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Objective: The levator hiatus defines the 'hernial portal' through which female pelvic organ prolapse develops. Hiatal area may therefore be an independent etiological factor for this condition. In this retrospective study we defined 'normality' for hiatal area by assessing its relationship with symptoms and clinical signs of prolapse., Methods: Datasets of 544 women seen in a tertiary urogynecological unit were assessed. Patients had undergone an interview, clinical examination and three-/four-dimensional (3D/4D) pelvic floor ultrasound imaging. All analysis was performed off-line, blinded against clinical data., Results: Information on prolapse symptoms was available for 538 women and 171 (32%) of these complained of such symptoms. There was a strong statistical relationship between hiatal dimensions, both at rest and on Valsalva maneuver, and prolapse symptoms (all P < 0.001). Receiver-operating characteristics (ROC) curve analysis yielded an area under the curve of 0.65 (95% CI, 0.60-0.70) for hiatal area at rest and 0.71 (95% CI, 0.66-0.76) for hiatal area on Valsalva. Cut-offs of 25 and 30 cm(2) on Valsalva gave sensitivities of 0.55 and 0.34 and specificities of 0.77 and 0.86, respectively, for detecting symptomatic prolapse. Similar values were obtained when significant prolapse (Grade 2 or higher) was used as the state variable., Conclusions: Levator hiatal area as measured by 3D translabial pelvic floor ultrasound examination is strongly associated with symptoms and clinical signs of prolapse. Based on the ROC curves that we obtained, we suggest that a hiatal area of > 25 cm(2) on Valsalva be defined as abnormal distensibility or 'ballooning' of the levator hiatus.

Objectives: Defecation proctography is the standard method used in the investigation of obstructed defecation. Translabial ultrasound has recently been shown to demonstrate rectocele, enterocele and rectal intussusception. We performed a comparative clinical study to determine agreement between the two methods., Methods: Thirty-seven women scheduled to undergo defecation proctography for obstructed defecation were recruited. Using both proctography and translabial ultrasound, we determined the anorectal angle, presence of a rectocele and rectocele depth, rectal intussusception and prolapse. Measurements were obtained by operators blinded to all other data. All patients rated discomfort on a scale of 0-10., Results: Six women did not attend defecation proctography, leaving 31 cases for comparison. The mean age was 53 years. Patients rated discomfort at a median of 1 (range 0-10) for ultrasound and 7 (range 0-10) for defecation proctography (P < 0.001). Defecation proctography suggested rectocele and rectal intussusception/prolapse more frequently than did ultrasound. While the positive predictive value of ultrasound (considering defecation proctography to be the definitive test) was 0.82 for rectocele and 0.88 for intussusception/prolapse, negative predictive values were only 0.43 and 0.27, respectively. Cohen's kappa values were 0.26 and 0.09, respectively. There was poor agreement between ultrasound and defecation proctography measurements of anorectal angle and rectocele depth., Conclusions: Translabial ultrasound can be used in the initial investigation of defecatory disorders. It is better tolerated than defecation proctography and also yields information on the lower urinary tract, pelvic organ prolapse and levator ani. Agreement between ultrasound and defecation proctography in the measurement of quantitative parameters was poor, but when intussusception or rectocele was diagnosed on ultrasound these results were highly predictive of findings on defecation proctography., (Copyright (c) 2008 ISUOG)

Objectives: The investigation of female pelvic floor biomechanics is attracting attention due to its importance in pelvic floor dysfunction and childbirth. To date, there are no established means of assessing pelvic floor elasticity. We propose the use of translabial ultrasound to estimate strain, one element of pubovisceral muscle elasticity., Methods: Ultrasound datasets of 98 women seen at a tertiary urogynecology clinic were reviewed using proprietary software. Data were processed to estimate muscle fiber strain during Valsalva and contraction by measuring hiatal circumference and deducting bony arc length. Clinical assessment included levator palpation during maximal contraction (modified Oxford grading scale) and at rest, with tone recorded on a new six-point scale. Analysis of imaging data was performed without knowledge of clinical data., Results: Mean age was 52.2 (range, 19-87) years and mean parity was 2.4 (range, 0-8). Mean (SD) hiatal area during contraction, rest and Valsalva was 15.4 (3.8) cm(2), 18.9 (5.0) cm(2) and 27.3 (8.9) cm(2), respectively. There was a moderate association between strain during contraction and Oxford grade (r = 0.439, P < 0.0001), and a weak but significant association between strain during Valsalva and resting tone (r = - 0.224, P = 0.033)., Conclusions: Translabial ultrasound can be used to measure strain, a component of pubovisceral muscle elasticity, and we have validated the technique against clinical assessment. Pubovisceral strain during contraction correlates positively with Oxford grade. Pubovisceral strain during Valsalva correlates negatively with resting tone grade. This new non-invasive ultrasound technique may be of value for assessing patients with pelvic floor dysfunction., (Copyright (c) 2008 ISUOG. Published by John Wiley & Sons, Ltd.)

Objective: Until recently, magnetic resonance was the only imaging method capable of assessing the levator ani in vivo. Three-dimensional (3D) ultrasound has recently been shown to be able to demonstrate the pubovisceral muscle. The aim of this study was to define the anatomy of the levator hiatus in young nulliparous women with the help of 3D ultrasound., Methods: In a prospective observational study, 52 nulligravid female Caucasian volunteers (aged 18-24 years) were assessed by two-dimensional (2D) and 3D translabial ultrasound after voiding whilst supine. Pelvic organ descent was assessed on Valsalva maneuver. Volumes were acquired at rest and on Valsalva maneuver, and biometric indices of the pubovisceral muscle and levator hiatus were determined in the axial and coronal planes., Results: In the axial plane, average diameters of the pubovisceral muscle were 0.4-1.1 cm (mean 0.73 cm). Average area measurements were 7.59 (range, 3.96-11.9) cm2. The levator hiatus at rest varied from 3.26 to 5.84 (mean 4.5) cm in the sagittal direction, and from 2.76 to 4.8 (mean 3.75) cm in the coronal plane. The hiatus area at rest ranged from 6.34 to 18.06 (mean 11.25) cm2 increasing to 14.05 (6.67-35.01) cm(2) on Valsalva maneuver (P = 0.009). There were significant correlations between pelvic organ mobility and hiatus area at rest (P = 0.018 to P < 0.001) and on Valsalva maneuver (all P < 0.001)., Conclusions: Biometric indices of the pubovisceral muscle and levator hiatus can be determined by 3D ultrasound. Significant correlations exist between hiatal area and pelvic organ descent. These data provide support for the hypothesis that levator ani anatomy plays an independent role in determining pelvic organ support., (Copyright 2005 ISUOG)