G. Bitman

OP34.05: Obstetric anal sphincter injury—how does a subsequent delivery affect long term outcome?

group women. Right-sided injury was seen twice as often as left, 32% vs. 16%; injury was bilateral in 2 patients (4%). In controls, 44/247 (18%) showed signs of levator ani disruption (P < 0.01); none were bilateral. Conclusions: III◦ or IV◦ anal sphincter tears pose increased risk for trauma of the anterior compartment. Although this risk factor cannot be modified to prevent LAM injury, it is a possible indication for thorough sonographic evaluation of the anterior compartment.

OC29.04: Risk factors for levator avulsion trauma in women with obstetric anal sphincter injuries

Objectives: In 10–30% of women, vaginal birth results in levator ani tears which are associated with female pelvic organ prolapse and reduced contraction strength in later life. This study was undertaken to determine whether women notice such changes after childbirth. Methods: This is a retrospective analysis of two perinatal imaging studies. Patients were followed up 3–6 months postpartum. They were asked to estimate pelvic floor strength relative to strength just before childbirth, using a percentage. Translabial 4D pelvic floor ultrasound was performed to determine structure and function of the levator ani muscle. Imaging analysis was performed offline, using proprietary software, blinded against all clinical data. Levator avulsion was diagnosed on tomographic imaging in the axial plane. Results: 513 primiparous women were seen for follow-up in the context of two prospective trials, at a median of 129 days postpartum. They had given birth to a singleton at a mean gestation of 40.0 (range, 36+0 to 42+5). There were 351 vaginal deliveries (27 Forceps, 60 Vacuum and 264 NVD) and 162 Caesareans (31.6%). At follow-up, 482 were able to rate their pelvic floor strength relative to the situation prior to childbirth, reporting an average strength of 89%. This reduction was associated with delivery mode (P < 0.001), length of 2nd stage (P = 0.017) and episiotomy (P = 0.019). 45 women were diagnosed with levator avulsion which was associated with a greater reduction (no avulsion, 90% vs., unilateral avulsion, 86%, bilateral avulsion 80%, P= 0.007 on ANOVA). Conclusions: Many women notice altered pelvic floor function after childbirth. Vaginal childbirth, episiotomy, perineal tears and length of 2nd stage are associated with subjectively reduced pelvic floor strength after first delivery. Women who have suffered a levator avulsion notice a significantly greater reduction in subjective strength.

OP23.04: Validation of transperineal ultrasound examination in the evaluation of urogynecological patients

Objectives: To evaluate the correlation between levator ultrasound morphology and pelvic floor pathology. Methods: A standardized pelvic floor questionnaire, physical examination (Baden–Walker classification), and multi-channel urodynamic testing (MMS, Holland). 2D, 3D and 4D transperineal ultrasound with a 4–8-MHz transabdominal probe, at rest, maximal Valsalva, and maximal contraction. Statistical analysis using SPSS software. Results: Forty-eight women were analyzed, median age 53 years. Levator avulsion defects were found in 79%, 19% right, 8% left and 52% bilaterally. In cases of bilateral avulsion, 28% had a larger avulsion defect on the right. Levator biometric indices are given in the Table. Levator ballooning (hiatal area ≥ 300 mm2) was observed in 4.5% of women at rest and 46.8% of women at maximal Valsalva. Levator ballooning at Valsalva correlated weakly with prolapse sensation (r = 0.32, 0.04 Fisher exact test) and voiding difficulty (r = 0.31, P = 0.04), but not with prolapse grading. Range and median of the ratios of the various biometric indices between maximum Valsalva and rest are shown in the Table. The Valsalva to rest ratio for the levator area at the genital hiatus was significantly larger than the other ratios. The Valsalva to rest ratio for area showed a weak correlation with prolapse sensation (r = 0.41, P = 0.01, Fisher exact test) and rectocele grading (r = 0.4, P = 0.012, Pearson Chi square). Conclusions: Levator ani defects are very common in patients with pelvic floor problems. The ratio between the levator areas at maximal Valsalva and at rest correlates with several prolapse symptoms and physical findings, and may represent the tissue elasticity of the levator ani. More research is needed to establish its significance to patient management and outcome.

OC30.04: Does the levator ani change in appearance?

Objective: Several mechanisms are believed to be in play maintaining anal continence, one of them being voluntary squeezing using the pelvic muscles. Here we study the effect of squeeze on the anal channel position and dimensions. Method: 20 healthy 0-gravida and 24 women with anal incontinence were recruited after written consent for 3D vaginal ultrasound measurements of angles and diameters during rest and squeeze. The anovaginal angle was defined as the angle between the posterior vaginal wall and the anterior wall of the channel assessed in a sagittal section. The anorectal angle was defined as the angle between the posterior wall of the anal channel and that of the rectal wall above the level of the puborectal muscle. Diameter and area of the mucosa were measured in the middle of the anal channel (lower level) and at the level of the puborectal muscle (upper level). Results: The 0-gravida had a mean age of 26 years with an incontinence score 0 on a scale 0–24. The incontinent women had a mean age of 59 years and their score was mean 11 (range 3–22). The ultrasound measurement results are presented in the table. Conclusion: Voluntary squeeze augments the bend of the anal and rectal tube at the level of the puborectal muscle and compresses the mucosal cuff at this level in young 0-gravida women. In incontinent women of a higher age, the anal tube is straighter, the mucosal cuff in the lower anal channel is smaller, and the effect of squeeze is less prominent or lacking.

P26.08: The urethral lumen on 3D transperineal ultrasound volumes—does it mean anything?

Early US lenght, there was a marked reduction in midsagittal mesh length 90.3 (SD 1.8) mm vs. 57.1 (SD 10.0) mm, P < 0.001. When early and late ultrasound measurements were compared (n = 30, Time Point 1–2), we observed a further reduction of about 15% in midsagittal dimensions [57.1 (SD 10.0) mm vs. 48.3 (SD 10.2) mm, P < 0.001]. The Inter-observer realiability series showed ICC for Early US length 0.74 and 0.82 for Late US length. Conclusions: The degree of shrinkage corresponds with data from experimental animal studies, where shrinkage was between 15%. We should point out that the surgical impact on final mesh length is markedly greater than shrinking. We should be using imaging to monitor our surgical results as standard.

P07.08: What is the best cut-off value for the levator-urethra gap ( LUG) measurement in the diagnosis of avulsion defects?

at rest and on PFMC. The size of a defect was defined by measuring sector angles. Results: Of 842 women, mean age was 54 (16-84) years. 89 % (751) were vaginally parous with median parity of 2 (1-8). The mean EAS defect angles at rest and on PFMC were 35.7o (2.5-142.8) and 34.9o (1.8-131.3) respectively. Significant EAS trauma was diagnosed in 143 (18%) at rest and 120 (14%) on PFMC. Figure 1 shows a comparison of defect angles at rest and on PFMC for positive slices 1-6. Contrary to expectations, the defect angle showed a reduction by 5-10 degrees on PFMC when comparing defect angle in women who had defects both at rest and on PFMC. Conclusions: Pelvic floor contraction does not enlarge EAS defect angles. On the contrary, defects seem smaller on PFMC. This may be explained by the large proportion of sphincter trauma that is partial, with a defect surrounded by undamaged or repaired muscle. The scar area is likely reduced by contraction of the surrounding intact sphincter muscle.

OP13.10: The “small woman” phenotype—the effect of height on levator morphology

area were significant univariate predictors, and remained significant in multivariate models for clinical and sonographic recurrence, with ROC analysis showing an area under the curve of 0.65 and 0.73 respectively. Avulsion was associated with an OR of 2.95 for recurrence; hiatal area on valsalva conveyed an additional 7% per cm2 for likelihood of recurrence. Predicted individual probability of recurrence varied from 12% to 95%. Conclusions: Recurrence risk after AC is largely determined by the state of the patient’s pelvic floor. The likelihood of recurrence may vary enormously between patient with a given degree of cystocele, depending on avulsion and hiatal ballooning. Both should be determined prior to prolapse surgery, especially if mesh use is contemplated.

OP13.04: Can ultrasound predict stress incontinence in women after obstetric anal sphincter injury?

Objectives: This study aims at evaluating the pelvic floor biometries during the first pregnancy of Chinese nulliparous women. The relationship with pelvic floor symptoms was also explored. Methods: Nulliparous Chinese women with singleton pregnancies were recruited. They were assessed at 10–13 weeks, 26–28 weeks and 35–38 weeks of gestation. Trans-labial 3D-ultrasound was performed at rest, Valsalva maneuver (VM) and pelvic floor contraction (PFMC) during each visit. Stress urinary incontinence, urgency urinary incontinence and dragging discomfort were also asked during each visit. Offline analysis of USG volume data sets were done by an investigator blinded to the information. Position of the anterior compartment (bladder neck vertical position), middle compartment (most inferior part of cervix) and posterior compartment (ano-rectal junction) and the hiatal dimensions were measured in a standard way. Results: In all, data of 187 women were reported here. Their mean age was 30.4 ± 4.0 years. There were significant descent of all three compartments and enlargement of hiatal area during rest, VM or PFMC as the pregnancy advanced. At second and third trimester, 54 (29%) and 60 (32%) women reported stress urinary incontinence, but there was no association with the bladder neck mobility. And 41 (22%) and 60 (32%) reported symptoms of dragging sensation but there was no association with the hiatal area. Conclusions: There were significant changes of pelvic floor biometries with descent of three compartments at rest, at VM and PFMC as pregnancy advanced. Stress urinary incontinence and dragging sensation were common during pregnancy; however, both were not associated with parameters of pelvic floor biometries.

OC30.06: Long term follow‐up of women with 3rd and 4th degree perineal tears using transperineal ultrasound

to age, BMI, parity, time from delivery, episiotomy, epidural anesthesia, birth weight, or delivery mode, but there was a trend towards higher TUI scores with a prolonged second stage (0.061). Women with a higher BMI had larger levator hiatal area dimensions (P=0.05), whereas shorter women tended to have more severe avulsion defects on TUI (P=0.027). Women with an avulsion defect in addition to the perineal tear were also more likely to have anorectal symptoms, although this was statistically significant only for fecal urgency (< 0.05). We observed a decrease in the incidence (61.4% vs. 29.5%, P<0.001) and TUI score of avulsion defects (6.18 ± 6.4 vs. 2.43 ± 4.8, (P<0.001), for the enrolment and last visits, respectively. Conclusion: There seems to be a change in the appearance of levator ani trauma during long term follow-up in women with 3rd and 4th degree perineal tears suggesting the need for continued evaluation.