Four-Dimensional Introital Ultrasound in Assessing Perioperative Pelvic Floor Muscle Functions of Women with Cystoceles

Abstract

Purpose Research on the use of ultrasound to explore the pelvic floor in women is rarely done with introital ultrasound. This study aimed to investigate the performance of four-dimensional (4D) introital ultrasound in the perioperative assessment of pelvic floor muscle (PFM) function in women with cystocele.

Materials and Methods The reliability and agreement of ultrasound measurements were determined by intraclass correlation coefficients (ICC) with 95 % confidence interval and Bland-Altman analysis in 20 women. The validity of ultrasound parameters was assessed by correlating squeezing ultrasound measurements with the modified Oxford scale (MOS) in 317 women. 4D introital ultrasound data of 241 women with (n = 29) and without (n = 212) postoperative cystocele at the 12-month postoperative assessment were retrospectively analyzed. Levator avulsion was diagnosed using tomographic ultrasound imaging. Involuntary and voluntary PFM functions were explored by dynamic changes in the bladder neck and genital hiatus, respectively, upon coughing and squeezing on 4D introital ultrasound.

Results The ICC for the reliability of all tested ultrasound parameters was good to very good. The changes and change ratios of most ultrasound measurements from resting to squeezing were fairly correlated with MOS. Women with postoperative cystocele demonstrated more rates of complete levator avulsion [41.3 % vs. 4.7 %, P < 0.001, odds ratio (OR) 14.26, 95 % confidence interval (CI) 4.88–42.42] and fewer rates of capable voluntary PFM contraction (65.5 % vs. 92.5 %, P < 0.001, OR 0.16, 95 % CI 0.06–0.43) than those without postoperative cystocele postoperatively.

Conclusion 4D introital ultrasound is feasible to assess perioperative PFM function in women with cystocele.

Zusammenfassung

Ziel Die Forschung über den Einsatz von Ultraschall zur Untersuchung des Beckenbodens bei Frauen wird selten mit Introitus-Sonografie durchgeführt. Ziel dieser Studie war es, die Leistungsfähigkeit der 4-dimensionalen (4D) Introitus-Sonografie bei der perioperativen Beurteilung der Funktion der Beckenbodenmuskulatur (PFM) bei Frauen mit Zystozele zu untersuchen.

Material und Methoden Die Reliabilität und Übereinstimmung der Ultraschallmessungen wurden bei 20 Frauen mittels Intraklassen-Korrelationskoeffizienten (ICC) mit 95 %-Konfidenzintervall und Bland-Altman-Analyse bestimmt. Die Validität der Ultraschallparameter wurde bei 317 Frauen durch Korrelation der Ultraschallmessungen beim Pressen mit der modifizierten Oxford-Skala (MOS) beurteilt. Daten der 4D-Introitus-Sonografie von 241 Frauen mit (n = 29) und ohne (n = 212) postoperative Zystozele in der 12-monatigen postoperativen Erfassung wurden retrospektiv analysiert. Eine Levator-Avulsion wurde mittels tomografischen Ultraschalls diagnostiziert. Die nichtwillentlichen und willentlichen PFM-Funktionen wurden durch dynamische Veränderungen im Blasenhals bzw. im genitalen Hiatus beim Husten und Pressen im 4D-Introital-Ultraschall untersucht.

Ergebnisse Die ICC für die Reliabilität aller untersuchten Ultraschallparameter war gut bis sehr gut. Bei den meisten Ultraschallmessungen waren die Änderungen und die Änderungsverhältnisse zwischen Ruhezustand und Pressen ordentlich mit der MOS korreliert. Frauen mit postoperativer Zystozele zeigten im Vergleich zu Frauen ohne eine höhere Rate an vollständiger Levator-Avulsion (41,3 % vs. 4,7 %; p < 0,001; Odds-Ratio (OR) 14,26; 95 %-Konfidenzintervall (CI) 4,88–42,42) und eine geringere Fähigkeit zur willentlichen PFM-Kontraktion (65,5 % vs. 92,5 %; p < 0,001; OR 0,16; 95 %-CI 0,06–0,43).

Schlussfolgerung Die 4D-Introitus-Sonografie ist zur Beurteilung der perioperativen PFM-Funktion bei Frauen mit Zystozele durchführbar.

Key words

introital ultrasound - levator avulsion - pelvic floor muscle - reliability - validity

Publication History

Received: 06 May 2019

Accepted: 28 November 2019

Article published online:
04 May 2020

• References

• 1 Chen L, Ashton-Miller JA, DeLancey JO. A 3D finite element model of anterior vaginal wall support to evaluate mechanisms underlying cystocele formation. J Biomech 2009; 42: 1371-1377
• 2 Chen L, Lisse S, Larson K. et al. Structural failure sites in anterior vaginal wall prolapse: identification of a collinear triad. Obstet Gynecol 2016; 128: 853-862
• 3 Vergeldt TF, Notten KJ, Weemhoff M. et al. Levator hiatal area as a risk factor for cystocele recurrence after surgery: a prospective study. BJOG 2015; 122: 1130-1137
• 4 Wong V, Shek K, Rane A. et al. Is levator avulsion a predictor of cystocele recurrence following anterior vaginal mesh placement?. Ultrasound Obstet Gynecol 2013; 42: 230-234
• 5 Friedman T, Eslick GD, Dietz HP. Risk factors for prolapse recurrence: systematic review and meta-analysis. Int Urogynecol J 2018; 29: 13-21
• 6 Dietz HP, Lekskulchai O. Ultrasound assessment of pelvic organ prolapse: the relationship between prolapse severity and symptoms. Ultrasound Obstet Gynecol 2007; 29: 688-691
• 7 Nyhus MØ, Salvesen KÅ, Volløyhaug I. Association between pelvic floor muscle trauma and contraction in parous women from a general population – a cross sectional study. Ultrasound Obstet Gynecol 2019; 53: 262-268
• 8 Huang WC, Yang SH, Yang JM. Pelvic floor muscle functions are improved after successful transobturator vaginal mesh procedures. Neurourol Urodyn 2017; 36: 380-384
• 9 Huang WC, Yang JM. Menopause is associated with impaired responsiveness of involuntary pelvic floor muscle contractions to sudden intra-abdominal pressure rise in women with pelvic floor symptoms: A retrospective study. Neurourol Urodyn 2018; 37: 1128-1136
• 10 Messelink B, Benson T, Berghmans B. et al. Standardization of terminology of pelvic floor muscle function and dysfunction: report from the pelvic floor clinical assessment group of the International Continence Society. Neurourol Urodyn 2005; 24: 374-380
• 11 Athanasiou S, Chaliha C, Toozs-Hobson P. et al. Direct imaging of the pelvic floor muscles using two-dimensional ultrasound: a comparison of women with urogenital prolapse versus controls. BJOG 2007; 114: 882-888
• 12 Thibault-Gagnon S, Auchincloss C, Graham R. et al. The temporal relationship between activity of the pelvic floor muscles and motion of selected urogenital landmarks in healthy nulliparous women. J Electromyogr Kinesiol 2018; 38: 126-135
• 13 Yang SH, Huang WC, Yang SY. et al. Validation of new ultrasound parameters for quantifying pelvic floor muscle contraction. Ultrasound Obstet Gynecol 2009; 33: 465-471
• 14 Brækken IH, Majida M, Ellstrøm-Engh M. et al. Test-retest and intra-observer repeatability of two-, three- and four-dimensional perineal ultrasound of pelvic floor muscle anatomy and function. Int Urogynecol J Pelvic Floor Dysfunct 2008; 19: 227-235
• 15 Tunn R, Petri E. Introital and transvaginal ultrasound as the main tool in the assessment of urogenital and pelvic floor dysfunction: an imaging panel and practical approach. Ultrasound Obstet Gynecol 2003; 22: 205-213
• 16 van Delft K, Thakar R, Sultan AH. Pelvic floor muscle contractility: Digital assessment vs transperineal ultrasound. Ultrasound Obstet Gynecol 2015; 45: 217-222
• 17 Dietz HP, Shek C. Levator avulsion and grading of pelvic floor muscle strength. Int Urogynecol J Pelvic Floor Dysfunct 2008; 19: 633-636
• 18 Haylen BT, de Ridder D, Freeman RM. International Urogynecological Association; International Continence Society. et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Neurourol Urodyn 2010; 29: 4-20
• 19 Johnston SL. Pelvic floor dysfunction in midlife women. Climacteric 2019; 11: 1-7
• 20 Ellerkmann RM, Cundiff GW, Melick CF. et al. Correlation of symptoms with location and severity of pelvic organ prolapse. Am J Obstet Gynecol 2001; 185: 1332-1337
• 21 Dietz HP, Bernardo MJ, Kirby A. et al. Minimal criteria for the diagnosis of avulsion of the puborectalis muscle by tomographic ultrasound. Int Urogynecol J 2011; 22: 699-704
• 22 Yang JM, Yang SH, Huang WC. Biometry of the pubovisceral muscle and levator hiatus in nulliparous Chinese women. Ultrasound Obstet Gynecol 2006; 28: 710-716
• 23 Schaer G, Koelbl H, Voigt R. et al. Recommendations of the German Association of Urogynecology on functional sonography of the lower female urinary tract. Int Urogynecol J Pelvic Floor Dysfunct 1996; 7: 105-108
• 24 Slieker-ten Hove M, Pool-Goudzwaard A, Eijkemans M. et al. Pelvic floor muscle function in a general population of women with and without pelvic organ prolapse. Int Urogynecol J 2010; 21: 311-319
• 25 Laycock J. Clinical evaluation of the pelvic floor. In: Schussler B, Laycock J, Norton P. et al. (eds.) Pelvic Floor Re-education. London: Springer-Verlag; 1994: 42-48
• 26 Majida M, Braekken IH, Umek W. et al. Interobserver repeatability of three and four-dimensional transperineal ultrasound assessment of pelvic floor muscle anatomy and function. Ultrasound Obstet Gynecol 2009; 33: 567-573
• 27 Oversand SH, Staff AC, Sandvik L. et al. Levator ani defects and the severity of symptoms in women with anterior compartment pelvic organ prolapse. Int Urogynecol J 2018; 29: 63-69
• 28 Abdool Z, Dietz HP, Lindeque BG. Interethnic variation in pelvic floor morphology in women with symptomatic pelvic organ prolapse. Int Urogynecol J 2018; 29: 745-750
• 29 Shafik A, Asaad S, Doss S. The histomorphologic structure of the levator ani muscle and its functional significance. Int Urogynecol J Pelvic Floor Dysfunct 2002; 13: 116-124
• 30 Shafik A, Doss S, Asaad S. Etiology of the resting myoelectric activity of the levator ani muscle: physioanatomic study with a new theory. World J Surg 2003; 27: 309-314