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Pelvic Floor: Gynecology

Determinants of the length of episiotomy or spontaneous posterior perineal lacerations during vaginal birth.
Rizk DE, Abadir MN, Thomas LB, Abu-Zidan F
Int Urogynecol J Pelvic Floor Dysfunct. 2005 Sep-Oct;16(5):395-400. Epub 2005 Jan 20.

The objective of this study was to measure the length of episiotomy or spontaneous posterior perineal laceration and their relationship to perineal measurements and obstetric variables. The length of the perineum and genital hiatus and vertical length of episiotomy or posterior perineal tears were measured in 114 consecutive parturients with spontaneous singleton term deliveries. Seventy-four (65%) women underwent episiotomy while 40 (35%) sustained spontaneous posterior tears. Perineal or genital hiatus length was significantly correlated to episiotomy (r=0.34, p=0.003) or laceration (r=0.37, p=0.02) length, respectively. This association was significant (p=0.001) in a generalized linear model with duration of second stage of labor (p=0.005), degree of tear (p=0), and parity (p=0). Perineal length was significantly related to maternal age (p=0.036) and weight (p=0.037) and hiatal length (p=0). Short perineum and genital hiatus, long second stage of labor, and low parity are associated with longer posterior perineal injury.

Obstetric factors associated with levator ani muscle injury after vaginal birth.
Kearney R, Miller JM, Ashton-Miller JA, Delancey JO
Obstet Gynecol. 2006 Jan;107(1):144-9.

OBJECTIVE: To identify obstetric factors associated with development of levator ani injury after vaginal birth. METHODS: Magnetic resonance images were taken of the pelvic floor of 160 women 9 to 12 months after first term vaginal delivery. Half the women had de novo stress incontinence and half were continent controls. Abnormalities of the pubovisceral portion were identified on magnetic resonance as present or absent. Defect severity was further scored in each muscle from 0 (no defect) to 3 (complete muscle loss). A summed score for the 2 sides (0 to 6) was assigned and grouped as minor (0-3) or major (4-6). Obstetric details were collected. The association between obstetric variables and muscle injury were analyzed using Fisher exact test and t tests. RESULTS: The following increased odds ratios for levator defect were found: forceps use 14.7 (95% confidence interval [CI] 4.9-44.3), anal sphincter rupture 8.1 (95% CI 3.3-19.5) and episiotomy 3.1 (95% CI 1.4-7.2) but not vacuum delivery 0.9 (95% CI 0.19-4.3), epidural use 0.9 (95% CI 0.4-2.0), or oxytocin use 0.8 (95% CI 0.3-1.8). Women with levator injury were 3.5 years older and had a 78-minute longer second stage of labor. Differences in gestational age, birth weight, and head circumference were not statistically significant. A major defect in the pubovisceral muscle was seen in 22 women and a minor defect in 7 women. CONCLUSION: Injuries to the levator ani muscles in women after their first vaginal delivery are associated with several obstetric factors indicating difficult vaginal birth and with older age. LEVEL OF EVIDENCE: II-3.

Pelvic floor muscle evaluation in incontinent patients.
Amaro JL, Moreira EC, De Oliveira Orsi Gameiro M, Padovani CR
Int Urogynecol J Pelvic Floor Dysfunct. 2005 Sep-Oct;16(5):352-4. Epub 2005 Jan 12.

The aim of this study was to assess pelvic floor muscle (PFM) strength and perception and its correlation with stress urinary incontinence (SUI). One hundred and one women were divided into two groups according to the presence (G1=51 patients) or absence (G2=50 patients) of SUI. Subjective [urine stream interruption test (UST), visual survey of perineal contraction and transvaginal digital palpation to assess pelvic muscle contraction] and objective evaluations of pelvic floor muscles in all patients were performed (vaginal manometry). During the UST, 25.5% of G1 patients and 80% of G2 patients were able to interrupt the urine stream (p<0.05). Digital evaluation of pelvic muscular contraction showed higher strength in G2 than in G1 patients (p<0.0001). Perineometer evaluation of PFM strength was significantly higher in the continent group (p<0.001). Pelvic floor muscle weakness in incontinent patients demonstrates the importance of functional and objective evaluation of this group of muscles.

Patients' knowledge of potential pelvic floor changes associated with pregnancy and delivery.
McLennan MT, Melick CF, Alten B, Young J, Hoehn MR
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jul 8;

Physicians cite pelvic floor injury as a major reason for Cesarean section as their personal preferred delivery mode. This study was undertaken to determine whether patients receive information about possible pelvic floor complications of pregnancy/delivery. Day 1 post-partum women completed a 52-item questionnaire assessing information given during routine antenatal care. Pelvic floor and general questions were intermixed. Of the 232 patients, the mean age was 26.9 years, with 59.5% white, 32.8% African-American and 7.7% other. Most (84.5%) had at least grade 12 education. The following percentage of patients reported receiving no information about: Kegel exercises 46.1%; episiotomy 51.3%; urinary incontinence 46.6%; fecal incontinence 80.6%; change in vaginal caliber 72.8%; neuropathy 84.9%. Counseling on all of these issues occurred significantly less frequently than education on general pregnancy topics. Our results suggest that knowledge and instruction of pelvic floor risks is very much lacking and provide us with an impetus to develop educational tools.

Obstetric antecedents for postpartum pelvic floor dysfunction.

Casey BM, Schaffer JI, Bloom SL, Heartwell SF, McIntire DD, Leveno KJ. Am J Obstet Gynecol 2005 May;192(5):1655-62.

OBJECTIVE: The purpose of this study was to evaluate prospectively the association between selected obstetric antecedents and symptoms of pelvic floor dysfunction in primiparous women up to 7 months after childbirth. STUDY DESIGN: All nulliparous women who were delivered between June 1, 2000, and August 31, 2002, were eligible for a postpartum interview regarding symptoms of persistent pelvic floor dysfunction. Responses from all women who completed a survey at or before their 6-month contraceptive follow-up visit were analyzed. Obstetric antecedents to stress, urge, and anal incontinence were identified, and attributable risks for each factor were calculated. RESULTS: During the study period, 3887 of 10,643 primiparous women (37%) returned within 219 days of delivery. Symptoms of stress and urge urinary incontinence, were significantly reduced (P < .01) in women who underwent a cesarean delivery. Symptoms of urge urinary incontinence doubled in women who underwent a forceps delivery (P = .04). Symptoms of anal incontinence were increased in women who were delivered of an infant who weighed >4000 g (P = .006) and more than doubled in those women who received oxytocin and had an episiotomy performed (P = .01). CONCLUSION: The likelihood of symptoms of pelvic floor dysfunction up to 7 months after delivery was greater in women who received oxytocin, who underwent a forceps delivery, who were delivered of an infant who weighed >4000 g, or who had an episiotomy performed. Women who underwent a cesarean delivery had fewer symptoms of urge and stress urinary incontinence.

Pudendal nerve stretch during vaginal birth: a 3D computer simulation.
Lien KC, Morgan DM, Delancey JO, Ashton-Miller JA. Am J Obstet Gynecol 2005 May;192(5):1669-76.

OBJECTIVE: The purpose of this study was to determine the increase in pudendal nerve branch lengths using a 3D computer model of vaginal delivery. STUDY DESIGN: The main inferior rectal and perineal branches of the pudendal nerve were dissected in 12 hemi-pelves from 6 adult female cadavers. Their 3D courses were digitized in the 4 specimens with the most characteristic nerve branching pattern, and the data were imported into a published 3D computer model of the pelvic floor. Each nerve branch was then represented by a stretchable cord with a fixation point at the ischial spine. The length change in each branch was then quantified as the fetal head descended through the pelvic floor. The maximum nerve strains ([final length minus original length/original length] x 100) were calculated for 5 degrees of perineal descent: reference descent from the literature, 1.25 cm and 2.5 cm caudal and cephalad. The effect of alternative fixation points on resultant nerve strain was also studied. RESULTS: The inferior rectal branch exhibited the maximum strain, 35%, and this strain varied by 15% from the scenario with the least perineal descent to that with the most perineal descent. The strain in the perineal nerve branch innervating the anal sphincter reached 33%, while the branches innervating the posterior labia and urethral sphincter reached values of 15% and 13%, respectively. The more proximal the nerve fixation point, the greater the nerve strain. CONCLUSION: During the second stage: (1) nerves innervating the anal sphincter are stretched beyond the 15% strain threshold known to cause permanent damage in appendicular peripheral nerve, and (2) the degree of perineal descent is shown to influence pudendal nerve strain.

A randomized trial of the effects of coached vs uncoached maternal pushing during the second stage of labor on postpartum pelvic floor structure and function.
Schaffer JI, Bloom SL, Casey BM, McIntire DD, Nihira MA, Leveno KJ. Am J Obstet Gynecol 2005 May;192(5):1692-6.

OBJECTIVE: The purpose of this study was to determine if refraining from coached pushing during the second stage of labor affects postpartum urogynecologic measures of pelvic floor structure and function. STUDY DESIGN: Nulliparous women at term were randomized to coached (n = 67) vs uncoached (n = 61) pushing. At 3 months' postpartum women underwent urodynamic testing, pelvic organ prolapse examination (POPQ), and pelvic floor neuromuscular assessment. RESULTS: Urodynamic testing revealed decreased bladder capacity (427 mL vs 482 mL, P = .051) and decreased first urge to void (160 mL vs 202 mL, P = .025) in the coached group. Detrusor overactivity increased 2-fold in the coached group (16% vs 8%), although this difference was not statistically significant (P = .17). Urodynamic stress incontinence was diagnosed in the coached group in 11/67 (16%) vs 7/61 (12%) in the uncoached group (P = .42). CONCLUSION: Coached pushing in the second stage of labor significantly affected urodynamic indices, and was associated with a trend towards increased detrusor overactivity.

Pelvic organ prolapse, constipation, and dietary fiber intake in women: a case-control study.
Arya LA, Novi JM, Shaunik A, Morgan MA, Bradley CS. Am J Obstet Gynecol 2005 May;192(5):1687-91.

OBJECTIVE: This study was undertaken to determine whether there is an association among pelvic organ prolapse, constipation, and dietary fiber intake. STUDY DESIGN: Sixty consecutive women with prolapse were compared with 30 control women without prolapse. All women completed 2 validated questionnaires to assess constipation and dietary fiber intake. Multivariate analysis was performed. RESULTS: The risk for constipation was greater in women with prolapse than controls (odds ratio 4.03, 95% CI 1.5-11.4). Median insoluble fiber intake was significantly lower in women with prolapse (2.4 g) than controls (5.8 g, P < .01). The increased risk for constipation was reduced but remained significant after controlling for age and insoluble dietary fiber intake (odds ratio 2.9, 95% CI 1.1-13.5). CONCLUSION: Women with pelvic organ prolapse are at a higher risk for constipation than controls. This increased risk for constipation is partially explained by lower intake of dietary insoluble fiber by women with prolapse than controls.

Should women be offered elective cesarean section in the hope of preserving pelvic floor function?
Sand PK. Int Urogynecol J Pelvic Floor Dysfunct 2005 Jun 2;.

Should women be offered elective cesarean section in the hope of preserving pelvic floor function?

Nygaard I. Int Urogynecol J Pelvic Floor Dysfunct 2005 Jun 2;.

Pelvic floor morbidity at 3 years after instrumental delivery and cesarean delivery in the second stage of labor and the impact of a subsequent delivery.
Bahl R, Strachan B, Murphy DJ
Am J Obstet Gynecol 2005 Mar;192(3):789-94.

Objective To compare pelvic floor symptoms at three years following instrumental delivery and cesarean section in the second stage of labor and to assess the impact of a subsequent delivery. Study design We conducted a prospective cohort study of 393 women with term, singleton, cephalic pregnancies who required instrumental vaginal delivery in theatre or cesarean section at full dilatation between February 1999 and February 2000. 283 women (72%) returned postal questionnaires at three years. Results Urinary incontinence at three years post delivery was greater in the instrumental delivery group as compared to the cesarean section group (10.5% vs 2.0%), OR 5.37 (95% CI, 1.7, 27.9). There were no significant differences in ano-rectal or sexual symptoms between the two groups. Pelvic floor symptoms were similar for women delivered by cesarean section after a failed trial of instrumental delivery compared to immediate cesarean section. A subsequent delivery did not increase the risk of pelvic floor symptoms at three years in either group. Conclusion An increased risk of urinary incontinence persists up to three years following instrumental vaginal delivery compared to cesarean section in the second stage of labor. However, pelvic floor symptoms are not exacerbated by a subsequent delivery.

Reliability of health-related quality-of-life measures 1 year after surgical procedures for pelvic floor disorders.
Wren PA, Janz NK, Brubaker L, Fitzgerald MP, Weber AM, Laporte FB, Wei JT
Am J Obstet Gynecol 2005 Mar;192(3):780-8.

Objective The purpose of this study was to assess the reliability and validity of condition-specific health-related quality-of-life measures in women who are treated surgically for pelvic organ prolapse and urinary incontinence. Study design The study used the cross-sectional telephone interview-based administration of a health-related quality-of-life measure, with a 2-week follow-up interview for test-retest reliability. Results Initial and follow-up interviews were completed by 88 women (mean age, 65.7 +/- 11.6 years) approximately 1 year after surgical procedures. Condition-specific measures demonstrated acceptable reliability with test-retest correlation coefficients that approached or exceeded 0.6 and Cronbach's alpha that exceeded 0.8 in most domains. Validity was demonstrated with significant correlations of the urinary domains of the Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire, with continence defined by the medical, epidemiologic, and social aspects of aging and Hunskaar severity measures (all P < .001). Conclusion The condition-specific health-related quality-of-life assessment is reliable and valid in women after surgical procedures for pelvic floor disorders. These findings support the inclusion of condition-specific health-related quality-of-life measures in clinical trials for women with pelvic floor disorders.