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“A Chinese Anatomy”— The Pelvic Supporting Tissues of the Chinese and Occidental Female Compared and Contrasted

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... The significant decrease in the pelvic floor during maximal-effort adduction and abduction contraction of the hip joint may be related to the change in lifestyle of Japanese youth who adopt a Western style, and the decrease in squatting movements. Anatomical findings showed that the incidence of stress urinary incontinence (SUI) was lower in Chinese people, who have a more-developed pelvic floor muscle thickness, than in Westerners 16) . ...
Article
Pelvic floor muscle training has been reported to be effective in preventing and improving urinary incontinence. Patients must learn to perform pelvic floor muscle contractions without pushing down the pelvic floor by contracting other muscle groups. This study aimed to determine the effect of maximal-effort contraction of the hip adductor and abductor muscles on the pelvic floor of young, healthy women. For these experiments, 23 healthy nulliparous women performed unilateral maximal-effort isometric contractions of the abductor and adductor hip muscles in a supine position. Simultaneously, the movement of the bladder’s posterior surface was measured using an ultrasonic imaging device. The displacement of the bladder base during maximal-effort contraction of the hip adductor/abductor muscles was calculated based on changes in the distance between the abdominal wall and the bladder base at rest. The results demonstrated that the bladder base significantly descended during maximal-effort isometric contraction of hip adduction/abduction. The maximal-effort isometric hip adduction/abduction muscle strength positively correlated with bladder base descent. These results indicated that isometric contraction of the hip adduction/abduction muscles under maximum effort pushed the pelvic floor downward. In pelvic floor muscle training, when the adductor and abductor muscles of the hip joint are contracted with maximum effort, the pelvic floor muscles cannot learn contraction and may inhibit movement.
... Our findings confirmed these results. Ethnic origins may be associated with differences in body type and variations in perineal anatomy [23,24]. These particularities in body tissue may increase the risk of perineal tears and, as found in our study for Asian women, may favor maternal complications. ...
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Background To identify risk factors, beyond fetal weight, associated with adverse maternal outcomes in delivering infants with a birthweight of 4000 g or greater, and to quantify their role in maternal complications. Methods All women (n = 1564) with singleton pregnancies who attempted vaginal delivery and delivered infants weighing at least 4000 g, in two French tertiary care centers from 2005 to 2008, were included in our study. The studied outcome was maternal complications defined as composite item including the occurrence of a third- or fourth-degree perineal laceration, or the occurrence of severe postpartum hemorrhage requiring the use of prostaglandins, uterine artery embolization, internal iliac artery ligation or haemostatic hysterectomy, or the occurrence of blood transfusion. Univariate analysis, multivariable logistic regression and estimation of attributable risk were used. Results Maternal complications were increased in Asian women (adjusted odds ratio [aOR], 3.1; 95% confidence interval [CI], 1.1–9.3, Attributable risk (AR): 3%), in prolonged labor (aOR = 1.9 [95% CI; 1.1–3.4], AR = 12%) and in cesarean delivery during labor (aOR = 2.2 [95% CI; 1.3–3.9], AR = 17%). Delivering infants with a birthweight > 4500 g also increased the occurrence of maternal complications (aOR = 2.7 [95% CI; 1.4–5.1]) but with an attributable risk of only 10%. Multiparous women with a previous delivery of a macrosomic infant were at lower risk of maternal complications (aOR = 0.5 [95% CI; 0.2–0.9]). Conclusion In women delivering infants with a birthweight of 4000 g or greater, some maternal characteristics as well as labor parameters may worsen maternal outcome beyond the influence of increased fetal weight.
... The fact that some data concur and others differ may be due to differences in levator ani muscle bundle thickness and fascial density in different population groups [10]. ...
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The aim of the study was to determine whether clinical and/or urodynamic changes in bladder function occur during pregnancy. Assessment consisted of a urinary symptom questionnaire, urogynecological examination and urodynamic investigations, which were repeated 6 weeks after pregnancy. Sixty-six patients had the initial and 40 the follow-up assessments. Statistical analysis was done by 95% confidence intervals (95% CI). Nocturia, frequency, dysuria, urgency and stress incontinence occurred significantly more frequently during pregnancy. Urinary tract infection was diagnosed in 18% of patients during pregnancy and asymptomatic bacteriuria in 9%. Genuine stress incontinence was diagnosed in 12% during pregnancy and in none after pregnancy (95% CI 1% to 24%). An unstable detrusor was diagnosed in 23% of patients during pregnancy and in 15% after pregnancy (95% CI -8% to 23%). Strong desire to void, urgency, maximum cystometric capacity, maximum flow rate and average flow rate were all statistically significantly decreased during pregnancy. It is concluded that significant changes occur in bladder function during pregnancy.
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This was a community-based study to evaluate the prevalence and characteristics of female urinary incontinence in women aged 18 and above in the Shatin District of Hong Kong. Of a total of 1018 female households contacted, 362 individuals were successfully interviewed and 123 women (34%) reported they had experienced at least one episode of urinary incontinence as adults. Of these, 18.5% reported persistent incontinence and 15.5% reported absence of incontinence after a single episode of urine loss. The risk factors for incontinence revealed by this study were body mass index and parity. Women who had never been incontinent had a lower body mass index and were usually nulliparous. Most of the respondents (43.9%) who had urinary incontinence considered the condition to be a minor problem and did not seek professional advice. This investigation indicates that a territory-wide study should be carried out to determine the incidence of urinary incontinence throughout Hong Kong.
Article
A new approach to pelvic floor rehabilitation is presented. The aim was to strengthen the three directional muscle forces observed during effort along with their ligamentous insertions. A new anatomical classification guided diagnosis of anatomical defects in the anterior, middle and posterior compartments of the vagina. Where relevant, HRT was administered to prevent long-term collagen loss. Electrotherapy, fast and slow twitch exercises strengthened the striated muscles of the pelvic floor and, therefore, their insertions also. Sixty patients aged 15--86 (mean age: 55 years) were independently assessed at the end of the 3 month programme using the same semiquantitative questionnaire and self-assessment. The median improvement rate per symptom was 65%. Symptom improvement was: stress incontinence,78%; urgency, frequency, 61%; nocturia, 75%; pelvic pain of unknown origin, 65%; involuntary leakage, 68% and bowel problems, 78%. Three patients reported significant worsening of their stress symptoms. This method potentially broadens the conditions amenable to nonsurgical therapy. The preliminary results are promising, and appear to sustain the theory on which they are based. More objective and longer term data, and especially, comparative testing of this regime by other investigators is required.
Article
The aim of this case-control study was to identify etiologic factors predictive for the development of severe pelvic organ prolapse. Three hundred and sixty-eight controls from a database describing pelvic organ support in the general population were identified as having known good pelvic organ support. Eighty-seven cases were identified from a urogynecology clinic with severe pelvic organ prolapse. The risk of severe prolapse was modeled using stepwise multiple logistic regression analysis. Additional analyses using chi2 and two-sample t-tests were conducted to determine differences in means for individual variables. Variables examined included age, gravidity, parity, number of vaginal deliveries, weight of largest infant delivered vaginally, menopause status, race, body mass index prior to pelvic surgery, and medical illnesses. The following four variables were selected in the regression analysis as predicting severe prolapse: age, weight of largest vaginal delivery, hysterectomy and previous prolapse surgery. Other variables that demonstrated statistically significant differences between groups by chi2 and two-sample t-tests were gravidity, parity, number of vaginal deliveries, menopausal status, race, history of incontinence surgery and the presence of hypertension. Variables that did not demonstrate any significant differences were body mass index, the presence of chronic obstructive pulmonous disease and diabetes mellitus. Advancing age, increasing weight of infants delivered vaginally, a history of hysterectomy and a history of previous prolapse surgery were found to be the strongest etiologic predictors of severe pelvic organ prolapse in our population.
Article
To estimate the frequency of obstetric anal sphincter laceration and to identify characteristics associated with this complication, including modifiable risk factors. A population-based, retrospective study of over 2 million vaginal deliveries at California hospitals was performed, using information from birth certificates and discharge summaries for 1992 through 1997. We excluded preterm births, stillbirths, breech deliveries, and multiple gestations. The main outcome measure was obstetric anal sphincter laceration (third and fourth degree). The frequency of anal sphincter lacerations was 5.85% (95% confidence interval [CI] 5.82, 5.88), decreasing significantly from 6.35% (95% CI 6.27, 6.43) in 1992 to 5.43% (95% CI 5.35, 5.51) in 1997 (P <.01). Using logistic regression analysis, we identified primiparity as the dominant risk factor (odds ratio [OR] for women with prior vaginal birth 0.15; 95% CI 0.14, 0.15). Birth weight over 4000 g was also highly significant (OR 2.17; 95% CI 2.07, 2.27). Lacerations occurred more often among women of certain racial and ethnic groups: Indian women (OR 2.5; 95% CI 2.23, 2.79) and Filipina women (OR 1.63; 95% CI 1.50, 1.77) were at highest risk. Episiotomy decreased the likelihood of third-degree lacerations (OR 0.81; 95% CI 0.78, 0.85), but increased the risk of fourth-degree lacerations (OR 1.12; 95% CI 1.05, 1.19). Operative delivery increased the risk of sphincter laceration, with vacuum delivery (OR 2.30; 95% CI 2.21, 2.40) presenting a greater risk than forceps delivery (OR 1.45; 95% CI 1.37, 1.52). Anal sphincter lacerations are strongly associated with primiparity, macrosomia, and operative vaginal delivery. Of the modifiable risk factors, operative vaginal delivery remains the dominant independent variable.
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Epidemiological studies have postulated racial differences in the incidence and prevalence of pelvic floor disorders. There are anecdotal data from cadaver dissections suggesting that Asian women benefit from stronger pelvic support structures. A prospective observational clinical study was conducted in order to test for differences in pelvic organ support in 200 nulliparous pregnant women. Assessment included translabial ultrasound, documenting the position of the pelvic organs and mobility on Valsalva relative to the inferoposterior symphyseal margin. The largest ethnic groups were Asian ( n=16) and Caucasian women ( n=161). On comparing the groups, both antepartum and postpartum analyses showed significantly less pelvic organ mobility in Asians. This was true for virtually all parameters of organ mobility and both anterior ( P=0.002 antepartum, P=0.009 postpartum) and posterior compartments ( P=0.04 antepartum, P=0.02 postpartum). No significant differences were detected for cervical mobility. It was concluded that Asian women seem to show less mobility of the anterior and posterior vaginal compartments than Caucasians.
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The purpose of this study was to determine dynamic pelvic floor and bony pelvis morphologic condition in asymptomatic multiethnic women. Pelvic floor anthropometry, at rest and after the Valsalva maneuver, and pelvimetry were compared with the use of magnetic resonance imaging in nulliparous young volunteers from 5 ethnic groups (n=11 x 5 volunteers: Emirati, other Arab, Filipino, Indian/Pakistani, and European/white volunteers), with the white volunteers as the reference group. The white volunteers were significantly taller (P <.0001) than the other women. Their levator hiatus was significantly longer than the Emirati women (P=.03) and wider than the Filipino women (P=.04). The bladder neck descent on straining was also significantly greater than the other groups (P <.00001). The white women also had the longest transverse diameter of the pelvic inlet (P=.002). Their sagittal outlet diameter was significantly longer than the Emirati and Arab women (P=.02), and their interspinous diameter was significantly longer than the Arab women (P=.002). Nulliparous, healthy white women have larger levator hiatus and bony pelvis with greater bladder neck descent on straining than non-white women.
Article
The purpose of this study was to determine whether differences existed on dynamometer recordings of muscle strength and electromyographic activity of the pelvic floor in 5 pregnant and 10 nonpregnant women. Pelvic-floor musculature strength measurements, using a perineometer, showed no significant differences between groups. All subjects could hold maximal voluntary contractions for three seconds, but pelvic-floor strength measurements decreased rapidly beyond three seconds. Integrated electromyographic recordings failed to show significant differences between groups. A periodicity of integrated electromyographic activity was observed in both pregnant and nonpregnant subjects. Great variability in the amount of integrated electromyographic activity was observed among both groups during maximal voluntary contractions. The practice of requesting that individuals with pelvic-floor dysfunction hold maximal voluntary contractions longer than three seconds may not be efficacious. Electromyographic measures must be complemented by strength measures for adequate evaluation and treatment of pelvic-floor dysfunction.
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To evaluate the prevalence and associated risk factors of lower urinary tract symptoms (LUTS). We randomly sampled 6066 women (3.0% of registered female residents aged 20 years and older in Fuzhou) and mailed Bristol Female Lower Urinary Tract Symptoms questionnaire to women for self-completion. 4684 (77.2%) women with evaluable data were included in this study. The prevalence of LUTS, voiding symptoms, storage symptoms was 39.7%, 13.4%, 37.3%, respectively. Among voiding symptoms, the prevalence of hesitancy, slow stream, intermittence, straining, terminal dribble, splitting was 6.8%, 5.5%, 4.8%, 4.5%, 4.1%, 3.5%, respectively. Among storage symptoms, stress incontinence, urge incontinence, urgency, frequency, nocturia, enuresis was 16.6%, 10.0%, 10.2%, 16.4%, 9.9%, 3.9%, respectively. A multiple logistic regression analysis showed menopause, parity > 2, constipation, fetal birthweight, and episiotomy were common potential risk factors for LUTS, voiding and storage symptoms. Higher BMI increased the occurrence of LUTS and storage symptoms, while cesarean delivery and labor protected against the development of storage symptoms. The prevalence of LUTS in Chinese women is lower than that of most reports in Occidental women. The prevalence of LUTS increases with age.
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To determine if variation exists between ethnicities for risk of perineal, vaginal, and cervical laceration at vaginal delivery. Retrospective cohort study of nulliparous women who underwent vaginal delivery of a vertex presentation. Predictor variable was ethnicity with outcome variables cervical, vaginal, and second-, third-, or fourth-degree perineal laceration. Logistic regression analysis was conducted to control for confounders. Of the 17,216 who met criteria, Filipino (OR = 1.92, 95% CI 1.64-2.25) and Chinese (OR = 1.60, 95% CI 1.33-1.92) women were at greatest risk for third- and fourth-degree laceration. Only Filipino (OR = 1.32, 95% CI 1.10-1.57) and other Asian (OR = 1.23, 95% CI 1.08-1.41) women were at slightly increased risk of vaginal laceration. No differences were seen for cervical laceration. Different ethnicities are at widely varying risk of perineal laceration, but little difference exists for vaginal or cervical lacerations. Research into the mechanisms behind this should investigate differences in perineal anatomy.
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To identify using three-dimensional (3D) ultrasound the morphological features and normal biometry of the levator hiatus in nulliparous Chinese women and to explore ethnic differences between these measurements and those in nulliparous Caucasian women. 3D sonographic data from 59 nulliparous Chinese women (aged 19-38 years) who had no pelvic organ prolapse and no symptoms of pelvic floor dysfunction were retrieved from an image dataset and analyzed by offline post-processing. The pubovisceral muscle and levator hiatus were measured in the planes of maximal pubovisceral muscle thickness and minimum hiatal dimension, respectively. In addition, the genitohiatal and levator ani angles were measured. These values were compared with those in a published study of Caucasian women. In Chinese women there was no relationship between minimum anteroposterior (AP) hiatal diameter and minimum lateral hiatal diameter. Body weight was correlated with hiatal area and minimum AP hiatal diameter (r = 0.391, P = 0.003 and r = 0.378, P = 0.004, respectively), whereas body mass index was correlated only with minimum AP hiatal diameter (r = 0.349, P = 0.008). There was a significant difference in average pubovisceral muscle thickness (P = 0.001) between nulliparous Chinese and Caucasian women. Body weight, body mass index, and ethnicity are factors affecting the biometry of the levator hiatus in Chinese nulliparous women.
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To summarize recent evidence suggesting a genetic basis for the development of urogenital prolapse and stress urinary incontinence. Epidemiological evidence suggests that some women have a genetic predisposition to the development of urogenital prolapse and stress incontinence. Abnormal expression of various structural proteins is thought to be the molecular genetic mechanism for the development of these conditions. A group of families with an autosomal dominant pattern of transmission of urogenital prolapse with high penetrance has been identified. No similar cohort of families with familial stress incontinence currently exists, although candidate genes have been identified that appear to predispose women to urogenital prolapse and stress incontinence. Additionally, animal models of urogenital prolapse have been developed that closely parallel the development of prolapse in humans. A growing body of evidence suggests a genetic basis for the development of urogenital prolapse and stress incontinence. Candidate genes have been identified that may result in alteration of the normal metabolism of various structural proteins which may ultimately predispose some women to both urogenital prolapse and stress incontinence. Further research into the genetic basis of these conditions may provide a comprehensive understanding of the biological basis of these disorders.
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To compare the prevalence of genital prolapse stratified by Asian American, black and white ethnic groups in women presenting for routine gynecologic examinations and to screen them for symptoms of pelvic floor problems. This was a descriptive study of women presenting for annual examinations. Demographic information on age, weight, gravidity, parity, weight of largest vaginally delivered infant, gynecologic surgery, medical problems (including hypertension, diabetes, pulmonary disease, smoking) and menopausal status were obtained from the patient and chart. Pelvic organ prolapse was assessed using the quantitative pelvic organ prolapse system. Subjects completed the Pelvic Floor Distress Inventory, which was graded along the 3 scales of Urinary Distress Inventory, Pelvic Organ Prolapse Distress Inventory and Colorectal-Anal Distress Inventory. One hundred sixty-seven women completed the study, including 73 whites, 60 Asian Americans and 34 blacks. The populations differed in that black women had higher body weight and were more likely to smoke, while white patients had lower parity and more use of hormone replacement therapy. Sixty-seven percent of Asian American patients had stage 2 or higher prolapse as compared to 26% of black and 28% of white patients. Multiple logistic regression showed that Asian American ethnicity independently correlated with higher rates of pelvic organ prolapse. There was no difference in survey results by race. There may be significant racial differences in the incidence of pelvic floor prolapse, with higher rates of stage 2 prolapse in asymptomatic Asian American women.
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We have previously reported preliminary (9 month) results using the tissue fixation system (TFS) in patients with stress incontinence. The aim of the study was to assess the effectiveness of the TFS in patients with genuine stress incontinence at 3 years. The TFS uses two small plastic anchors to fix a (adjustable) midurethral polypropylene mesh sling into the pelvic muscles and tissues below the retropubic space. Thirty-six patients with stress incontinence, mean age 55 (35-87), mean weight 76 kg, (33-117 kg), mean 0.8 previous operations for stress incontinence, underwent a TFS midurethral sling operation between 2003 and 2004. The suburethral vaginal fascia was also tightened. The patients were contacted by telephone independently by a nurse. The critical question was "Do you leak when you cough?" A negative answer was taken as a cure. If she said "sometimes", she was asked on a scale of 1 to 100 what her improvement was. Of the 31 patients contacted, total symptomatic cure was reported by 25 patients (80%) and > 70% cure in a further two patients (6.5%). Five patients could not be contacted. There was a slight deterioration in cure rate for stress incontinence between 9 months and 3 years, similar to that seen with retropubic midurethral sling surgery.
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This manuscript compares the efficacy and safety of duloxetine with placebo in Taiwanese women with SUI. Taiwanese women with SUI were were randomly assigned to placebo (n = 61) or duloxetine 80 mg/day (n = 60) in this double-blind, 8-week, placebo-controlled study. Outcome variables included: incontinence episode frequency (IEF), Incontinence Quality of Life questionnaire (I-QOL) scores, and Patient Global Impression of Improvement rating (PGI-I). Decrease in IEF was significantly greater in duloxetine-treated than placebo-treated women (69.98% vs 42.56%, P < .001). No treatment differences in I-QOL scores were significant. There were significant differences in PGI-I rating. Treatment-emergent adverse events (TEAEs) were experienced by more duloxetine-treated than placebo-treated women (80.0% vs 44.3%; P < .001). Discontinuations due to adverse events were significantly greater for duloxetine-treated than placebo-treated women (26.7% vs 6.6%; P = .003). Data provide evidence for the safety and efficacy of duloxetine for the treatment for Taiwanese women with SUI. ClinicalTrials.gov Identifier: NCT00475358.
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The epidemiology of urinary dysfunction in a Chinese population living in Hong Kong was investigated. Fifteen hundred ethnic Chinese women answered a telephone questionnaire including symptoms of urinary dysfunction, anthropometric measurements, obstetric history and place of birth. The relative predictive value of these factors was analyzed using logistic regression. The prevalence of urinary dysfunction was 13%. Ten percent reported stress incontinence, and 4% had urgency or urge incontinence. The strongest predictor was place of birth, with women born in mainland China having the highest prevalence of pure stress incontinence (OR 1.33, CI 1.1-1.6). For the symptoms of detrusor instability age was the strongest predictor, with women over 50 years being at greater risk (OR 2.8, CI 1.6-5.0). Contrary to earlier beliefs, urinary dysfunction in Chinese women is as common as in Caucasian women. Place of birth is the strongest predictor for pure stress incontinence, with women born in mainland China being at greater risk. This suggests that environmental factors in early life have a differential effect on the development of urinary incontinence.
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To determine whether resting activity of the pelvic floor muscles (PFMs) and abdominal muscles varied in different sitting postures in parous women with and without stress urinary incontinence (SUI). PFM and abdominal muscle activity was recorded in 3 sitting postures: slump supported, upright unsupported, and very tall unsupported. Spinal curves were measured in slump supported and upright unsupported. A research laboratory. Women (N=17) with a history of vaginal delivery, 8 who were symptomatic of SUI and 9 who were asymptomatic. Not applicable. Electromyographic activity of (1) the resting PFM recorded per vaginam with surface electrodes and (2) superficial abdominal muscles using surface electrodes. Changes in spinal curves were measured with a flexible ruler. Electromyographic activity of the PFM increased significantly from slump supported to upright unsupported postures in both groups (P<.001) but with lower levels of activity in women with SUI (P<.05). PFM activity increased further in very tall unsupported sitting in comparison with slump supported sitting (P<.001). Obliquus internus abdominis electromyographic activity was greater in upright unsupported than in slump supported sitting (P<.05), and electromyographic activity of other abdominal muscles was greater in very tall unsupported than slump supported. Women with SUI had a trend for greater activity in the abdominal muscles in upright unsupported than asymptomatic women. Asymptomatic women had a greater depth of lumbar lordosis in upright unsupported sitting than women with SUI (P=.04). More upright sitting postures recruit greater PFM resting activity irrespective of continence status. Further investigation should consider the effect of sitting posture in rehabilitation.
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Female pelvic organ prolapse is a common condition that is said to be multifactorial in aetiology. While a number of risk factors such as vaginal childbirth, obesity and ageing are commonly accepted, it is not clear as to how these risk factors affect the development of prolapse-that is, which pathophysiologic mechanisms are responsible for disease manifestation. Measures used in epidemiological studies, such as presentation for surgical treatment, are generally confounded by other conditions, and evidence is lacking for some of the most frequently quoted aetiological factors. In this paper, I will try to summarise the available evidence in order to separate hearsay and hypothesis from available research findings and to suggest a way forward for diagnosis and treatment.
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Pelvic organ prolapse carries a significant social burden. The disease negatively affects the quality of life of afflicted patients and involves significant health care costs that are expected to increase over the next three decades. Socioeconomic and demographic factors are associated with the development of pelvic organ prolapse, but a growing body of evidence also suggests that genetic factors are involved in the development of the disease. This review summarizes the current understanding of the epidemiology, social burden, and genetics of pelvic organ prolapse.
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Objective: There seems to be substantial variation in the prevalence of pelvic floor disorders between different ethnic groups. This may be due partially to differences in pelvic floor structure and functional anatomy. To date, data on this issue are sparse. The aim of this study was to compare hiatal dimensions, pelvic organ descent and levator biometry in young, healthy nulliparous Caucasian and African women. Methods: Healthy nulliparous non-pregnant volunteers attending a local nursing school in Uganda were invited to participate in this study during two fistula camps. All volunteers underwent a simple physician-administered questionnaire and a four-dimensional translabial ultrasound examination. Offline analysis was performed to assess hiatal dimensions, pelvic organ descent, levator muscle thickness and area. To compare findings with those obtained in nulliparous non-pregnant Caucasians, we retrieved the three-dimensional/four-dimensional ultrasound volume datasets of a previously published study. Results: The dataset of 76 Ugandan and 49 Caucasian women was analyzed. The two groups were not matched but they were comparable in age and body mass index. All measurements of hiatal dimensions and pelvic organ descent were significantly higher among the Ugandans (all P ≤ 0.01); however, muscle thickness and area were not significantly different between the two groups. Conclusions: Substantial differences between Caucasian and Ugandan non-pregnant nulliparae were identified in this study comparing functional pelvic floor anatomy. It appears likely that these differences in functional anatomy are at least partly genetic in nature. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
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Pelvic organ prolapse (POP) is a common highly disabling disorder with a large hereditary component. It is characterized by a loss of pelvic floor support that leads to the herniation of the uterus in or outside the vagina. Genome-wide linkage studies have shown an evidence of POP association with the region 9q21 and six other loci in European pedigrees. The aim of our study was to test the above associations in a case-control study in Russian population. Twelve SNPs including SNPs cited in the above studies and those selected using the RegulomeDB annotations for the region 9q21 were genotyped in 210 patients with POP (stages III-IV) and 292 controls with no even minimal POP. Genotyping was performed using the polymerase chain reaction with confronting two-pair primers (PCR-CTPP). Association analyses were conducted for individual SNPs, 9q21 haplotypes, and SNP-SNP interactions. SNP rs12237222 with the highest RegulomeDB score 1a appeared to be the key SNP in haplotypes associated with POP. Other RegulomeDB Category 1 SNPs, rs12551710 and rs2236479 (scores 1d and 1f, resp.), exhibited epistatic effects. In this study, we verified the region 9q21 association with POP in Russians, using RegulomeDB annotations.
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Objective To compare the differences in levator ani muscle biometry and hiatal dimensions between pregnant nulliparous Caucasian and East Asian women.Methods Offline analysis of three/four-dimensional ultrasound volume data obtained from two groups of pregnant nulliparous women, Caucasian and East Asian, was performed. Volume acquisition was performed in the late third trimester using the same method in both groups, in the context of two prospective observational studies with identical entry criteria. Pelvic organ descent and levator hiatal dimensions were assessed using the volumes acquired on Valsalva maneuver, and pubovisceral muscle thickness was measured from the volumes obtained on pelvic floor muscle contraction (PFMC).ResultsDatasets of 200 East Asian and 168 Caucasian women were analyzed. Compared with Caucasian women, East Asian women had a significantly lower body mass index. All indices of pelvic organ descent were significantly higher in the Caucasian group than in the East Asian group. The difference, expressed as a percentage, in levator hiatal area on both Valsalva maneuver and PFMC was markedly greater in Caucasian (32% vs 19%; P < 0.001) than in East Asian (24% vs 20%; P = 0.01) women. After controlling for potential confounders using multivariate regression analysis, racial origin remained the only significant factor associated with differences in pelvic organ descent and hiatal dimensions. The thickness and area of pubovisceral muscle were significantly higher in the East Asian group.Conclusions Pregnant women of East Asian racial origin have a thicker pubovisceral muscle, smaller hiatus and less mobility of pelvic organs than do pregnant Caucasian women.
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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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To evaluate the pelvic floor biometry in Chinese women one year following childbirth and to explore the factors affecting it. Translabial ultrasound was performed at rest, at valsalva (VM) and at pelvic floor muscle contraction (PFMC) at first, second and third trimester and 8 weeks, 6 months and 12 months after delivery in a cohort of primiparous women. Offline analysis was performed to measure the position of bladder neck, cervix, ano-rectal junction and hiatal dimensions at each posture and at each visit; and to detect levator ani muscle (LAM) injury at PFMC 8 weeks and 12 months after delivery. 442 women were recruited and 328 (74.2%) completed the study. 48 women had LAM injury at 8 weeks, and only 38 women had LAM injury by 12 months. When comparing results between the first trimester and 12 months after delivery, the bladder neck was more distal at VM, bladder neck displacement was increased and cervix was lower at rest and at VM in vaginal delivery (VD) group. In Cesarean section (CS) group, bladder neck and ano-rectal junction were more distal at VM only; cervix was lower at rest, VM and PFMC; hiatal area was increased at rest and VM. There was a greater increase in hiatal area after VD. Overall, 34.6% had irreversible hiatal distension (>20% increase in hiatal area after delivery when compared with first trimester). LAM injury increased this risk (odds ratios 5.2-9.3 at different postures). Pregnancy beyond 35 weeks of gestation has an effect on women's pelvic floor, irrespective of the mode of delivery. The pelvic organs remain more mobile after delivery; but there is no difference between VD or CS, except in hiatal distension, which is greater after VD. LAM injury was the most important cause of irreversible hiatal distension.
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This paper constitutes a brief review of the physiological progress in female urethrovesical function which has occurred since the early 1950s. Special emphasis has been placed upon stress urinary incontinence. While progress has been made, the whole subject of female urethrovesical function needs to be re-explored with studies performed on adult females and not inferred from studies done upon adult males.
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Global management of pelvic floor disorders : towards pelvic perineology. Pelvic floor disorders involve the three components of the pelvic floor : urologic, gynaecologic and coloproctologic. They are often associated because of their common embryology, anatomy and phy- siopathology. Pelvic floor disorders result from : - a change in the abdominal forces : increase, change in the orienta- tion ; - an anomaly of the pelvic viscera in the morphology and/or their location and relationship ; - a degradation of the supporting connective tissue. The disorders can be secondary to pregnancy, delivery, old age, hormonal deficiency or any increase in abdominal pressure such as in chronic straining during defecation, sport or cough and finally following perineal or pelvic surgery. Thus, in 18 % of patients presenting a pelvic floor disorder, all three levels are concerned : 7 % of patients with genital prolapse and between 19 % and 31 % of patients presenting urinary incontinence have fecal incontinence. Finally, 38 % of urinary incontinent pa- tients have associated genital prolapse. All surgeons, urologist, gynaecologist and coloprocologist dealing with pelvic floor disorders have to take into consideration that the management of one of the levels will probably have an impact on another level and that consequently a global approach to pelvic statics disorders is necessary. For these reasons it seems logical to gather pelvis and perineum on one side, and the different levels of the pelvic floor on the other side, in one single discipline : pelvic perineology.
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Background: Women suffering from urinary incontinence have impaired quality of life (QoL). Pelvic floor muscle training (PFMT) has been recommended to be the first-line treatment for them. Aims: This study evaluated the role of (PFMT) in women with urinary incontinence. Materials and methods: All women suffering from urinary incontinence without pelvic organ prolapse who attended the urogynaecology unit of a university hospital from January 2009 to June 2010 were recruited. Urinary symptoms and impact on QoL were assessed using the Chinese validated Urogenital Distress Inventory short form (UDI-6) and Incontinence Impact Questionnaire short form (IIQ-7) before and after PFMT. Urodynamic studies (UDS) were used to differentiate the diagnoses of urinary incontinence. Results: Three hundred and seventy-two women, aged 52.3 ± 10.8 years and practised PFMT for 9.9 ± 7.3 months, completed the study. Over 65% recorded improvement in both UDI-6 and IIQ-7. Stratified for urodynamic diagnosis, stress incontinence group and those who had no UDS abnormality had significant improvement in their urinary symptoms and QoL after PFMT. UDI-6 and IIQ-7 also improved significantly after PFMT in groups where the clinical presentation was stress incontinence, overactive bladder symptoms or mixed urinary incontinence. Age was not associated with a significant difference in the response to PFMT. Conclusions: Pelvic floor muscle training appears to be an effective first-line intervention for improving urinary symptoms and QoL of women presenting with urinary incontinence. Future studies on long-term effectiveness and cost-effectiveness are also required.
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Introduction and hypothesis: This study evaluated factors and their prevalence associated with urinary (UI) and fecal (FI) incontinence during and after a woman's first pregnancy. Methods: Nulliparous Chinese women with no UI or FI before pregnancy were studied with a standardized questionnaire for UI and FI from early pregnancy until 12 months after childbirth. Maternal characteristics and obstetric data were analyzed using descriptive analysis, independent sample t test, chi-square test, and logistic regression. Results: Three hundred and twenty-eight (74.2 %) women completed the study. The prevalence of antenatal UI increased with gestation. Overall, 192 (58.5 %), 60 (18.3 %), and 76 (23.1 %) had normal vaginal delivery, instrumental delivery, and cesarean section, respectively. Twelve months after delivery, prevalence of stress urinary incontinence (SUI) and urge urinary incontinence (UUI) was 25.9 % [95 % confidence interval (CI) 21.5-30.6] and 8.2 % (95 % CI 5.2-11.2), respectively. In those who delivered vaginally, the prevalence was 29.7 % and 9.1 %, respectively. Prevalence of FI was 4.0 % (95 % CI 1.9-6.1). On logistic regression, vaginal delivery [odds ratio (OR) 3.6], antenatal SUI (OR 2.8), and UUI (OR 2.4) were associated with SUI. Antenatal UUI (OR 6.4) and increasing maternal body mass index (BMI) at the first trimester (OR 1.2) were associated with UUI. Antenatal FI was associated with FI (OR 6.1). Conclusions: The prevalence of SUI, UUI, and FI were 25.9 %, 8.2 %, and 4.0 %, respectively, 12 months after delivery. Vaginal delivery, antenatal SUI, and UUI were associated with SUI; antenatal UUI and increasing maternal BMI at the first trimester were associated with UUI. Antenatal FI was associated with FI. Pregnancy, regardless of route of delivery and obstetric practice, had an effect on UI and FI.
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EDITORIAL COMMENT: A large prolapse of the uterus and vagina (often called a procidentia, although strictly speaking this term refers to any prolapse) may be associated with urgency, frequency, difficulty in passing urine, no urinary symptoms at all, or as in this patient with anuria and acute obstructive renal failure. Women with longstanding prolapses that have not been reduced and which rarely are irreducible, often have hydronephrosis and chronic renal failure. However it is exceedingly uncommon for a prolapse to be associated with anuria as occurred in this patient. The Editor has experience of an elderly patient admitted to the Austin Hospital, Melbourne, 32 years ago who was thought to be demented and who died shortly after admission. At autopsy she was found to have a large uterovaginal prolapse and hydronephrosis, the cause of death apparently being renal failure. A similar case was also reported in a letter in the BMJ approximately 30 years ago. These cases are rare but make the point that a patient who has a uterovaginal prolapse should have the mass replaced and her renal function assessed prior to the anticipated surgery. Usually it is possible to operate on such a patient within 4 or 5 days even when there has been gross ulceration of the cervix and posterior vagina which normally heals rapidly when the uterus and prolapsed vaginal walls (cystocele, enterocele ± rectocele) are reduced and the vagina packed with gauze soaked in oestrogen cream. When a prolapse is large, the bladder can be outside the body with kinking of the ureters, and passage of ureteric catheters may be impossible because of this. Reduction of the prolapse will relieve this obstruction of the ureters, and so lead to improvement in renal function. (See Illustrated Textbook of Gynaecology. Eric VMackay et al. Figures 23.10 and 23.11, pages 344 and 345).
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To assess the prevalence of levator ani muscle injury in Chinese women after their first delivery and investigate associated factors. A prospective observational study was conducted involving Chinese nulliparous women recruited in the first trimester of pregnancy. Translabial ultrasound was performed at 35-38 weeks' gestation and 8 weeks postpartum and three-dimensional volume datasets were obtained. Offline analysis to detect levator ani muscle injury was performed by investigators blinded to the delivery details. 339 women, with a mean age of 30.6 ± 3.9 years, completed the study. Overall, 201 (59.3%) had a spontaneous vaginal delivery, 62 (18.3%) an operative vaginal delivery (48 ventouse extraction and 14 forceps delivery), 14 (4.1%) an elective Cesarean section and 62 (18.3%) an emergency Cesarean section. No levator ani muscle injury was detected in any woman antenatally. After vaginal delivery, 57 (21.7% (95% CI, 16.7-26.7%)) women had levator ani muscle injury. The rates of injury for spontaneous vaginal delivery, ventouse extraction and forceps delivery were 15.4%, 33.3% and 71.4%, respectively. There was no levator ani muscle injury in the Cesarean section groups. Logistic regression analysis showed that only operative vaginal delivery (odds ratio, 3.09) was associated with an independent increase in the likelihood of levator ani muscle injury. Intrapartum epidural analgesics, duration of second stage of labor and infant birth weight were not independently associated with levator ani muscle injury. The prevalence of levator ani muscle injury in Chinese women after their first vaginal delivery was 21.7% (95% CI, 16.7-26.7%). Operative vaginal delivery was found to increase the likelihood of women suffering such injury. A longer follow-up of these women and future studies on the effects of episiotomy are proposed.
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The purpose of this study was to investigate the reliability and validity of the Chinese version of Pelvic Floor Distress Inventory (PFDI) and Pelvic Floor Impact Questionnaire (PFIQ). Women who presented for pelvic floor disorders completed the Chinese version of PFDI and PFIQ, SF-36, a 3-day urinary and fecal diary. POP-Q assessment, urodynamic study, anal manometry, and ultrasound were performed where appropriate. Five hundred and ninety-seven women completed the study. The Cronbach's alpha and test-retest reliability of PFDI and PFIQ was 0.92 and 0.98, and 0.77 and 0.79, respectively. Convergent validity was demonstrated with negative correlation of PFDI and PFIQ with SF-36; positive correlation of staging of prolapse, urinary or fecal incontinent episodes with the respective subscales of PFDI and PFIQ. The Chinese version of PFDI and PFIQ are reliable and valid condition-specific health-related quality of life questionnaires for women with pelvic floor disorders.
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The normal pelvic floor functions as a balanced synergistic system composed of muscle, connective tissue (CT), and nerve components, with CT being the most vulnerable. The aim was to address a wide range of pelvic floor dysfunctions by strengthening all possible components of the system with minimal time loss, weaving every element of treatment seamlessly into a daily routine. The study group consisted of patients from a tertiary referral pelvic floor clinic who, after testing, opted for nonsurgical treatment of their problem. There were no exclusion criteria. The patients had presented with symptoms which included stress, urge, frequency, nocturia, abnormal emptying and pelvic pain, and the fate of these was tracked prospectively. The regime comprised four visits in 3 months. An anatomical classification guided diagnosis of anatomical defects in the anterior, middle and posterior compartments of the vagina. HRT was administered to all patients, electrotherapy 20 min per day for 4 weeks, squeezing 3 x 12 per day, reverse pushdowns 3 x 12 per day and squatting or equivalent up to 20 min per day. Of 147 patients (mean age 52.5 years), 53% completed the programme. Median QOL improvement reported was 66%, mean cough stress test urine loss reduced from 2.2 g (range 0-20.3 g) to 0.2 g (range 0-1.4 g), p =<0.005, and 24-h pad loss from a mean of 3.7 g (range 0-21.8 g) to a mean of 0.76 g (range 0-9.3 m), p =<0.005. Frequency, nocturia and pelvic pain were significantly improved ( p=<0.005). Residual urine reduced from mean 202 ml to mean 71 ml ( p=<0.005). This method extends indications for nonsurgical therapy beyond stress incontinence, and the results appear to encourage this approach. Confirmation by other investigators is required.