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Victoria L Handa - One of the best experts on this subject based on the ideXlab platform.

  • the role of the Genital Hiatus and prolapse symptom bother
    International Urogynecology Journal, 2021
    Co-Authors: Kristin Voegtline, Keila S Muniz, Sarah Olson, Victoria L Handa
    Abstract:

    Pelvic organ prolapse (POP) severity is poorly correlated with prolapse symptoms. The objective of this study was to investigate the association between Genital Hiatus (GH) size and presence and severity of bulge symptoms. This analysis utilized data from a longitudinal study of parous women. Women underwent annual assessment of POP, GH size, and bulge symptoms. “Bother” was scored by participants reporting bulge symptoms. Three analyses evaluated the association between GH size and bulge symptoms, each using linear mixed models. First, we compared case visits (bulge symptoms reported) to control visits (bulge symptoms never reported), matching for stage. Second, among women who reported bulge sensation at least once during the study, we compared GH size at visits with and without bulge symptoms. Third, among women who reported bulge sensation, we investigated whether GH size was associated with “bother” score, controlling for stage. Of 1528 women (7440 visits), 148 women (803 visits) reported bulge symptoms at ≥ 1 visit and 1380 women never reported bulge symptoms (6637 visits). Comparing 315 case visits (bulge symptoms reported) to 1260 control visits (bulge symptoms never reported), GH size was significantly greater among case visits (3.05 cm versus 2.85 cm, p ≤ 0.0001). In the case-crossover analysis, GH size was similar for visits with and without bulge symptoms (p = 0.63). When evaluating GH size and degree of bulge symptom bother, bother severity was significantly associated with GH size (p = 0.003). Independent of stage, GH size was significantly associated with prolapse bulge symptoms and bother severity.

  • surgical repair of the Genital Hiatus a narrative review
    International Urogynecology Journal, 2021
    Co-Authors: Jacqueline Y Kikuchi, Keila S Muniz, Victoria L Handa
    Abstract:

    An enlarged Genital Hiatus (GH) is associated with the development of prolapse and may be associated with prolapse recurrence following surgery; however, there is insufficient evidence to support surgical reduction of the GH as prophylaxis against future prolapse. The objective of this review is (1) to review the association between GH size and pelvic organ prolapse and (2) to discuss the existing literature on surgical procedures that narrow the GH. A literature search was performed in the PubMed search engine, using the keyword “Genital Hiatus.” Articles were included if they addressed any of the following topics: (1) normative GH values; (2) associations between the GH and prolapse development or recurrence; (3) surgical alteration of the GH; (4) indications, risks or benefits of surgical alteration of the GH. An enlarging GH has been observed prior to the development of prolapse. Multiple studies show that an enlarged pre- and/or postoperative GH is associated with an increased risk of recurrent prolapse following prolapse repair surgery. There are limited data on the specific risks of GH alteration related to bowel and sexual function. GH size and prolapse appear to be strongly associated. Because GH size appears to be a risk factor for pelvic organ prolapse, the GH size should be carefully considered at the time of surgery. Surgeons should discuss with their patients the risks and potential benefits of additional procedures designed to reduce GH size.

  • Genital Hiatus size and the development of prolapse among parous women
    Female pelvic medicine & reconstructive surgery, 2021
    Co-Authors: Victoria L Handa, Joan L Blomquist, Megan Carroll, Alvaro Munoz
    Abstract:

    Objective In cross-sectional studies, pelvic organ prolapse is strongly associated with Genital Hiatus (GH) size. The objective of this study was to estimate prolapse incidence by the size of the GH among parous women followed prospectively. Methods Data were derived from a longitudinal study of pelvic floor disorders. Participants were followed annually for 2-9 years. Genital Hiatus size and prolapse beyond the hymen were assessed with annual pelvic organ prolapse quantification examinations. Kaplan-Meier methods described prolapse-free survival as a function of GH size. Accounting for changes over time in GH size, lognormal models were used to estimate prolapse-free survival by GH size. This analysis was repeated separately for women who gave birth exclusively by cesarean versus those with at least one vaginal birth. Results Among 1,492 participants, median age at enrollment was 38 years; 153 (10.3%) developed prolapse over 2-9 years. The cumulative probability of prolapse increased substantially as the size of the GH increased. Lognormal models predicted that the estimated median time to develop prolapse would be 33.4 years for women with a persistent GH of 3 cm; in contrast, the estimated median time to develop prolapse would be 5.8 years for a GH of 4.5 cm or greater. Considering separately women who gave birth by cesarean versus those with at least 1 vaginal birth, GH size drastically modified prolapse risk in both birth groups. Conclusions Prolapse incidence is strongly associated with GH size, regardless of delivery mode. These findings suggest that a wider GH is an important predictor of future prolapse risk.

  • pelvic floor muscle strength and the incidence of pelvic floor disorders after vaginal and cesarean delivery
    American Journal of Obstetrics and Gynecology, 2020
    Co-Authors: Joan L Blomquist, Alvaro Munoz, Megan Carroll, Victoria L Handa
    Abstract:

    Background Pelvic floor disorders (including urinary and anal incontinence and pelvic organ prolapse) are associated with childbirth. Injury to the pelvic floor muscles during vaginal childbirth, such as avulsion of the levator ani muscle, is associated with weaker pelvic floor muscle strength. As weak pelvic floor muscle strength may be a modifiable risk factor for the later development of pelvic floor disorders, it is important to understand how pelvic floor muscle strength affects the course of pelvic floor disorders over time. Objective To investigate the association between pelvic floor muscle strength and the incidence of pelvic floor disorders, and to identify maternal and obstetrical characteristics that modify the association. Materials and Methods This is a longitudinal study investigating pelvic floor disorders after childbirth. Participants were recruited 5–10 years after their first delivery and were assessed for pelvic floor disorders annually for up to 9 years. Stress incontinence, overactive bladder, and anal incontinence were assessed at each annual visit using the Epidemiology of Prolapse and Incontinence Questionnaire. Pelvic organ prolapse was assessed on physical examination, and was defined as descent of the vaginal walls or cervix beyond the hymen during forceful Valsalva. The primary exposure of interest was pelvic floor muscle strength, defined as the peak pressure during a voluntary pelvic muscle contraction (measured with a perineometer). The relationship between pelvic floor muscle strength and the cumulative incidence (time to event) of each pelvic floor disorder was evaluated using lognormal models, stratified by vaginal vs cesarean delivery. The relative hazard for each pelvic floor disorder (among those women free of the disorder at enrollment and thus more than 5–10 years from first delivery), was estimated using semiparametric proportional hazard models as a function of delivery mode, pelvic floor muscle strength, and other covariates. Results Of 1143 participants, the median age was 40 (interquartile range, 36.6–43.7) years, and 73% were multiparous. On perineometry, women with at least 1 vaginal delivery were more likely to have a low peak pressure, defined as Conclusion After vaginal delivery, but not cesarean delivery, the cumulative incidence of pelvic organ prolapse, stress incontinence, and overactive bladder is associated with pelvic muscle strength, but the associations attenuate when adjusting for Genital Hiatus and body mass index.

  • levator morphology and strength after obstetric avulsion of the levator ani muscle
    Female pelvic medicine & reconstructive surgery, 2020
    Co-Authors: Victoria L Handa, Joan L Blomquist, Alvaro Munoz, Jennifer Roem, Hans Peter Dietz
    Abstract:

    OBJECTIVES Obstetric levator avulsion may be an important risk factor for prolapse. This study compares the size of the levator Hiatus, the width of the Genital Hiatus, and pelvic muscle strength between vaginally parous women with or without levator avulsion, 5 to 15 years after delivery. METHODS Parous women were assessed for levator ani avulsion, using 3-dimensional transperineal ultrasound. Women with and without levator ani avulsion were compared with respect to levator Hiatus areas (measured on ultrasound), Genital Hiatus (measured on examination), and pelvic muscle strength (measured with perineometry). Further analysis also considered the association of forceps-assisted birth. RESULTS At a median interval of 11 years from first delivery, levator avulsion was identified in 15% (66/453). A history of forceps-assisted delivery was strongly associated with levator avulsion (45% vs 8%; P < 0.001). Levator avulsion was also associated with a larger levator Hiatus area (+7.3 cm; 95% confidence interval [CI], 4.1-10.4, with Valsalva), wider Genital Hiatus (+0.6 cm; 95% CI, 0.3-0.9, with Valsalva), and poorer muscle strength (-14.5 cm H2O; 95% CI, -20.4 to -8.7, peak pressure). Among those with levator avulsion, forceps-assisted birth was associated with a marginal increase in levator Hiatus size but not Genital Hiatus size or muscle strength. CONCLUSIONS Obstetric levator avulsion is associated with a larger levator Hiatus, wider Genital Hiatus, and poorer pelvic muscle strength. Forceps-assisted birth is an important marker for levator avulsion but may not be an independent risk factor for the development of pelvic muscle weakness or changes in Hiatus size in the absence of levator avulsion.

Anthony G. Visco - One of the best experts on this subject based on the ideXlab platform.

  • robotic assisted sacrocolpopexy early postoperative outcomes after surgical reduction of enlarged Genital Hiatus
    Obstetrical & Gynecological Survey, 2018
    Co-Authors: Megan S Bradley, Amy L Askew, Monique H Vaughan, Amie Kawasaki, Anthony G. Visco
    Abstract:

    (Abstracted from Am J Obstet Gynecol 2018;218:514.e1–514.e8)Robotic-assisted sacrocolpopexy (RSC) has comparable surgical outcomes and less perioperative morbidity than abdominal sacrocolpopexy.

  • surgical alteration of Genital Hiatus size and anatomic failure after vaginal vault suspension
    Obstetrics & Gynecology, 2018
    Co-Authors: Monique H Vaughan, Anthony G. Visco, Amie Kawasaki, Nazema Y Siddiqui, Laura K Newcomb, Alison C Weidner, Megan S Bradley
    Abstract:

    OBJECTIVE:To compare anatomic outcomes after native tissue vaginal vault suspension among women categorized by their preoperative and 6-week postoperative Genital Hiatus size.METHODS:We performed a retrospective cohort study in women who underwent native tissue vaginal vault suspension between 2005

  • robotic assisted sacrocolpopexy early postoperative outcomes after surgical reduction of enlarged Genital Hiatus
    American Journal of Obstetrics and Gynecology, 2018
    Co-Authors: Megan S Bradley, Amy L Askew, Monique H Vaughan, Amie Kawasaki, Anthony G. Visco
    Abstract:

    Background Currently, the decision to perform a concurrent posterior repair/perineoplasty at the time of robotic-assisted sacrocolpopexy is not standardized. Objective We sought to compare anatomic failure after robotic-assisted sacrocolpopexy among 3 groups of patients categorized by their preoperative and postoperative Genital Hiatus size. Study Design We performed a retrospective cohort study of women who underwent robotic-assisted sacrocolpopexy, from January 2013 through September 2016. We defined a wide Genital Hiatus as ≥4 cm and a normal Genital Hiatus as Results Our study population consisted of 452 women with a mean age of 59.3 ± 10.0 years and a mean body mass index of 27.8 ± 5.3 kg/m2. Of the women with reported race, 394/447 (88.1%) were white. The Genital Hiatus groups were distributed as follows: 57 (12.6%) were persistently wide, 296 (65.5%) were improved, and 99 (21.9%) were stably normal. The stably normal group had less advanced preoperative prolapse (stage ≥3) than the other groups (P Conclusion Surgical reduction of an enlarged preoperative Genital Hiatus decreases early composite anatomic failure, after robotic sacrocolpopexy, specifically related to the posterior compartment. Studies investigating the correlation of intraoperative measurement of Genital Hiatus to postoperative Genital Hiatus are needed to help clinicians determine who may benefit from a concomitant posterior repair/perineoplasty at the time of robotic-assisted sacrocolpopexy.

  • a comparison of perineometer to brink score for assessment of pelvic floor muscle strength
    American Journal of Obstetrics and Gynecology, 2005
    Co-Authors: Andrew F Hundley, Anthony G. Visco
    Abstract:

    Objective The Brink scale is a commonly used digital assessment of pelvic floor muscle strength. The Peritron perineometer, a compressible vaginal insert that records pressure in centimeters of water, offers an objective method for this evaluation. This study evaluates the inter- and intrarater reliability of perineometry measurements and correlates those values with Brink scores. Study design Subjects were prospectively enrolled and underwent pelvic floor muscle strength assessment by 2 examiners each using a perineometer and the Brink scale. Perineometer measurements of maximum pressure, average pressure, and total duration were recorded for 3 consecutive pelvic floor muscle contractions (Kegels). The Brink assessment was performed by placing 2 fingers vaginally during a single Kegel contraction. Brink scores consisted of 3 separate 4-point rating scales for pressure, vertical finger displacement, and duration. The order of the examiners and the 2 assessment methods were randomized, and each examiner was blinded to the results of the other. Pearson and Spearman correlation coefficients were used for analysis as appropriate. Repeated-measures analysis of variance was used to assess intrarater reliability between repeated perineometer measurements. Results One hundred women were consecutively enrolled and completed the study. Interrater reliability for the perineometer maximum squeeze pressure (r=0.88) and baseline resting pressure (r=0.78) was high. Maximum squeeze pressure correlation was unaffected by the presence or absence of estrogen (r=0.89 versus r=0.85), nulliparity versus parity (0.85 versus 0.88), or Genital Hiatus 4 or greater or less than 4 (r=0.96 versus r=0.86). Total Brink score and each individual submeasurement showed good correlations (total: r=0.68; pressure: r=0.68; displacement: r=0.58; duration: r=0.44). The correlation between maximum squeeze pressure and total Brink score during the first and second exams was good (r=0.68 versus r=0.71). For intrarater reliability, there were no significant differences among the 3 maximum squeeze pressures recorded during the first exam ( P =.11), but for the second exam, the first squeeze was significantly stronger than the successive 2 ( P =.009) attempts. Conclusion Perineometer measurements of pelvic floor muscle contractions show very good inter- and intrarater reliability. The Brink total and pressure scores had a slightly lower interrater reliability. Variables such as estrogen status, parity, and Genital Hiatus did not appear to affect correlation. There was good correlation between the maximum perineometer pressure and the total Brink score, suggesting that these 2 methods of assessment have similar levels of reproducibility. Additionally, the perineometer demonstrated good short-term test-retest reliability.

Megan S Bradley - One of the best experts on this subject based on the ideXlab platform.

  • impact of Genital Hiatus size on anatomic outcomes after mesh augmented sacrospinous ligament fixation
    Female pelvic medicine & reconstructive surgery, 2021
    Co-Authors: Monique H Vaughan, Lauren E Giugale, Nazema Y Siddiqui, Megan S Bradley
    Abstract:

    Objective Our objective is to compare anatomic outcomes at medium term after mesh-augmented sacrospinous ligament fixation among women categorized by their preoperative and postoperative Genital Hiatus size. Methods We performed a retrospective cohort study in women undergoing Uphold mesh-augmented sacrospinous ligament fixation between 2010 and 2017. We compared 3 groups: (1) women with a wide Genital Hiatus preoperatively and 6 weeks postoperatively ("Persistently Wide" cohort), (2) women with a wide Genital Hiatus preoperatively but normal Hiatus 6 weeks postoperatively ("Improved" cohort), and (3) women with a normal Genital Hiatus preoperatively and 6 weeks postoperatively ("Stably Normal" cohort). We defined a wide Hiatus as 4 cm or greater and a normal Hiatus as less than 4 cm. The primary outcome was anatomic failure, defined as recurrent prolapse beyond the hymen or retreatment for prolapse with surgery or pessary. Results Ninety-seven women were included in the study. Overall, mean age was 68 years (±7.15 years), mean body mass index was 28.36 kg/m2 (±5.34 kg/m2) and mean follow up time was 400 ± 216 days. Anatomic failure did not differ between groups (Persistently Wide, 15.4%; Improved, 11.1%; Stably Normal, 10.0%; P = 0.88). In logistic regression, the odds of anatomic failure remained similar among all groups (P = 0.93). Conclusions A persistently wide Genital Hiatus alone was not associated with anatomic failure in this small study cohort. Therefore, surgical reduction of the Genital Hiatus with level III support procedures may not affect prolapse recurrence at the time of mesh-augmented sacrospinous ligament fixation. Further studies are needed to confirm this relationship and investigate other potential mechanisms for these findings.

  • robotic assisted sacrocolpopexy early postoperative outcomes after surgical reduction of enlarged Genital Hiatus
    Obstetrical & Gynecological Survey, 2018
    Co-Authors: Megan S Bradley, Amy L Askew, Monique H Vaughan, Amie Kawasaki, Anthony G. Visco
    Abstract:

    (Abstracted from Am J Obstet Gynecol 2018;218:514.e1–514.e8)Robotic-assisted sacrocolpopexy (RSC) has comparable surgical outcomes and less perioperative morbidity than abdominal sacrocolpopexy.

  • surgical alteration of Genital Hiatus size and anatomic failure after vaginal vault suspension
    Obstetrics & Gynecology, 2018
    Co-Authors: Monique H Vaughan, Anthony G. Visco, Amie Kawasaki, Nazema Y Siddiqui, Laura K Newcomb, Alison C Weidner, Megan S Bradley
    Abstract:

    OBJECTIVE:To compare anatomic outcomes after native tissue vaginal vault suspension among women categorized by their preoperative and 6-week postoperative Genital Hiatus size.METHODS:We performed a retrospective cohort study in women who underwent native tissue vaginal vault suspension between 2005

  • robotic assisted sacrocolpopexy early postoperative outcomes after surgical reduction of enlarged Genital Hiatus
    American Journal of Obstetrics and Gynecology, 2018
    Co-Authors: Megan S Bradley, Amy L Askew, Monique H Vaughan, Amie Kawasaki, Anthony G. Visco
    Abstract:

    Background Currently, the decision to perform a concurrent posterior repair/perineoplasty at the time of robotic-assisted sacrocolpopexy is not standardized. Objective We sought to compare anatomic failure after robotic-assisted sacrocolpopexy among 3 groups of patients categorized by their preoperative and postoperative Genital Hiatus size. Study Design We performed a retrospective cohort study of women who underwent robotic-assisted sacrocolpopexy, from January 2013 through September 2016. We defined a wide Genital Hiatus as ≥4 cm and a normal Genital Hiatus as Results Our study population consisted of 452 women with a mean age of 59.3 ± 10.0 years and a mean body mass index of 27.8 ± 5.3 kg/m2. Of the women with reported race, 394/447 (88.1%) were white. The Genital Hiatus groups were distributed as follows: 57 (12.6%) were persistently wide, 296 (65.5%) were improved, and 99 (21.9%) were stably normal. The stably normal group had less advanced preoperative prolapse (stage ≥3) than the other groups (P Conclusion Surgical reduction of an enlarged preoperative Genital Hiatus decreases early composite anatomic failure, after robotic sacrocolpopexy, specifically related to the posterior compartment. Studies investigating the correlation of intraoperative measurement of Genital Hiatus to postoperative Genital Hiatus are needed to help clinicians determine who may benefit from a concomitant posterior repair/perineoplasty at the time of robotic-assisted sacrocolpopexy.

Dee E Fenner - One of the best experts on this subject based on the ideXlab platform.

  • structural failure sites in posterior vaginal wall prolapse stress 3d mri based analysis
    International Urogynecology Journal, 2021
    Co-Authors: Luyun Chen, James A Ashtonmiller, Dee E Fenner, Bing Xie, Mary Duarte E Thibault, John O.l. Delancey
    Abstract:

    The objective was to identify structural failure sites in rectocele by comparing women with and those without posterior vaginal wall prolapse and accessing their relative contribution to rectocele size based on stress MRI-based measurements. We studied three-dimensional stress MRI at maximal Valsalva of 25 women with (cases) and 25 without (controls) posterior vaginal prolapse of similar age and parity. Vaginal wall factors (posterior wall length and width); attachment factors (paravaginal posterior wall location, posterior fornix height, and perineal height); and hiatal factors (hiatal size and levator ani defects) were measured using Slicer 4.3.0® and a custom Python program. Stepwise linear regression was used to assess the relative contribution of all factors to the posterior prolapse size. We identified three primary factors with large effect sizes of 2 or greater: two attachment factors—posterior paravaginal descent and perineal height; and one hiatal factor—Genital Hiatus size. These were the strongest predictors of the presence and size of rectocele, the most common failure sites, found in 60–76% of cases; and highly correlated with one another (r = 0.72–0.84, p < .001). Longer vaginal length, wider distal vagina, lower posterior fornix, and larger levator ani Hiatus had smaller effect sizes and were less likely to fall outside the norm (20–24%) than the three primary factors. When considering all the supporting factors, the combination of perineal height, posterior fornix height, and vaginal length explained 73% of the variation in rectocele size. Lower perineal and lateral posterior vaginal location and enlarged Genital Hiatus size were strong predictors of rectocele occurrence and size and correlated highly.

  • defining normal recovery of pelvic floor function and appearance in a high risk vaginal delivery cohort
    International Urogynecology Journal, 2020
    Co-Authors: Pamela S Fairchild, John O.l. Delancey, Lisa Kane Low, Katherine M Kowalk, Giselle E Kolenic, Dee E Fenner
    Abstract:

    Childbirth pelvic floor trauma leads to pelvic floor disorders. Identification of significant injuries would facilitate intervention for recovery. Our objectives were to identify differences in pelvic floor appearance and function following delivery and patterns of normal recovery in women sustaining high-risk labor events. We completed a prospective cohort study comparing women undergoing vaginal births involving risk factors for pelvic floor injury with women undergoing cesareans. Data were collected on multidimensional factors including levator ani muscle (LA) tears. Descriptive and bivariate statistics were used to compare the groups. We identified potential markers of pelvic floor injury based on effect size. Eighty-two women post-vaginal delivery and 30 women post-cesarean enrolled. The vaginal group had decreased perineal body length between early postpartum, 6 weeks (p   0.05). Measures of strength improved between each time point (all p < 0.002). When compared with cesarean delivery, women post-vaginal birth had longer Genital Hiatus and lower anterior and posterior vaginal walls (all p < 0.05). Based on theoretical considerations and effect sizes, those with Bp ≥0 cm, Kegel force ≤1.50 N, and/or an LA tear on imaging were considered to have significant pelvic floor injury. Using this definition, at 6 weeks, 27 (46.4%) women were classified as injured. At 6 months, 13 (29.6%) remained injured. We propose that pelvic floor muscle strength, posterior vaginal wall support, and imaging consistent with LA tear are potential indicators of abnormal or prolonged recovery in this cohort with high-risk labor events.

  • Comparison of levator ani muscle defects and function in women with and without pelvic organ prolapse
    Obstetrical & Gynecological Survey, 2007
    Co-Authors: John O.l. Delancey, Rohna Kearney, Wolfgang Umek, Janis M Miller, Dee E Fenner, Yvonne Hsu, Daniel M. Morgan, Kenneth E. Guire, Hero K. Hussain, JAMES ANTHONY ASHTON-MILLER
    Abstract:

    The levator ani muscles are critical for providing upward support to the pelvic organs and minimizing the load on the connective tissue that attaches these organs to the pelvis. When the muscles fail, pelvic organ prolapse may ensue, making surgery necessary. Vaginal birth substantially increases the risk of prolapse in occurring in parous women, but it is not clear whether levator ani defects lead to prolapse later in life. The possibility that this may be the case has lent support to cesarean delivery on request. This case-control study compared the structure and function of the levator ani muscle in 151 women with prolapse and 135 control subjects matched for age, race, and hysterectomy status. Case patients had prolapse of a vaginal wall, a hysterectomy scar, or the cervix extending at least 1 cm above the hymen during a Valsalva maneuver. MR imaging served to identify major defects with more than half the levator ani missing, and minor defects with less than half the muscle missing. An instrumented vaginal speculum was used to quantify vaginal closure force at rest and during maximum pelvic muscle contraction. The incidence of major levator ani defects was 55% in cases and 16% in controls, for an adjusted odds ratio (OR) of 7.3 (95% confidence interval [CI], 3.9-13.6). Women in the two groups were, however, about equally likely to have minor defects. Incidence rates of major defects were 53% for women reporting having had a forceps delivery and 28% for the others (adjusted OR, 3.4; 95% CI, 1.95-5.78). Women with prolapse had lower estimates of vaginal closure force during pelvic muscle contraction than did control subjects (2.0 versus 3.2 Newtons). Women with levator ani defects generated less force than those lacking defects (2.0 versus 3.1 Newtons). The Genital Hiatus was 50% longer in case women than in controls (4.7 versus 3.1 cm). In both the case and control groups, women without levator ani defects had higher maximal contraction force estimates than those with defects. This case-control study showed that women having pelvic organ prolapse more often have defective levator ani muscles than control women, and generate less vaginal closure force during maximal muscle contraction.

  • comparison of levator ani muscle defects and function in women with and without pelvic organ prolapse
    Obstetrics & Gynecology, 2007
    Co-Authors: John O.l. Delancey, Rohna Kearney, Wolfgang Umek, Janis M Miller, Dee E Fenner, Yvonne Hsu, Daniel M. Morgan, Kenneth E. Guire, Hero K. Hussain, James A Ashtonmiller
    Abstract:

    BACKGROUND: To compare levator ani defects and pelvic floor function among women with prolapse and controls. METHODS: Levator ani structure and function were measured in a case–control study with group matching for age, race, and hysterectomy status among 151 women with prolapse (cases) and 135 controls with normal support (controls) determined by pelvic organ prolapse quantification examination. Magnetic resonance imaging was used to determine whether there were “major” (more than half missing), “minor” (less than half of the muscle missing), or no defects in the levator ani muscles. Vaginal closure force at rest and during maximal pelvic muscle contraction was measured with an instrumented vaginal speculum. RESULTS: Cases were more likely to have major levator ani defects than controls (55% compared with 16%), with an adjusted odds ratio of 7.3 (95% confidence interval 3.9–13.6, P<.001) but equally likely to have minor defects (16% compared with 22%). Of women who reported delivery by forceps, 53% had major defects compared with 28% for the nonforceps women, adjusted odds ratio 3.4 (95% confidence interval 1.95–5.78). Women with prolapse generated less vaginal closure force during pelvic muscle contraction than controls (2.0 Newtons compared with 3.2 Newtons P<.001), whereas those with defects generated less force than women without defects (2.0 Newtons compared with 3.1 Newtons, P<.001). The Genital Hiatus was 50% longer in cases than controls (4.71.4 cm compared with 3.11.0 cm, P<.001).

  • posterior vaginal wall defects and their relation to measures of pelvic floor neuromuscular function and posterior compartment symptoms
    American Journal of Obstetrics and Gynecology, 2002
    Co-Authors: Michael F Fialkow, Carolyn Gardella, Jennifer L Melville, Gretchen M Lentz, Dee E Fenner
    Abstract:

    Abstract Objective: The purpose of this study was to describe the pelvic floor neuromuscular function and posterior compartment symptoms in patients with posterior vaginal wall prolapse. Study Design: Two hundred twenty-seven women who were referred to a urogynecology and urology clinic were enrolled prospectively. Each patient completed a health history questionnaire and standardized physical examination that specifically graded uterovaginal prolapse according to the pelvic organ prolapse quantification system. Results: Sixty-nine women had a pelvic organ prolapse quantification system point (most dependent portion of the posterior vaginal wall during straining as measured from the hymeneal ring) of ≤−1. Older age, a history of hysterectomy, a Genital Hiatus of >3 cm (48% vs 24%; P =.002), and perineal descent of ≥2 cm (14% vs 5%; P =.042) were significantly more common in women with posterior vaginal prolapse. When women with posterior prolapse and symptomatic complaints were compared with asymptomatic women with prolapse, a perineal descent of ≥2 cm (21% vs 0%; P =.004) was significantly more common in the symptomatic group. Conclusion: Pelvic floor neuromuscular function should be related to posterior vaginal prolapse and symptoms; however, only perineal descent appears associated strongly with both symptoms and prolapse in this population. (Am J Obstet Gynecol 2002;187:1443-9.)

John O.l. Delancey - One of the best experts on this subject based on the ideXlab platform.

  • does preoperative resting Genital Hiatus size predict surgical outcomes
    Journal of Obstetrics and Gynaecology Research, 2021
    Co-Authors: Payton Schmidt, Luyun Chen, John O.l. Delancey, Caroline K Cox, Shriya Suresh, Whitney Horner, Carolyn W Swenson
    Abstract:

    AIM To determine whether preoperative Genital Hiatus at rest is predictive of medium-term prolapse recurrence. METHODS We conducted a retrospective study of women who underwent native tissue prolapse surgery from 2002 to 2017 with pelvic organ prolapse quantification data including resting Genital Hiatus at one of three time points: preoperatively, 6 weeks, and ≥1 year postoperatively. Demographics and clinical data were abstracted from the chart. Prolapse recurrence was defined by anatomic outcomes (Ba > 0, Bp > 0, and/or C ≥ -4) or retreatment. Descriptive statistics, bivariate analyses, and logistic regression analyses were performed. RESULTS Of the 165 women included, 36 (21.8%) had prolapse recurrence at an average of 1.5 years after surgery. Preoperative resting Genital Hiatus did not differ between women with surgical success versus recurrence (3.5 cm [interquartile range, IQR 2.25, 4.0) vs 3.5 cm (IQR 3.0, 4.0), p = 0.71). Point Bp was greater in the recurrence group at every time point. Preoperative Bp (odds ratio [OR] 1.24, confidence interval [CI] [1.06-1.45], p = 0.01) and days from surgery (OR 1.001, CI [1.000-1.001], p < 0.01) were independently associated with recurrence. Preoperative Genital Hiatus at rest and strain were significantly larger among women who underwent a colpoperineorrhaphy (rest: 4.0 [3.0, 4.5] cm vs 3.5 [3.0, 4.0] cm, p < 0.01; strain: 6.0 [4.0, 6.5] cm vs 5.0 [4.0, 6.0] cm, p = 0.01). CONCLUSIONS Preoperative Genital Hiatus at rest was not associated with prolapse recurrence when the majority of women underwent colpoperineorrhaphy. Preoperative Bp was more predictive of short-term prolapse recurrence. For every 1 cm increase in point Bp, there is a 24% increased odds of recurrence.

  • structural failure sites in posterior vaginal wall prolapse stress 3d mri based analysis
    International Urogynecology Journal, 2021
    Co-Authors: Luyun Chen, James A Ashtonmiller, Dee E Fenner, Bing Xie, Mary Duarte E Thibault, John O.l. Delancey
    Abstract:

    The objective was to identify structural failure sites in rectocele by comparing women with and those without posterior vaginal wall prolapse and accessing their relative contribution to rectocele size based on stress MRI-based measurements. We studied three-dimensional stress MRI at maximal Valsalva of 25 women with (cases) and 25 without (controls) posterior vaginal prolapse of similar age and parity. Vaginal wall factors (posterior wall length and width); attachment factors (paravaginal posterior wall location, posterior fornix height, and perineal height); and hiatal factors (hiatal size and levator ani defects) were measured using Slicer 4.3.0® and a custom Python program. Stepwise linear regression was used to assess the relative contribution of all factors to the posterior prolapse size. We identified three primary factors with large effect sizes of 2 or greater: two attachment factors—posterior paravaginal descent and perineal height; and one hiatal factor—Genital Hiatus size. These were the strongest predictors of the presence and size of rectocele, the most common failure sites, found in 60–76% of cases; and highly correlated with one another (r = 0.72–0.84, p < .001). Longer vaginal length, wider distal vagina, lower posterior fornix, and larger levator ani Hiatus had smaller effect sizes and were less likely to fall outside the norm (20–24%) than the three primary factors. When considering all the supporting factors, the combination of perineal height, posterior fornix height, and vaginal length explained 73% of the variation in rectocele size. Lower perineal and lateral posterior vaginal location and enlarged Genital Hiatus size were strong predictors of rectocele occurrence and size and correlated highly.

  • defining normal recovery of pelvic floor function and appearance in a high risk vaginal delivery cohort
    International Urogynecology Journal, 2020
    Co-Authors: Pamela S Fairchild, John O.l. Delancey, Lisa Kane Low, Katherine M Kowalk, Giselle E Kolenic, Dee E Fenner
    Abstract:

    Childbirth pelvic floor trauma leads to pelvic floor disorders. Identification of significant injuries would facilitate intervention for recovery. Our objectives were to identify differences in pelvic floor appearance and function following delivery and patterns of normal recovery in women sustaining high-risk labor events. We completed a prospective cohort study comparing women undergoing vaginal births involving risk factors for pelvic floor injury with women undergoing cesareans. Data were collected on multidimensional factors including levator ani muscle (LA) tears. Descriptive and bivariate statistics were used to compare the groups. We identified potential markers of pelvic floor injury based on effect size. Eighty-two women post-vaginal delivery and 30 women post-cesarean enrolled. The vaginal group had decreased perineal body length between early postpartum, 6 weeks (p   0.05). Measures of strength improved between each time point (all p < 0.002). When compared with cesarean delivery, women post-vaginal birth had longer Genital Hiatus and lower anterior and posterior vaginal walls (all p < 0.05). Based on theoretical considerations and effect sizes, those with Bp ≥0 cm, Kegel force ≤1.50 N, and/or an LA tear on imaging were considered to have significant pelvic floor injury. Using this definition, at 6 weeks, 27 (46.4%) women were classified as injured. At 6 months, 13 (29.6%) remained injured. We propose that pelvic floor muscle strength, posterior vaginal wall support, and imaging consistent with LA tear are potential indicators of abnormal or prolonged recovery in this cohort with high-risk labor events.

  • Comparison of levator ani muscle defects and function in women with and without pelvic organ prolapse
    Obstetrical & Gynecological Survey, 2007
    Co-Authors: John O.l. Delancey, Rohna Kearney, Wolfgang Umek, Janis M Miller, Dee E Fenner, Yvonne Hsu, Daniel M. Morgan, Kenneth E. Guire, Hero K. Hussain, JAMES ANTHONY ASHTON-MILLER
    Abstract:

    The levator ani muscles are critical for providing upward support to the pelvic organs and minimizing the load on the connective tissue that attaches these organs to the pelvis. When the muscles fail, pelvic organ prolapse may ensue, making surgery necessary. Vaginal birth substantially increases the risk of prolapse in occurring in parous women, but it is not clear whether levator ani defects lead to prolapse later in life. The possibility that this may be the case has lent support to cesarean delivery on request. This case-control study compared the structure and function of the levator ani muscle in 151 women with prolapse and 135 control subjects matched for age, race, and hysterectomy status. Case patients had prolapse of a vaginal wall, a hysterectomy scar, or the cervix extending at least 1 cm above the hymen during a Valsalva maneuver. MR imaging served to identify major defects with more than half the levator ani missing, and minor defects with less than half the muscle missing. An instrumented vaginal speculum was used to quantify vaginal closure force at rest and during maximum pelvic muscle contraction. The incidence of major levator ani defects was 55% in cases and 16% in controls, for an adjusted odds ratio (OR) of 7.3 (95% confidence interval [CI], 3.9-13.6). Women in the two groups were, however, about equally likely to have minor defects. Incidence rates of major defects were 53% for women reporting having had a forceps delivery and 28% for the others (adjusted OR, 3.4; 95% CI, 1.95-5.78). Women with prolapse had lower estimates of vaginal closure force during pelvic muscle contraction than did control subjects (2.0 versus 3.2 Newtons). Women with levator ani defects generated less force than those lacking defects (2.0 versus 3.1 Newtons). The Genital Hiatus was 50% longer in case women than in controls (4.7 versus 3.1 cm). In both the case and control groups, women without levator ani defects had higher maximal contraction force estimates than those with defects. This case-control study showed that women having pelvic organ prolapse more often have defective levator ani muscles than control women, and generate less vaginal closure force during maximal muscle contraction.

  • comparison of levator ani muscle defects and function in women with and without pelvic organ prolapse
    Obstetrics & Gynecology, 2007
    Co-Authors: John O.l. Delancey, Rohna Kearney, Wolfgang Umek, Janis M Miller, Dee E Fenner, Yvonne Hsu, Daniel M. Morgan, Kenneth E. Guire, Hero K. Hussain, James A Ashtonmiller
    Abstract:

    BACKGROUND: To compare levator ani defects and pelvic floor function among women with prolapse and controls. METHODS: Levator ani structure and function were measured in a case–control study with group matching for age, race, and hysterectomy status among 151 women with prolapse (cases) and 135 controls with normal support (controls) determined by pelvic organ prolapse quantification examination. Magnetic resonance imaging was used to determine whether there were “major” (more than half missing), “minor” (less than half of the muscle missing), or no defects in the levator ani muscles. Vaginal closure force at rest and during maximal pelvic muscle contraction was measured with an instrumented vaginal speculum. RESULTS: Cases were more likely to have major levator ani defects than controls (55% compared with 16%), with an adjusted odds ratio of 7.3 (95% confidence interval 3.9–13.6, P<.001) but equally likely to have minor defects (16% compared with 22%). Of women who reported delivery by forceps, 53% had major defects compared with 28% for the nonforceps women, adjusted odds ratio 3.4 (95% confidence interval 1.95–5.78). Women with prolapse generated less vaginal closure force during pelvic muscle contraction than controls (2.0 Newtons compared with 3.2 Newtons P<.001), whereas those with defects generated less force than women without defects (2.0 Newtons compared with 3.1 Newtons, P<.001). The Genital Hiatus was 50% longer in cases than controls (4.71.4 cm compared with 3.11.0 cm, P<.001).