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John O.l. Delancey - One of the best experts on this subject based on the ideXlab platform.
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injury associated Levator Ani muscle and anal sphincter ooedema following vaginal birth a secondary analysis of the emrld study
British Journal of Obstetrics and Gynaecology, 2021Co-Authors: Fernanda Pipitone, Janis M Miller, John O.l. DelanceyAbstract:OBJECTIVE To determine whether all three components of the Levator Ani muscle (pubovisceral [= pubococcygeal], puborectal and iliococcygeal) and the external anal sphincter are equally affected by oedema associated with muscle injury after vaginal birth. DESIGN Observational cross-sectional study. SETTING Michigan Medicine, University of Michigan. POPULATION Primiparous women classified as high risk for Levator Ani muscle injury during childbirth. METHOD MRI scans obtained 6-8 weeks postpartum were analysed. Muscle oedema was assessed on axial and coronal fluid-sensitive magnetic resonance (MRI) scans. Presence of oedema was separately determined in each Levator Ani muscle component and in the external anal sphincter for all subjects. Descriptive statistics and correlation with obstetric variables were obtained. MAIN OUTCOME MEASURES Oedema score on fluid-sensitive MRI scans. RESULTS Of the 78 women included in this cohort, 51.3% (n = 40/78) showed muscle oedema in the pubovisceral (one bilateral avulsion excluded), 5.1% (n = 4/78) in the puborectal and 5.1% (n = 4/78) in the iliococcygeal muscle. No subject showed definite oedema on external anal sphincter. Incidence of oedema on the pubovisceral muscle was seven times higher than on any of the other analysed muscles (all paired comparisons, P < 0.001). CONCLUSIONS Even in the absence of muscle tearing, the pubovisceral muscle shows by far the highest incidence of injury, establishing that Levator components are not equally affected by childbirth. External anal sphincter did not show oedema-even in women with sphincter laceration- suggesting a different injury mechAnism. Developing a databased map of injured areas helps understand injury mechAnisms that can guide us in honing research on treatment and prevention. TWEETABLE ABSTRACT Injury-associated Levator Ani muscle and anal sphincter oedema mapping on MRI reveals vulnerable muscle components after childbirth.
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magnetic resonance imaging Levator Ani damage and pelvic organ prolapse
2021Co-Authors: John O.l. DelanceyAbstract:MRI research has proven that Levator Ani muscle injury which occurs during birth is a dominant factor in the development of pelvic organ prolapse. The Levator Ani muscle consists of three portions: the pubococcygeal (also called the pubovisceral), the puborectal, and the iliococcygeal. The normal activity of these muscles closes the urogenital hiatus in the Levator Ani muscle and prevents stresses being placed on the pelvic connective tissues. MRI has revealed that vaginal birth, especially with forceps, injures the pubovisceral muscle in 10–15% of women delivering vaginally. MR imaging including fluid-sensitive scans at two time points (2 and 6 months after birth) shows that this injury is caused by muscle tearing, not neuropathy, or compression. When the injury involves more than half of the pubovisceral muscle, it is clinically significant. Women with prolapse have this injury 55% of the time compared to 16% in those with normal support, an odds ratio of 7.3. Levator injuries not only lead to reduced muscle contraction force and an enlarged hiatus but also a distortion of the fascial and Levator arches on the pelvic wall. When this muscle failure exists, abdominal pressure pushes the organs downward through the enlarged hiatus stressing the suspensory tissues that attach the pelvic organs to the pelvic sidewalls resulting in prolapse.
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comparison of muscle fiber directions between different Levator Ani muscle subdivisions in vivo mri measurements in women
International Urogynecology Journal, 2014Co-Authors: James A Ashtonmiller, Janis M Miller, Cornelia Betschart, Jinyong Kim, John O.l. DelanceyAbstract:Introduction and hypothesis This study describes a technique to quantify muscle fascicle directions in the Levator Ani (LA) and tests the null hypothesis that the in vivo fascicle directions for each LA subdivision subtend the same parasagittal angle relative to a horizontal reference axis.
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comparison of muscle fiber directions between different Levator Ani muscle subdivisions in vivo mri measurements in women
International Urogynecology Journal, 2014Co-Authors: James A Ashtonmiller, Janis M Miller, Cornelia Betschart, Jinyong Kim, John O.l. DelanceyAbstract:This study describes a technique to quantify muscle fascicle directions in the Levator Ani (LA) and tests the null hypothesis that the in vivo fascicle directions for each LA subdivision subtend the same parasagittal angle relative to a horizontal reference axis. Visible muscle fascicle direction in the each of the three LA muscle subdivisions, the pubovisceral (PVM; synonymous with pubococcygeal), puborectal (PRM), and iliococcygeal (ICM) muscles, as well as the external anal sphincter (EAS), were measured on 3-T sagittal MRI images in a convenience sample of 14 healthy women in whom muscle fascicles were visible. Mean ± standard deviation (SD) angle values relative to the horizontal were calculated for each muscle subdivision. Repeated measures ANOVA and post-hoc paired t tests were used to compare muscle groups. Pubovisceral muscle fiber inclination was 41 ± 8.0°, PRM was −19 ± 10.1°, ICM was 33 ± 8.8°, and EAS was −43 ± 6.4°. These fascicle directions were statistically different (p < 0.001). Pairwise comparisons among Levator subdivisions showed angle differences of 60° between PVM and PRM, and 52° between ICM and PRM. An 84° difference existed between PVM and EAS. The smallest angle difference between Levator divisions was between PVM and ICM 8°. The difference between PRM and EAS was 24°. All pairwise comparisons were significant (p < 0.001). The null hypothesis that muscle fascicle inclinations are similar in the three subdivisions of the Levator Ani and the external anal sphincter was rejected. The largest difference in Levator subdivision inclination, 60°, was found between the PVM and PRM.
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are bony pelvis dimensions associated with Levator Ani defects a case control study
International Urogynecology Journal, 2013Co-Authors: Mitchell B Berger, Stergios K Doumouchtsis, John O.l. DelanceyAbstract:Introduction and hypothesis Bony pelvis dimensions have been shown to differ in women with and without pelvic floor dysfunction. The goal of this study was to determine whether bony pelvis dimensions are different when comparing women with severe bilateral Levator Ani defects (LAD) with those with normal muscles.
Janis M Miller - One of the best experts on this subject based on the ideXlab platform.
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injury associated Levator Ani muscle and anal sphincter ooedema following vaginal birth a secondary analysis of the emrld study
British Journal of Obstetrics and Gynaecology, 2021Co-Authors: Fernanda Pipitone, Janis M Miller, John O.l. DelanceyAbstract:OBJECTIVE To determine whether all three components of the Levator Ani muscle (pubovisceral [= pubococcygeal], puborectal and iliococcygeal) and the external anal sphincter are equally affected by oedema associated with muscle injury after vaginal birth. DESIGN Observational cross-sectional study. SETTING Michigan Medicine, University of Michigan. POPULATION Primiparous women classified as high risk for Levator Ani muscle injury during childbirth. METHOD MRI scans obtained 6-8 weeks postpartum were analysed. Muscle oedema was assessed on axial and coronal fluid-sensitive magnetic resonance (MRI) scans. Presence of oedema was separately determined in each Levator Ani muscle component and in the external anal sphincter for all subjects. Descriptive statistics and correlation with obstetric variables were obtained. MAIN OUTCOME MEASURES Oedema score on fluid-sensitive MRI scans. RESULTS Of the 78 women included in this cohort, 51.3% (n = 40/78) showed muscle oedema in the pubovisceral (one bilateral avulsion excluded), 5.1% (n = 4/78) in the puborectal and 5.1% (n = 4/78) in the iliococcygeal muscle. No subject showed definite oedema on external anal sphincter. Incidence of oedema on the pubovisceral muscle was seven times higher than on any of the other analysed muscles (all paired comparisons, P < 0.001). CONCLUSIONS Even in the absence of muscle tearing, the pubovisceral muscle shows by far the highest incidence of injury, establishing that Levator components are not equally affected by childbirth. External anal sphincter did not show oedema-even in women with sphincter laceration- suggesting a different injury mechAnism. Developing a databased map of injured areas helps understand injury mechAnisms that can guide us in honing research on treatment and prevention. TWEETABLE ABSTRACT Injury-associated Levator Ani muscle and anal sphincter oedema mapping on MRI reveals vulnerable muscle components after childbirth.
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comparison of muscle fiber directions between different Levator Ani muscle subdivisions in vivo mri measurements in women
International Urogynecology Journal, 2014Co-Authors: James A Ashtonmiller, Janis M Miller, Cornelia Betschart, Jinyong Kim, John O.l. DelanceyAbstract:Introduction and hypothesis This study describes a technique to quantify muscle fascicle directions in the Levator Ani (LA) and tests the null hypothesis that the in vivo fascicle directions for each LA subdivision subtend the same parasagittal angle relative to a horizontal reference axis.
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comparison of muscle fiber directions between different Levator Ani muscle subdivisions in vivo mri measurements in women
International Urogynecology Journal, 2014Co-Authors: James A Ashtonmiller, Janis M Miller, Cornelia Betschart, Jinyong Kim, John O.l. DelanceyAbstract:This study describes a technique to quantify muscle fascicle directions in the Levator Ani (LA) and tests the null hypothesis that the in vivo fascicle directions for each LA subdivision subtend the same parasagittal angle relative to a horizontal reference axis. Visible muscle fascicle direction in the each of the three LA muscle subdivisions, the pubovisceral (PVM; synonymous with pubococcygeal), puborectal (PRM), and iliococcygeal (ICM) muscles, as well as the external anal sphincter (EAS), were measured on 3-T sagittal MRI images in a convenience sample of 14 healthy women in whom muscle fascicles were visible. Mean ± standard deviation (SD) angle values relative to the horizontal were calculated for each muscle subdivision. Repeated measures ANOVA and post-hoc paired t tests were used to compare muscle groups. Pubovisceral muscle fiber inclination was 41 ± 8.0°, PRM was −19 ± 10.1°, ICM was 33 ± 8.8°, and EAS was −43 ± 6.4°. These fascicle directions were statistically different (p < 0.001). Pairwise comparisons among Levator subdivisions showed angle differences of 60° between PVM and PRM, and 52° between ICM and PRM. An 84° difference existed between PVM and EAS. The smallest angle difference between Levator divisions was between PVM and ICM 8°. The difference between PRM and EAS was 24°. All pairwise comparisons were significant (p < 0.001). The null hypothesis that muscle fascicle inclinations are similar in the three subdivisions of the Levator Ani and the external anal sphincter was rejected. The largest difference in Levator subdivision inclination, 60°, was found between the PVM and PRM.
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identification of sensitive predictors of Levator Ani tear during first complex vaginal birth
Journal of Midwifery & Women's Health, 2013Co-Authors: Lisa Kane Low, Ruth Zielinski, Yebin Tao, Catherine Brandon, Janis M MillerAbstract:Objective To determine maternal characteristics and birth events most predictive of increasing severity of Levator Ani tears, a recognized predisposing factor to pelvic floor disorders later in a woman's lifespan, so that prevention strategies may be developed. Significance Several studies link vaginal birth with Levator Ani tears resulting in increased risk of developing pelvic floor disorders later in life. The events of vaginal birth that contribute to development of Levator Ani tears and how these factors are linked are not explicitly known. Prior retrospective investigations indicated age greater than 33 years, use of forceps or vacuum, more than 150 minutes in second stage, anal sphincter tear, or macrosomic infant greater than 4000 grams were risk factors for Levator Ani tears. Taken together, we refer to women who had at least one of these factors as having a “complex” birth. Methods We purposefully recruited and enrolled primiparous women immediately postpartum who experienced a complex vaginal birth. Participants were evaluated with magnetic resonance imaging (MRI) 2 months postpartum. Severity level of Levator Ani tears was graded by degree of muscle volume loss measured on an ordinal scale as: 0) none, 1) less than 50% loss unilateral, 2) greater than or equal to 50% unilateral or less than 50% bilateral, and 3) greater than or equal to 50% bilateral. During analysis additional risk factors considered included episiotomy, infant head circumference, duration of active pushing, and use of epidural and oxytocin. Ordinal logistic regression was used for analysis with significance at P < .05 for univariate predictors. Findings Ninety women successfully completed the MRI and the majority (64.4%) showed no visible Levator Ani muscle loss, 10% showed only minor muscle volume loss, with 25.8% in severe muscle loss categories. Significant predictors of tear severity were time spent in active pushing (P = 0.04), not total time in second stage, and age (P = 0.02). Use of episiotomy was not statistically significant (P = 0.05). Discussion Despite recruiting women who experienced a complex birth, only about a quarter actually had clinically relevant Levator Ani tears. In this investigation of at-risk women, significant predictors of Levator Ani tear severity included increasing age and duration of active pushing. When considering prevention, age is not modifiable, but monitoring active pushing time and potentially avoiding episiotomy warrant further investigation. Funding NIH Funding R21HD049818 and P50HD044406 002.
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urethral closure pressures among primiparous women with and without Levator Ani muscle defects
International Urogynecology Journal, 2011Co-Authors: Cynthia A Brincat, John O.l. Delancey, Janis M MillerAbstract:Introduction and hypothesis Vaginal birth is an established risk factor for Levator Ani (LA) defects and incontinence. We hypothesized an association between urethral pressure profiles and LA defects.
Hans Peter Dietz - One of the best experts on this subject based on the ideXlab platform.
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Levator morphology and strength after obstetric avulsion of the Levator Ani muscle
Female pelvic medicine & reconstructive surgery, 2020Co-Authors: Victoria L Handa, Joan L Blomquist, Jennifer Roem, Alvaro Munoz, Hans Peter DietzAbstract: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.
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does Levator Ani hiatal area configuration affect pelvic organ prolapse
Ultrasound in Obstetrics & Gynecology, 2019Co-Authors: Talia Friedman, Y Xuan, Hans Peter DietzAbstract:OBJECTIVE Levator Ani trauma and hiatal overdistension have been shown to be associated with female pelvic organ prolapse (POP); however, the role of the shape of the Levator hiatus in POP has not been examined to date. The aim of this study was to investigate the association between the configuration of the Levator Ani hiatus and POP. METHODS This was a retrospective study of 547 women who attended a tertiary urogynecological center for symptoms of pelvic floor and lower urinary tract dysfunction between October 2014 and August 2016. All women underwent a standardized interview and prolapse assessment using the International Continence Society (ICS) Pelvic Organ Prolapse Quantification (POP-Q) method and four-dimensional translabial ultrasound (TLUS). Measurements of the hiatal anteroposterior diameter (APD), coronal diameter (CD) and hiatal area (HA), at rest and on maximal Valsalva maneuver, and those of organ descent were performed offline at a later date by an investigator blinded to all other data. Hiatal configuration was defined as the ratio APD/CD. Associations between HA and HA adjusted by APD/CD at rest and on maximal Valsalva and symptoms and signs of prolapse were analyzed statistically using logistic regression modelling. RESULTS The mean age of the women was 54 ± 13.6 (range, 16-89) years. Of the 547 women included, 241 (44%) presented with prolapse symptoms. Clinically significant POP was detected in 406 (74%) patients and significant prolapse on TLUS was detected in 331 (61%). Hiatal ballooning was observed in 310 (57%) women and this was strongly associated with signs and symptoms of POP. HA at rest and on Valsalva was associated with significant POP both on clinical examination and on TLUS. Adjusted odds ratios for hiatal shape showed no effect of the hiatal configuration on the association between HA and POP. CONCLUSION Hiatal shape does not seem to influence the association between HA and symptoms and signs of prolapse. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
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comparison of Levator Ani muscle avulsion injury after forceps assisted and vacuum assisted vaginal childbirth
Obstetrics & Gynecology, 2015Co-Authors: Hafsa U Memon, Joan L Blomquist, Hans Peter Dietz, Christopher B Pierce, Milena M Weinstein, Victoria L HandaAbstract:Objective Using three-dimensional transperineal ultrasound, we compared the prevalence of Levator Ani muscle injury after forceps with vacuum-assisted vaginal delivery.
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comparison between transperineal ultrasound and digital detection of Levator Ani trauma can we improve the odds
Neurourology and Urodynamics, 2014Co-Authors: Jennifer Kruger, Hans Peter Dietz, Stephanie Budgett, Chantale DumoulinAbstract:Aims To investigate the predictive ability of four digital assessment parameters to detect Levator Ani (LA) muscle defects (avulsion injury) and compare these to transperineal tomographic ultrasound images. Methods This was an observational study imbedded in a larger quasi-experimental cohort study for women with urinary incontinence. Seventy-two women, ≥60 years who had attended or were going to attend physiotherapy for treatment of urinary incontinence, were included in the study. Inclusion criteria from the parent study were symptoms of stress, urge or both types of urinary incontinence. The predictive ability of the following digital parameters: direct palpation of a discontinuity of the LA muscle from insertion on the pubic ramus; palpation of the distance between the muscle insertion sites; palpation of LA strength; palpation of LA tone, were analyzed against findings from tomographic transperineal ultrasound images. Correlation between methods was measured using Cohen's kappa for each of the individual parameters. Results Seventeen women (24%) presented with a complete or partial avulsion of the puborectalis muscle as diagnosed with tomographic ultrasound imaging. Nine women (13%) had complete avulsions, one of which was bilateral. The predictive ability of the digital assessment parameters varied from poor (k = 0.187, 95% CI [0.02–0.36]) to moderate (k = 0.569, 95% CI [0.31–0.83]). The new parameter of ‘width between insertion sites’ performed best. Conclusions Adding the parameter of “width between insertion sites” appears to enhance our ability to detect avulsion of the Levator Ani (LA) muscle by digital examination however it does not distinguish between unilateral or bilateral avulsion. Neurourol. Urodynam. 33:307–311, 2014. © 2013 Wiley Periodicals, Inc.
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Rectal intussusception is associated with abnormal Levator Ani muscle structure and morphometry
Techniques in Coloproctology, 2010Co-Authors: N. Rodrigo, Ka Lai Shek, Hans Peter DietzAbstract:Background Anorectal symptoms are common in urogynaecological patients, and so are anatomical abnormalities of the anorectum associated with such symptoms. One such abnormality is rectal intussusception (RI). The aim of this retrospective study was to determine the prevalence of RI in a tertiary urogynaecological population and to describe the associated symptoms, signs and ultrasound findings, in particular those relating to pelvic floor function and anatomy. It was hypothesized that RI is associated with abnormal Levator Ani muscle anatomy and function.
James A Ashtonmiller - One of the best experts on this subject based on the ideXlab platform.
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comparison of muscle fiber directions between different Levator Ani muscle subdivisions in vivo mri measurements in women
International Urogynecology Journal, 2014Co-Authors: James A Ashtonmiller, Janis M Miller, Cornelia Betschart, Jinyong Kim, John O.l. DelanceyAbstract:This study describes a technique to quantify muscle fascicle directions in the Levator Ani (LA) and tests the null hypothesis that the in vivo fascicle directions for each LA subdivision subtend the same parasagittal angle relative to a horizontal reference axis. Visible muscle fascicle direction in the each of the three LA muscle subdivisions, the pubovisceral (PVM; synonymous with pubococcygeal), puborectal (PRM), and iliococcygeal (ICM) muscles, as well as the external anal sphincter (EAS), were measured on 3-T sagittal MRI images in a convenience sample of 14 healthy women in whom muscle fascicles were visible. Mean ± standard deviation (SD) angle values relative to the horizontal were calculated for each muscle subdivision. Repeated measures ANOVA and post-hoc paired t tests were used to compare muscle groups. Pubovisceral muscle fiber inclination was 41 ± 8.0°, PRM was −19 ± 10.1°, ICM was 33 ± 8.8°, and EAS was −43 ± 6.4°. These fascicle directions were statistically different (p < 0.001). Pairwise comparisons among Levator subdivisions showed angle differences of 60° between PVM and PRM, and 52° between ICM and PRM. An 84° difference existed between PVM and EAS. The smallest angle difference between Levator divisions was between PVM and ICM 8°. The difference between PRM and EAS was 24°. All pairwise comparisons were significant (p < 0.001). The null hypothesis that muscle fascicle inclinations are similar in the three subdivisions of the Levator Ani and the external anal sphincter was rejected. The largest difference in Levator subdivision inclination, 60°, was found between the PVM and PRM.
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comparison of muscle fiber directions between different Levator Ani muscle subdivisions in vivo mri measurements in women
International Urogynecology Journal, 2014Co-Authors: James A Ashtonmiller, Janis M Miller, Cornelia Betschart, Jinyong Kim, John O.l. DelanceyAbstract:Introduction and hypothesis This study describes a technique to quantify muscle fascicle directions in the Levator Ani (LA) and tests the null hypothesis that the in vivo fascicle directions for each LA subdivision subtend the same parasagittal angle relative to a horizontal reference axis.
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a comparison of the effect of age on Levator Ani and obturator internus muscle cross sectional areas and volumes in nulliparous women
Neurourology and Urodynamics, 2012Co-Authors: Vikky Morris, John O.l. Delancey, Meghan P Murray, James A AshtonmillerAbstract:Aims: Functional tests have demonstrated minimal loss of vaginal closure force with age. So we tested the null hypotheses that age neither affects the maximum cross-sectional area (CSA) nor the volume of the Levator muscle. Corresponding hypotheses were also tested in the adjacent obturator internus muscle, which served as a control for the effect of age on appendicular muscle in these women. Methods: Magnetic resonance images of 15 healthy younger (aged 21–25 years) and 12 healthy older nulliparous women (aged >63 years) were selected to avoid the confounding effect of childbirth. Models were created from tracing outlines of the Levator Ani muscle in the coronal plane, and obturator internus in the axial plane using 3D Slicer v. 3.4. Muscle volumes were calculated using Slicer, while CSA was measured using Imageware TM at nine locations. The hypotheses were tested using repeated measures analysis of variance with P < 0.05 being considered significant. Results: The effect of age did not reach statistical significance for the decrease in Levator Ani muscle maximum CSA or the decrease in volume (4.3%, P ¼ 0.62 and 10.9%, 0.12, respectively). However, age did significantly adversely decrease obturator internus muscle maximum CSA and volume (24.5% and 28.2%, P < 0.001, respectively). Significant local age-related changes were observed dorsally in both muscles. Conclusions: Unlike the adjacent appendicular muscle, obturator internus, the Levator Ani muscle in healthy nullipara does not show evidence of significant age-related atrophy. Neurourol. Urodynam. 31:481–486, 2012. 2012 Wiley Periodicals, Inc.
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comparison of Levator Ani muscle defects and function in women with and without pelvic organ prolapse
Obstetrics & Gynecology, 2007Co-Authors: John O.l. Delancey, Rohna Kearney, Yvonne Hsu, Wolfgang Umek, Janis M Miller, Daniel M. Morgan, Dee E. Fenner, Kenneth E. Guire, Hero K. Hussain, James A AshtonmillerAbstract: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).
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measurement of the pubic portion of the Levator Ani muscle in women with unilateral defects in 3 d models from mr images
International Journal of Gynecology & Obstetrics, 2006Co-Authors: Luyun Chen, James A Ashtonmiller, Yvonne Hsu, John O.l. DelanceyAbstract:Objective: Develop a method to quantify the cross-sectional area of the pubic portion of the Levator Ani muscle, validate the method in women with unilateral muscle defects, and report preliminary findings in those women. Method: Multi-planar proton density magnetic resonance images of 12 women with a unilateral defect in the pubic portion of their Levator Ani were selected from a larger study of Levator Ani muscle anatomy in women with and without genital prolapse. Three-dimensional bilateral models of the Levator Ani were reconstructed (using 3-D Slicer, version 2.1b1) and divided into iliococcygeal and pubic portions. Muscle cross-sectional areas were calculated at four equally spaced locations perpendicular to a line drawn from the pubic origin to the visceral insertion using the I-DEASR® computer modeling software. Results: The cross-sectional area of the muscle on the side with the defect was smaller than the normal side at all the four locations. The average bilateral difference was up to 81% at location 1 (nearest pubic origin). Almost all of the volume difference (13.7%, P =0.0004) was attributable to a reduction in the pubic portion (24.6%, P <0.0001), not the iliococcygeal portion ( P =0.64), of the muscle. Conclusions: A method was developed to quantify cross-sectional area of the pubic portion of the Levator Ani perpendicular to the intact muscle direction. Significant bilateral cross-sectional area differences were found between intact and defective muscles in women with a unilateral defect.
Chantale Dumoulin - One of the best experts on this subject based on the ideXlab platform.
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comparison between transperineal ultrasound and digital detection of Levator Ani trauma can we improve the odds
Neurourology and Urodynamics, 2014Co-Authors: Jennifer Kruger, Hans Peter Dietz, Stephanie Budgett, Chantale DumoulinAbstract:Aims To investigate the predictive ability of four digital assessment parameters to detect Levator Ani (LA) muscle defects (avulsion injury) and compare these to transperineal tomographic ultrasound images. Methods This was an observational study imbedded in a larger quasi-experimental cohort study for women with urinary incontinence. Seventy-two women, ≥60 years who had attended or were going to attend physiotherapy for treatment of urinary incontinence, were included in the study. Inclusion criteria from the parent study were symptoms of stress, urge or both types of urinary incontinence. The predictive ability of the following digital parameters: direct palpation of a discontinuity of the LA muscle from insertion on the pubic ramus; palpation of the distance between the muscle insertion sites; palpation of LA strength; palpation of LA tone, were analyzed against findings from tomographic transperineal ultrasound images. Correlation between methods was measured using Cohen's kappa for each of the individual parameters. Results Seventeen women (24%) presented with a complete or partial avulsion of the puborectalis muscle as diagnosed with tomographic ultrasound imaging. Nine women (13%) had complete avulsions, one of which was bilateral. The predictive ability of the digital assessment parameters varied from poor (k = 0.187, 95% CI [0.02–0.36]) to moderate (k = 0.569, 95% CI [0.31–0.83]). The new parameter of ‘width between insertion sites’ performed best. Conclusions Adding the parameter of “width between insertion sites” appears to enhance our ability to detect avulsion of the Levator Ani (LA) muscle by digital examination however it does not distinguish between unilateral or bilateral avulsion. Neurourol. Urodynam. 33:307–311, 2014. © 2013 Wiley Periodicals, Inc.
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changes in Levator Ani anatomical configuration following physiotherapy in women with stress urinary incontinence
The Journal of Urology, 2007Co-Authors: Chantale Dumoulin, Q Peng, Hans Stodkildejorgensen, K Shishido, Christos E ConstantinouAbstract:Purpose: We quantified the effect of pelvic floor muscle training on the anatomical configuration of the Levator Ani using magnetic resonance imaging.Materials and Methods: Five female participants with stress urinary incontinence underwent magnetic resonance imaging before and after participating in a pelvic floor muscle physiotherapy program. Axial T1-weighted images of the Levator Ani were taken with the participant in a supine position. Source images were then manually segmented and surface modeling was applied to build a 3-dimensional model of the Levator Ani. Models were then measured to determine the Levator Ani surface area as well as the encircled volume at rest and during voluntary contraction. The percentage of Levator Ani retraction and symphysis pubis movement during voluntary contraction before and after physiotherapy were also measured.Results: After physiotherapy the Levator Ani surface area at rest was significantly smaller than before physiotherapy, decreasing from 677.11 ± 45.00 to 620....