 88.5%, respectively. MRI was more sensitive in detecting levator avulsion (63.4%) than 3D-TPUS (27.1%). Conclusion MRI and 3D-TPUS had strong positive correlations with findings on palpation, and at certain cut-offs for hiatal dimensions, they can be used as complementary and objective tools to improve the accuracy of diagnosis and management planning of PFD.
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Affiliation(s)
- Dahlia O El-Haieg
- Department of Obstetrics and Gynecology, Zagazig University, Zagazig, Egypt
| | - Nadia M Madkour
- Department of Obstetrics and Gynecology, Zagazig University, Zagazig, Egypt
| | | | - Reda A Ahmad
- Department of Obstetrics and Gynecology, Zagazig University, Zagazig, Egypt
| | - Somayya M Sadek
- Department of Obstetrics and Gynecology, Zagazig University, Zagazig, Egypt
| | - Rania M Al-Molla
- Department of Radiodiagnosis, Zagazig University, Zagazig, Egypt
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Fissurectomy with vertical non-full-thickness sphincterotomy for chronic anal fissure. Tech Coloproctol 2019; 23:1009-1013. [DOI: 10.1007/s10151-019-02087-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 09/08/2019] [Indexed: 01/01/2023]
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Taithongchai A, Sultan AH, Wieczorek PA, Thakar R. Clinical application of 2D and 3D pelvic floor ultrasound of mid-urethral slings and vaginal wall mesh. Int Urogynecol J 2019; 30:1401-1411. [DOI: 10.1007/s00192-019-03973-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 04/22/2019] [Indexed: 12/22/2022]
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Maßlo K, Möllers M, de Murcia KO, Klockenbusch W, Schmitz R. New Method for Assessment of Levator Avulsion Injury: A Comparative Elastography Study. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2019; 38:1301-1307. [PMID: 30208248 DOI: 10.1002/jum.14810] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 08/07/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE The aim of this study was to introduce elastography as a new method for sonographic assessment of postpartum pelvic floor trauma. METHODS We examined 86 postpartum primiparous women, of whom 43 had undergone primary caesarean section (group_CS) and 43 vaginal delivery (group_VD). In a puborectal-symphysis plane, B-mode and elastographic ultrasonography were used to evaluate pelvic floor trauma. The strain value of left and right puborectal muscle was assessed close to the symphysis (Trauma_Elastography). The strain ratio maximum of this measurement was stored (Trauma_Index). RESULTS The elastographic evaluation revealed more trauma-suspicious lesions than the B-mode investigation (60.5% versus 39.5%; P < .001). The median Trauma_Index was higher in group_VD compared to group_CS (1.63 versus 1.18; P < .001). CONCLUSION Sonographic elastography assessment in a new examination plane shows postpartum trauma of the pelvic floor in women after vaginal delivery. This new method may help to identify women with a higher risk of postpartum pelvic floor disorders.
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Affiliation(s)
- Katharina Maßlo
- Department of Obstetrics and Gynaecology, Asklepios Klinik Altona, Hamburg, Germany
| | - Mareike Möllers
- Department of Obstetrics and Gynaecology, University Hospital Münster, Münster, Germany
| | | | - Walter Klockenbusch
- Department of Obstetrics and Gynaecology, University Hospital Münster, Münster, Germany
| | - Ralf Schmitz
- Department of Obstetrics and Gynaecology, University Hospital Münster, Münster, Germany
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Alshiek J, Jalalizadeh M, Wei Q, Chitnis P, Shobeiri SA. Ultrasongraphic age‐related changes of the pelvic floor muscles in nulliparous women and their association with pelvic floor symptoms: A pilot study. Neurourol Urodyn 2019; 38:1305-1312. [DOI: 10.1002/nau.23979] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 02/14/2019] [Accepted: 03/03/2019] [Indexed: 12/29/2022]
Affiliation(s)
- Jonia Alshiek
- Department of Obstetrics & GynecologyINOVA Women's HospitalFalls Church Virginia
| | - Mehrsa Jalalizadeh
- Department of Obstetrics & GynecologyINOVA Women's HospitalFalls Church Virginia
| | - Qi Wei
- Biomedical Engineering, George Mason UniversityFalls Church Virginia
| | - Parag Chitnis
- Biomedical Engineering, George Mason UniversityFalls Church Virginia
| | - S. Abbas Shobeiri
- Department of Obstetrics & GynecologyINOVA Women's HospitalFalls Church Virginia
- Biomedical Engineering, George Mason UniversityFalls Church Virginia
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Pihl S, Uustal E, Blomberg M. Anovaginal distance and obstetric anal sphincter injury: a prospective observational study. Int Urogynecol J 2018; 30:939-944. [PMID: 30535980 PMCID: PMC6511353 DOI: 10.1007/s00192-018-3838-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 11/21/2018] [Indexed: 02/06/2023]
Abstract
INTRODUCTION AND HYPOTHESIS No measurements are available for diagnosing the extent of obstetric lacerations. The primary aim of this study was to evaluate the relation between the anovaginal distance (AVD) measured with transperineal ultrasound immediately after delivery and external anal sphincter injury. A secondary aim was to assess whether the palpated perineal thickness was associated with the AVD. METHODS A prospective observational study of 150 primiparous women at the University Hospital, Linköping, Sweden. After vaginal delivery, initial inspection and palpation of the perineal thickness were performed by the midwife. The women were then divided into subgroups depending on the degree of the suspected perineal laceration. Transperineal ultrasound of the AVD was performed by a physician. Diagnostics of the perineal laceration were done according to standard care. RESULTS Women with an external sphincter injury had a shorter AVD and shorter palpatory perineal thickness compared with women without anal sphincter injury. No external sphincter injuries were diagnosed when the AVD and/or palpation height was > 20 mm. The mean AVD in the group with probable second-degree laceration (n = 85) was 18.8 mm (95% CI 17.8-19.8), in suspected third-degree laceration (n = 33) 15.7 mm (95% CI 13.7-17.7) and in probable third-degree laceration (n = 32) 11.8 mm (95% CI 9.7-13.9) (p < 0.001). CONCLUSIONS A short AVD could be a warning sign postpartum and should increase the awareness of possible external sphincter injury before suturing. An AVD of 20 mm seems to indicate a cutoff level of the occurrence of external sphincter injury, but this needs further evaluation.
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Affiliation(s)
- Sofia Pihl
- Department of Obstetrics and Gynecology, and Department of Clinical and Experimental Medicine, Linköping University, SE-581 85, Linköping, Sweden.
| | - Eva Uustal
- Department of Obstetrics and Gynecology, and Department of Clinical and Experimental Medicine, Linköping University, SE-581 85, Linköping, Sweden
| | - Marie Blomberg
- Department of Obstetrics and Gynecology, and Department of Clinical and Experimental Medicine, Linköping University, SE-581 85, Linköping, Sweden
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Madkour NM. Transperineal ultrasound imaging of the pelvic floor muscles in women with pelvic floor dysfunction symptoms: A cross-sectional study. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2018. [DOI: 10.1016/j.mefs.2017.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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