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Objectives: To assess the evolution of levator ani muscle (LAM) avulsion from 1 year to 8 years after first delivery in women with and those without subsequent vaginal delivery. In addition, to assess whether women with full or partial avulsion 8 years after first delivery have larger LAM hiatal area and more symptoms of pelvic organ prolapse compared to women with normal LAM insertion., Methods: In this single-center longitudinal study, 195 women who were primiparous at the start of the study were included and underwent transperineal ultrasound examination 1 year and 8 years after first delivery. Muscle insertion was assessed by tomographic ultrasound imaging in the axial plane. Full LAM avulsion was defined as abnormal muscle insertion in all three central slices. Partial LAM avulsion was defined as abnormal muscle insertion in one or two central slices. Eight years after the first delivery, LAM hiatal area was assessed at rest, during maximum pelvic floor muscle contraction and on maximum Valsalva maneuver. To assess symptoms of pelvic organ prolapse, the vaginal symptoms module of the International Consultation on Incontinence Questionnaire was used., Results: At 1-year follow-up, 25 (12.8%) women showed signs of LAM avulsion, of whom 20 fulfilled the sonographic criteria of full avulsion and five of partial avulsion. Eight years after the first delivery, 35 (17.9%) women were diagnosed with avulsion, of whom 25 were diagnosed with full avulsion and 10 with partial avulsion. No woman with partial or full avulsion at 1 year had improved avulsion status at 8-year follow-up. Of the 150 women who had subsequent vaginal delivery, 21 (14.0%) women were diagnosed with partial or full LAM avulsion 1 year after first delivery, and 31 (20.7%) women were diagnosed with partial or full avulsion 8 years after first delivery. Of the 45 women without subsequent vaginal delivery, one woman with partial avulsion 1 year after first delivery was diagnosed with full avulsion at 8-year follow-up. All women with full avulsion at 1-year follow-up were diagnosed with full avulsion at 8-year follow-up regardless of whether they had subsequent vaginal delivery. At 8-year follow-up, women with full avulsion had statistically significantly larger LAM hiatal area compared to women with normal muscle insertion. Mean ± SD vaginal symptom scores ranged between 5.5 ± 5.7 and 6.0 ± 4.0 and vaginal symptom quality of life scores ranged between 0.9 ± 1.4 and 1.5 ± 2.2 and did not differ significantly between women with normal muscle insertion and women with partial or full avulsion at 8-year follow-up., Conclusions: More LAM avulsions were present 8 years compared with 1 year after first delivery in women with subsequent vaginal delivery. Except for one primipara, all women without subsequent vaginal delivery had unchanged LAM avulsion status between 1 year and 8 years after their first delivery. Larger LAM hiatal area was found in women with full avulsion compared to those with normal muscle insertion at 8-year follow-up. Vaginal symptoms scores were low and did not differ between women with normal muscle insertion and those with partial or full avulsion at 8-year follow-up. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology., (© 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.)

Objectives: Women have a 11% lifetime risk of undergoing surgery for vaginal prolapse. Levator ani muscle (LAM) avulsion is one etiological factor associated with primary and recurrent pelvic organ prolapse. Pelvic organ prolapse has been shown to greatly affect the quality of life and well-being of women. Conduct a meta-analysis identifying risk factors associated with LAM avulsion recognised on transperineal ultrasound (TPUS) or magnetic resonance imaging (MRI) in primiparous women after vaginal birth., Study Design: OVID Medline, Embase and the Cochrane Library from inception to January 2021 were searched. Review Manager 5.3 (The Cochrane Collaboration) was used to analyse data. Odds ratios (OR) with 95% confidence intervals (95% CIs) were calculated. The heterogeneity among studies was calculated using the I 2 statistic., Results: Twenty-five studies were eligible for inclusion (n = 9333 women). Major LAM avulsion was diagnosed in an average of 22 % (range 12.7-39.5 %) of cases. Twenty-two studies used TPUS and three used MRI to diagnose avulsion. Modifiable and non-modifiable risk factors were identified. Significant predictors identified were forceps (OR 6.25 [4.33 - 9.0]), obstetric anal sphincter injuries (OR 3.93 [2.85-5.42]), vacuum (OR 2.41 [1.40-4.16]), and maternal age (OR 1.06 [1.02-1.10])., Conclusions: This is the first meta-analysis of both modifiable and non-modifiable risk factors associated with LAM avulsion. This information could be used to develop a clinically applicable risk prediction model to target postnatal women at risk of LAM avulsion with a view to prevent the onset of pelvic floor organ prolapse., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Pelvic organ prolapse (POP) is a common diagnosis with an incidence in the population of up to 50%. POP causes restrictions in everyday life and reduces patients' quality of life. Therapy is either conservative in the form of physiotherapy or the use of different types of pessaries, possibly. in case of inappropriateness or failure of conservative treatment, an operative solution is chosen. Avulsion injury of the levator ani muscle (MLA) is a strong factor in the development of POP. Some patients undergo repeated surgeries for POP, negatively impacting their quality of life. Studies show that the stage of POP and avulsion injury is associated with an increased risk of recurrence after index prolapse surgery. Ultrasound diagnosis of MLA injuries might help in predicting the risk of recurrence. Assessment of pelvic floor function is crucial for the success of surgical management of POP.

Introduction: Pelvic floor trauma in the form of partial or complete avulsions of the levator ani muscle (LAM) affects 6-42% of women after vaginal birth and can cause tremendous long-term morbidity. Many studies assessed morphological pelvic floor trauma after childbirth but lacked to evaluate women's associated short-term complaints. A proper assessment of trauma and subjective complaints after birth could help to assess possible associations between them and their relevance to women's daily life. Therefore, we aimed to assess women's complaints within the first months after birth in association to their LAM trauma., Materials and Methods: Between 3/2017 and 4/2019, we prospectively evaluated vaginal births of 212 primiparous women with singletons in vertex presentation ≥ 36 + 0 gestational weeks for levator ani muscle (LAM) trauma by translabial ultrasound, for pelvic organ prolapse by clinical examination, and for urogynecological complaints using questionnaires 1-4 days (P1), 6-10 weeks (P2), and 6-9 months (P3) after birth. The questionnaires were self-designed but oriented to and modified from validated questionnaires. Women's complaints were evaluated for P1-P3 according to their LAM trauma state., Results: At P1, 67% of women showed an intact LAM, whereas 14.6% presented a hematoma, 6.6% a partial avulsion (PAV), and 11.8% a complete avulsion (CAV). At P2, 75.9% showed an intact LAM, 9.9% a PAV, and 14.2% a CAV. At P3, 72.9% of women with a LAM trauma in P1 and/or P2 were assessed with 21.6% being intact and 39.2% having a PAV and CAV, respectively. Obstetrical and baseline characteristics differed slightly between the groups. When comparing the time before and during pregnancy with the time after childbirth, birth itself affected women's complaints in all LAM state groups, but the presence of a LAM trauma, especially a CAV, had more negative effects., Conclusions: Vaginal birth changes the anatomical structure of the maternal birth canal and genital tract, and it alters women's perceptions and body function. In our study, LAM trauma did not change these effects tremendously within the first months. Therefore, other maternal, fetal, and obstetrical factors need consideration for the explanation of maternal complaints, in addition to long-term effects of trauma and dysfunction of the LAM and other birth canal structures., Competing Interests: The authors declare that they have no competing interests., (Copyright © 2022 N. Kimmich et al.)

Objectives: Women working in the medical field may be at risk for pelvic floor dysfunction due to high physical activity levels leading to increased abdominal pressure; however, the actual situation remains unknown. This study aimed to clarify the prevalence of symptoms of pelvic floor dysfunction and its associated factors among Japanese women working in the medical field., Methods: A cross-sectional study was conducted among female employees at a public hospital in Japan from July to August 2020. Participants answered a web-based questionnaire. Three types of symptoms related to pelvic floor dysfunction were assessed based on one or more subscale scores in the Pelvic Floor Distress Inventory-Short Form 20 (PFDI-20)., Results: Out of 466 female employees in the hospital, 294 responded (response rate 63.1%). The mean age was 42.8 ± 10.3 years old and 221 (73.5%) were nurses. The prevalence of at least one type of symptom was 63.9%. The prevalence of recto-anal symptoms (45.9%) was highest, followed by lower urinary tract (37.1%) and pelvic organ prolapse symptoms (22.8%). The total PFDI-20 score was associated with constipation (β = .254), body mass index (β = .136), and part-time work (β = .167) after adjusting for other variables., Conclusion: This study showed a high prevalence of symptoms related to pelvic floor dysfunction among women working in the medical field. Lifestyle management to prevent constipation and obesity is a promising strategy to improve symptoms of pelvic floor dysfunction., (© 2022 John Wiley & Sons Australia, Ltd.)

Introduction and Hypothesis: Labor is a known risk factor for pelvic floor dysfunction (PFD); however, the impact of operative vaginal delivery (OVD), particularly spatulas, remains unclear. The aim of this study was to compare postpartum PFD symptoms in women undergoing spontaneous vaginal delivery (SVD) and those undergoing OVD., Methods: An observational prospective study (MOODS: Maternal-neonatal Outcomes in Operative Vaginal Delivery) was enrolled at Hospital de Braga from February to October 2018. All singleton term OVD (Thierry spatulas and vacuum extractor) and a convenience SVD sample were recruited, in a 2:1 ratio. To assess PFD symptoms Pelvic Floor Distress Inventory-20 (PFDI-20) was applied at 3, 6, and 12 months postpartum. The questionnaire is divided into three subscales: Urinary (UDI), Colorectal-Anal (CRADI), and Pelvic Organ Prolapse Distress Inventory (POPDI)., Results: Of the 304 women recruited, 207 were included, 34.3% with SVD and 65.7% with OVD. Thierry spatulas were used in 53.7% of women undergoing OVD. Frequency of nulliparous (p < 0.001), episiotomy (p < 0.001), neuraxial anesthesia (p < 0.001), postpartum pain (p = 0.001) and occiput-posterior fetal position (p < 0.001) were significantly higher in OVD. Second phase of labor duration was longer in OVD (p = 0.001). At 3 months postpartum, women undergoing OVD and spatula-assisted delivery had higher UDI score, POPDI score, and global score, with no differences at 6 months and 1 year. After controlling for confounding variables, OVD and spatulas were still associated with greater POPDI scores at 3 months postpartum., Conclusions: Operative vaginal delivery, particularly with spatulas, seems to be associated with a higher prevalence of early PFD symptoms, mainly regarding pelvic organ prolapse., (© 2021. The International Urogynecological Association.)

Background: Recurrence of pelvic organ prolapse (POP) after transvaginal mesh (TVM) implantation pelvic floor reconstruction surgery remains an unresolved problem in clinical practice. In this retrospective observational study, clinical and pelvic floor ultrasound (PFUS) parameters were analyzed in order to identify high-risk factors of POP recurrence., Methods: The clinical and PFUS data from September 2013 to November 2019 of patients who underwent TVM were retrospectively analyzed. The patients with prolapse recurrence on postoperative follow-up diagnosed by PFUS were selected as case group, the clinical and PFUS parameters of them were compared with the control group in which the patients had no sign of prolapse recurrence. Univariate and multivariate regression analyses were performed based on age, BMI, gravidity, parity, surgical history (non-POP hysterectomy and incontinence-or-POP surgery), preoperative POP stage, follow-up in years, levator avulsion and hiatal area (HA) on Valsalva., Results: Altogether 102 patients entered the study and the median interval between PFUS and TVM surgery was 2.5 years. Univariate analysis showed that levator avulsion and HA were significantly different between case group and control; multivariate regression analysis showed that only HA was related to prolapse recurrence after TVM (OR = 1.202, 95% CI 1.100-1.313, P < 0.001). The area under the ROC curve was 0.775 (95% CI 0.684-0.867, P < 0.001)., Conclusions: Hiatal area on Valsalva was related to prolapse recurrence after TVM surgery and it is an important parameter for postoperative follow-up of TVM surgery., (© 2022. The Author(s).)

Objective: To document the deterioration in pelvic organ support occurring throughout all trimesters during the first pregnancy of women with no known risk factors. Secondarily to make a comprehensive review in order to verify the current findings and methodologies of similar studies in the literature., Study Design: In this prospective study, forty-one primigravid women with a singleton pregnancy were recruited during their first trimester. During follow-up pelvic organ support changes were documented by using Pelvic Organ Prolapse Quantification (POP-Q) system. Additionally, pelvic floor muscle strength examination, by modified Oxford scoring (MOS), and symptom assessment by Pelvic Floor Distress Inventory-Short Form (PFDI-20) were performed at three time points: first (T1), second (T2), and third trimester (T3) (n = 33). The Wilcoxon test was performed to test the significance of pairwise differences. Spearman correlation coefficient was estimated to determine the linear association of the findings., Results: Both distal and proximal anterior and posterior vaginal walls (Points Aa, Ba, Ap and Bp) with cervix (C) descended towards the hymen, throughout first pregnancy with a significant caudal shift on progressing from T2 to T3 (p ≤ 0.017). Posterior fornix (Point D) made a non-significant cranial shift (p = 0.527). The genital hiatus, perineal body and total vaginal length increased significantly (p ≤ 0.001). No significant difference in MOS was observed throughout pregnancy. The scores of PFDI-20 with all its domains worsened significantly during pregnancy, especially in T3 (p ≤ 0.011). Moderate correlations were observed between posterior vaginal descent and anorectal symptoms (rho 0.427, p < 0.05), and between the changes in genital hiatus and prolapse symptoms (rho 0.406, p < 0.05)., Conclusion: A significant descent both in all compartments of vaginal wall and perineum with an increase in total vaginal length, was observed together with an associated pelvic floor dysfunction throughout the first pregnancy of women., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Objective: This study aimed to determine if genital hiatus (GH) size is a predictor of worsening pelvic organ prolapse and a preference for a therapeutic intervention in women with pelvic organ prolapse who opt for expectant management over therapeutic intervention at their initial encounter., Methods: This was a retrospective cohort study analyzing the GH size of women who opted for expectant management in the initial treatment of pelvic organ prolapse at one academic institution from 2002 to 2015. Participants were divided into 2 groups: (1) large GH was defined as ≥4 cm and (2) normal GH was defined as <4 cm. The primary outcome was women opting for therapeutic intervention for their prolapse at a later visit, defined as pessary insertion or surgical intervention. Secondary measures evaluated GH as a predictor of worsening anatomy or symptoms., Results: One hundred eleven participants were enrolled. Fifty-two women had a large GH, and 59 women had a normal GH. Median length of follow-up was 24 months (range, 6-110 months). Of the 52 with a large GH, 22 (42%) opted for intervention; of the 59 women with a normal GH, 16 (27%) opted for intervention. There was no statistically significant difference between groups in the number who eventually chose intervention (P = 0.09). There was no difference in secondary outcomes between groups with respect to worsening bother, worsening pelvic organ prolapse quantification stage, or an increase in the prolapse leading edge of ≥2 cm., Conclusions: Women with a large GH, when compared with those with a normal GH, were not more likely to choose intervention over continued observation., Competing Interests: The authors have declared they have no conflicts of interest., (Copyright © 2021 American Urogynecologic Society. All rights reserved.)

Abstract: Levator ani defect (LAD) closely correlates with pelvic organ prolapse. This study aimed to compare the LAD grading between 3-dimensional ultrasonography (3D-US) and magnetic resonance imaging (MRI) and investigate the reasons for the difference using 3-dimensional pelvic models.Seventy-two Chinese women who were to undergo repair surgery were assessed by the prolapse staging, 3D-US and MRI. LAD was graded according to the grading systems described with regard to 3D-US (Dietz et al.) and MRI (Delancey et al.) The puborectalis attachment width and the puborectalis thickness were measured on the reconstructed pelvic models offline within the software. The results were analyzed using the weighted kappa and the ANOVA test.The grading systems used for 3D-US and MRI showed the good agreement (κ = 0.75), whereas the consensus of the extent (ie, partial or complete) of tears showed the moderate agreement (κ = 0.56). Additionally, iliococcygeus tears detected by MRI (n = 3) accompanied with complete puborectalis tears on the same side. The averaged width of intact puborectalis attachment was 13.75 ± 3.43 mm. The width of intact puborectalis attachment was remarkably higher than that of the injured attachment (P = .005). The averaged puborectalis thickness was 9.85 ± 2.13 mm.Comparison of 3D-US and MRI showed the good agreement on LAD grading. The moderate agreement in assessing partial or complete tears resulted from the grading criteria of 3D-US. The morphological characteristics of puborectalis assisted in identifying complete tears., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: Vaginal childbirth is an established main aetiological factor in the pathogenesis of female pelvic floor dysfunction. However, pregnancy itself is also likely to have an effect. This study investigated the effect of pregnancy on pelvic floor functional anatomy., Study Design: This was a retrospective observational study involving vaginally nulliparous women who presented to a tertiary urogynaecology unit with symptoms and signs of pelvic floor dysfunction between 2006 and 2014. Nulliparous women were compared with those who delivered exclusively by Caesarean Section (CS). All had undergone a standardised clinical interview, ICS POP-Q assessment and 3D/4D translabial pelvic floor ultrasound. Main outcome measures included sonographically determined pelvic organ position and hiatal dimensions on Valsalva and pelvic floor muscle contraction (PFMC)., Results: Of 2930 women seen during the study period, 242 had never given birth vaginally. One hundred and twenty-nine (53 %) were nulliparous, and 113 (47 %) were delivered by CS only. The CS group demonstrated significantly higher pelvic organ mobility in the anterior compartment (all P < 0.05) and a larger hiatal area on Valsalva (P = 0.004). All sonographic measures of pelvic floor muscle function demonstrated greater tissue displacement on PFMC in the CS group (all P < 0.05)., Conclusions: Compared to nulliparas, women who delivered exclusively by CS showed increased pelvic organ descent on Valsalva and tissue displacement on PFMC, implying increased tissue elasticity/ compliance or reduced stiffness, consistent with a small permanent hormonal and/or mechanical effect of pregnancy., Competing Interests: Declaration of Competing Interest HP Dietz and KL Shek have received speaker fees and travel assistance from GE Medical. HP has received speaker fees and travel assistance from Mindray. I Kamisan Atan and W Zhang have no conflict of interest to declare., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Introduction and Hypothesis: Tears of the levator ani muscle are common after vaginal birth and associated with pelvic organ prolapse (POP). Although such trauma is usually attributed to the first vaginal birth, epidemiological evidence suggests an additional effect of subsequent vaginal deliveries. Our hypothesis was: "The prevalence of avulsion increases with the number of vaginal births"., Methods: We conducted a retrospective cohort study in patients who presented to a tertiary urogynaecology clinic. Assessment included a physician-directed interview, POP-Q and 4D translabial ultrasound (TLUS), supine, after voiding, at rest, on maximum pelvic floor muscle contraction (PFMC) and Valsalva. Offline analysis of levator integrity was undertaken by tomographic imaging (TUI) at a later date, blinded against all other data., Results: A total of 1,124 patients had been seen between 1 January 2014 and 30 June 2016, on average 33 (0.32-69.7) years after their first birth. Mean age was 56 (19-90) years. 1,012 (90%) were vaginally parous with a median vaginal parity of 2 (1-8). On TUI, avulsion was diagnosed in 257 (23%) women, all of whom were vaginally parous. On univariate analysis, there was no significant difference in the prevalence of avulsion on comparing vaginally primiparous and multiparous women (P = 0.6), nor was there any difference between vaginal parity groups (one, two, three, and ≥4 births; p = 0.7). This remained true after controlling for potential confounding factors using multivariate regression (p = 0.6)., Conclusions: There was no significant difference in the prevalence of avulsion between vaginally primiparous and multiparous women. Vaginal deliveries after a first vaginal birth are unlikely to cause avulsion.

Objective: There is limited knowledge on how exercise impacts the pelvic floor muscles (PFM) and prevalence of stress urinary incontinence (SUI) and pelvic organ prolapse (POP) postpartum. The purpose of this study was to investigate whether early onset of general exercise postpartum negatively affects the PFM and/or increases the risk of SUI and POP 12 months postpartum., Methods: This study used a prospective cohort design. At 6 weeks postpartum, 57 women classified as exercisers (exercising ≥3 times at ≥30 min/wk) were compared with 120 nonexercisers (mean age = 29 years, SD = 4.3). Manometry was used to measure vaginal resting pressure, PFM strength, and PFM endurance, and symptoms of SUI and POP were assessed using questionnaires. Data were presented as standardized beta coefficients (B) and odds ratios (OR)., Results: No differences were found between exercisers (n = 57) and non-exercisers (n = 120) at 6 weeks postpartum on vaginal resting pressure (B = -0.04 [95% CI = -3.4 to 2.1]), PFM strength (B = 0.03 [95% CI = -4.7 to 7.4]), PFM endurance (B = -0.02 [95% CI = -59 to 46]), or symptoms of SUI (OR = 0.51 [95% CI = 0.25 to 1.1]) or POP (OR = 0.62 [95% CI = 0.26 to 1.5]) measured at 12 months postpartum. Adjusting for covariates, women with body mass index between 25 and 29.9 and >30 were more likely to report SUI 12 months postpartum (OR = 2.2 [95% CI = 1.0 to 4.7] and OR = 3.3 [95% CI = 1.2 to 9.4], respectively). Women with physically strenuous occupations were more likely to report POP 12 months postpartum (OR = 3.0 [95% CI = 1.2 to 7.3])., Conclusions: This study suggests that regular exercise 6 weeks postpartum has no negative effect on PFM function or on SUI or POP. Being overweight, however, was associated with more SUI, and women with physically strenuous occupations reported more POP., Impact: Results from this study suggest that first-time mothers should be encouraged to start general exercise within the first 6 weeks after giving birth. Women at risk for PFD should be advised accordingly and potentially modifiable risk factors should be addressed prior to delivery., Lay Summary: First-time mothers are encouraged to talk with a physical therapist about starting regular general exercise in the early postpartum weeks. Health care providers should advise patients on possible preventive measures for women at risk for PFD., (© The Author(s) 2020. Published by Oxford University Press on behalf of the American Physical Therapy Association. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Objectives: It is hypothesized that unilateral high-grade tears damage levator ani muscle (LAM) integrity and increase LAM distensibility. This study aimed to investigate how a unilateral high-grade tear caused overdistension of LAM and whether tear positions affect the degree of distension., Methods: A total of 209 women were screened by translabial ultrasonography. Then, 18 nulliparous women with an intact LAM and 26 postpartum women with unilateral levator ani defects were recruited. The anteroposterior diameter (AP), coronal diameter (LR), and hiatal area (HA) of the minimum levator hiatus were recorded and compared for assessing the distensibility. All 44 subjects underwent magnetic resonance imaging for the diagnosis of levator ani defect and detection of tear positions. Within the software, 3-dimensional pelvic models were developed from magnetic resonance imaging scans for the direct visualization and measurements., Results: Of the 26 postpartum women, 15 were diagnosed with unilateral high-grade tear (caudad in 9, cephalad in 6). The △AP, △LR, and △HA (Valsalva-rest) values of women with a unilateral high-grade tear were significantly larger than those of women with an intact LAM (P < 0.05). The △AP, △LR, and △HA (Valsalva-rest) values of cephalad tears were larger than those of women with caudad tears (P < 0.05)., Conclusions: A unilateral high-grade tear caused the overdistension of LAM. It was validated that cephalad tears caused higher degree of LAM distension than caudad tears.

More women participate in sports than ever before and the proportion of women athletes at the Olympic Games is nearly 50%. The pelvic floor in women may be the only area of the body where the positive effect of physical activity has been questioned. The aim of this narrative review is to present two widely held opposing hypotheses on the effect of general exercise on the pelvic floor and to discuss the evidence for each. Hypothesis 1: by strengthening the pelvic floor muscles (PFM) and decreasing the levator hiatus, exercise decreases the risk of urinary incontinence, anal incontinence and pelvic organ prolapse, but negatively affects the ease and safety of childbirth. Hypothesis 2: by overloading and stretching the PFM, exercise not only increases the risk of these disorders, but also makes labor and childbirth easier, as the PFM do not obstruct the exit of the fetus. Key findings of this review endorse aspects of both hypotheses. Exercising women generally have similar or stronger PFM strength and larger levator ani muscles than non-exercising women, but this does not seem to have a greater risk of obstructed labor or childbirth. Additionally, women that specifically train their PFM while pregnant are not more likely to have outcomes associated with obstructed labor. Mild-to-moderate physical activity, such as walking, decreases the risk of urinary incontinence but female athletes are about three times more likely to have urinary incontinence compared to controls. There is some evidence that strenuous exercise may cause and worsen pelvic organ prolapse, but data are inconsistent. Both intra-abdominal pressure associated with exercise and PFM strength vary between activities and between women; thus the threshold for optimal or negative effects on the pelvic floor almost certainly differs from person to person. Our review highlights many knowledge gaps that need to be understood to understand the full effects of strenuous and non-strenuous activities on pelvic floor health.

Objectives: Obstetric levator avulsion may be an important risk factor for prolapse. This study compares the size of the levator hiatus, the width of the genital hiatus, and pelvic muscle strength between vaginally parous women with or without levator avulsion, 5 to 15 years after delivery., Methods: Parous women were assessed for levator ani avulsion, using 3-dimensional transperineal ultrasound. Women with and without levator ani avulsion were compared with respect to levator hiatus areas (measured on ultrasound), genital hiatus (measured on examination), and pelvic muscle strength (measured with perineometry). Further analysis also considered the association of forceps-assisted birth., Results: At a median interval of 11 years from first delivery, levator avulsion was identified in 15% (66/453). A history of forceps-assisted delivery was strongly associated with levator avulsion (45% vs 8%; P < 0.001). Levator avulsion was also associated with a larger levator hiatus area (+7.3 cm; 95% confidence interval [CI], 4.1-10.4, with Valsalva), wider genital hiatus (+0.6 cm; 95% CI, 0.3-0.9, with Valsalva), and poorer muscle strength (-14.5 cm H2O; 95% CI, -20.4 to -8.7, peak pressure). Among those with levator avulsion, forceps-assisted birth was associated with a marginal increase in levator hiatus size but not genital hiatus size or muscle strength., Conclusions: Obstetric levator avulsion is associated with a larger levator hiatus, wider genital hiatus, and poorer pelvic muscle strength. Forceps-assisted birth is an important marker for levator avulsion but may not be an independent risk factor for the development of pelvic muscle weakness or changes in hiatus size in the absence of levator avulsion.

Objective: To study possible associations between pelvic floor muscle contraction, levator ani muscle (LAM) trauma and/or pelvic organ prolapse (POP) ≥ Stage 2 in parous women recruited from a general population., Methods: This was a secondary analysis of data from a cross-sectional study of 608 parous women from a general population examined using the POP quantification system (POP-Q) and three-dimensional/four-dimensional transperineal ultrasound for identification of LAM macrotrauma (avulsion) and microtrauma (distension of levator hiatal area > 75 th percentile on Valsalva maneuver). Muscle contraction was assessed using the modified Oxford scale (MOS), perineometry and ultrasound measurement of proportional change of anteroposterior hiatal diameter and levator hiatal area at rest and on pelvic floor muscle contraction. The Mann-Whitney U-test was used to study associations between pelvic floor muscle contraction, LAM trauma and POP., Results: Women with macrotrauma (n = 113) had significantly weaker median pelvic floor muscle contraction, as measured using MOS and perineometry, than did women with an intact LAM (n = 493) (contraction strength was 1.5 (range, 0.0-5.0) vs 3.5 (range, 0.0-5.0) on MOS, and vaginal squeeze pressure was 15.0 (range, 0.0-78.0) cmH 2 O vs 28.0 (range, 0.0-129.0) cmH 2 O on perineometry; P < 0.001). This was also demonstrated by ultrasound measurement, with a proportional change in hiatal area of 19.9% (range, 4.1-48.0%) vs 34.0% (range, 0.0-64.0%) (P < 0.001) and proportional change in anteroposterior diameter of 16.2% (range, -5.7 to 42.6%) vs 26.0% (range, -3.4 to 49.4%) (P < 0.001). No statistically significant difference between women with (n = 65), and those without (n = 378), microtrauma was found after excluding women with macrotrauma. Women with POP had weaker muscle contraction than those without; in those with POP-Q ≥ 2 (n = 275) compared with those with POP-Q < 2 (n = 333), muscle contraction strength was 3.0 (range, 0.0-5.0) vs 3.5 (range, 0.0-5.0) on MOS, vaginal squeeze pressure was 21.0 (range, 0.0-98.0) cmH 2 O vs 28.0 (range, 3.0-129.0) cmH 2 O on perineometry, proportional change in hiatal area was 29.6% (range, 0.0-60.9%) vs 33.8% (range, 0.0-64.4%) and proportional change in anteroposterior diameter was 22.8% (range, -5.7 to 49.4%) vs 25.7% (range, -3.4 to 49.4%) (P < 0.001 for all)., Conclusions: LAM macrotrauma was associated with weaker pelvic floor muscle contraction measured using palpation, perineometry and ultrasound. Women with POP had weaker contraction than did women without POP. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd., (Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.)

Background: Pelvic organ prolapse is a common health problem in women and has a negative influence on quality of life. A major cause of pelvic organ prolapse is levator injury., Objective: The objective of the study was to evaluate the association of mediolateral episiotomy with levator injury (levator avulsion, ballooning, or combined) and urogynecological complaints., Study Design: A prospective observational cohort study was performed in 204 primiparous women with a spontaneous vaginal delivery without anal sphincter tear in a general hospital between 2012 and 2015. One hundred three of these women had had a mediolateral episiotomy. Validated urogynecological questionnaires and transperineal 3-dimensional/4-dimensional ultrasound were completed after delivery. Outcome measures were levator avulsion, ballooning (hiatal area of more than 25 cm 2 ), and urogynecological questionnaire scores. Statistical analysis was performed using univariate and multiple logistic regression analysis., Results: The median time at investigation after vaginal delivery was 13 months (range 6-33). Levator injury (avulsion, ballooning, or combined) was identified in 35 of the 103 women who had undergone mediolateral episiotomy (40.0%) and 33 of the 101 women without episiotomy (32.7%) (P = .69). No differences were found in the incidence of levator avulsion 27 (26.7%) vs 23 (22.8%) (P = .53) or in levator ballooning (20 [19.4%] vs 23 [22.8%] (P = .58) between both groups. There was an association between longer duration of the second stage of labor and the incidence of levator avulsion (odds ratio, 1.24 [95% confidence interval, 1.01-1.52]). Nonocciput anterior fetal position increased the risk of levator ballooning and levator injury (odds ratio, 10.19 [95% confidence interval, 1.89-54.91] and odds ratio, 12.16 [95% confidence interval, 1.41-104.38], respectively). No differences in urogynecological complaints were found., Conclusion: Mediolateral episiotomy is not associated with the occurrence of levator injury or urogynecological complaints in women with a spontaneous vaginal delivery who did not obtain an anal sphincter injury. Levator injury was associated with a prolonged second stage of labor and a nonocciput anterior fetal position., (Copyright © 2018. Published by Elsevier Inc.)

Objectives: With vaginal childbirth, 10% to 30% of women sustain levator ani muscle avulsion. The objective of this study was to estimate the cumulative incidence of prolapse and other pelvic floor disorders (PFDs), comparing vaginally parous women with and without levator avulsion., Methods: Parous women enrolled in a longitudinal study were assessed annually for PFDs with the Pelvic Organ Prolapse Quantification Examination (for prolapse) and the Epidemiology of Prolapse and Incontinence Questionnaire (for stress incontinence, overactive bladder, and anal incontinence). Three-dimensional transperineal ultrasound was used to identify levator avulsion. Women with and without levator avulsion after vaginal delivery were compared for the cumulative incidence of PFDs. Further analysis also stratified by forceps delivery., Results: At the time of assessment, 453 participants were 6 to 17 years from first delivery (median, 11 years). Levator avulsion was identified in 15% (66/453) and was more common among those who had undergone forceps-assisted delivery (P < 0.001). Levator avulsion was strongly associated with prolapse beyond the hymen (odds ratio, 2.7; 95% confidence interval, 1.3-5.7) and with symptoms of prolapse (odds ratio, 3.0; 95% confidence interval-1.2, 7.3). These associations persisted after controlling for forceps-assisted delivery. In contrast, the odds of stress incontinence, overactive bladder, and anal incontinence were marginally (but not significantly) increased among women with levator avulsion in this cohort., Conclusions: Obstetric levator avulsion is strongly associated with pelvic organ prolapse. The relationship between levator avulsion and other PFDs may not be significant.

Introduction and Hypothesis: Vaginal childbirth clearly has an effect on pelvic floor anatomy, and pregnancy itself also likely plays a role. This study investigated the effects of consecutive pregnancies by comparing pelvic organ support and function in urogynecological patients delivered by cesarean section (CS) only., Methods: This was a retrospective study using 161 archived data sets of urogynecological patients delivered exclusively by CS presenting with symptoms of pelvic floor dysfunction between 2007 and 2015. Patients had undergone an interview, clinical examination using the Pelvic Organ Prolapse Quantification (POP-Q) system, and 3D/4D translabial ultrasound (TLUS) using Voluson systems. Measures of functional pelvic floor anatomy were obtained from stored ultrasound (US) volumes at a later date, using proprietary software, and blinded against all other data., Results: One hundred and sixty-one women delivered exclusively by CS were seen in a urogynecological clinic. Volume data analysis was possible in 151 patients. Mean age was 52 (26-82) years, with a mean body mass index (BMI) of 29.5 (18.4-48.7) kg/m 2 . Forty-three (28.5%) women had one CS, 67 (44.4%) had two, and 41 (27.1%) had three or more. On multivariate analysis, adjusting for age, BMI, history of hysterectomy, and incontinence or prolapse surgery, there were no significant differences between groups., Conclusions: On comparing women with one, two, or three or more CS, we found no significant differences in any measured sonographic parameters of pelvic organ descent and pelvic floor muscle function. This implies that subsequent pregnancies after the first are unlikely to exert significant additional effects on pelvic floor functional anatomy.

Pelvic floor dysfunction is defined as abnormal function of the pelvic floor and includes conditions that can have significant adverse impacts on a woman's quality of life, including urinary incontinence (stress, urge, and mixed), fecal incontinence, pelvic organ prolapse, sexual dysfunction, diastasis recti abdominis, pelvic girdle pain, and chronic pain syndromes. Women's health care providers can screen for, identify, and treat pelvic floor dysfunction. This article examines the case of a woman with multiple pelvic-floor-related problems and presents the evidence for the use of pelvic floor physical therapy (PFPT) for pregnancy-related pelvic floor dysfunction. PFPT is an evidence-based, low-risk, and minimally invasive intervention, and women's health care providers can counsel women about the role that PFPT may play in the prevention, treatment, and/or management of pelvic floor dysfunction., (© 2018 by the American College of Nurse-Midwives.)

The objective of this narrative review is to study the impact of pregnancy and childbirth on pelvic floor function as assessed by objective measurement techniques with quantitative data carried out during pregnancy and after childbirth. A literature search in MEDLINE and relevant and up-to-date journals from 1960 until April 2017 was performed for articles dealing with the impact of pregnancy and childbirth on pelvic floor function as assessed by objective measurement methods. Only studies describing objective measurement techniques. i.e., urodynamics, ultrasound (US), magnetic resonance imaging (MRI), Pelvic Organ Prolapse Quantification (POP-Q) system, and neurophysiologic tests carried out throughout pregnancy and after childbirth are included. Relevant studies presenting objective quantitative data are analyzed and briefly summarized. The number of studies meeting selection criteria was relatively few. Pregnancy, especially first pregnancy, is associated bladder neck lowering, increased bladder neck mobility, pelvic organ descent, decreased levator ani strength, and decreased urethral resistance. These changes are accentuated after vaginal delivery. Data on the impact of obstetrical and neonatal variables are transient and seem of less importance. Cesarean delivery is not completely protective. In most women, pelvic floor muscle function recovers in the year after delivery. Objective measurement techniques during pregnancy may allow identification of women susceptible to pelvic floor dysfunction later in life and offer the opportunity for counseling and preventive treatment strategies.

Introduction and Hypothesis: There is a lack of prospective studies evaluating the impact of childbirth on the pelvic floor in non-white populations. We intended to study delivery-related changes in pelvic floor morphology in Black South African primiparae. We also intended to determine the impact of anatomical changes on symptoms in the postpartum period., Methods: A total of 153 nulliparous women between 35 and 39 weeks gestation were recruited from a district antenatal clinic. All women had a standardized interview, completed the International Consultation on Incontinence Vaginal Symptoms questionnaire followed by three/four dimensional transperineal ultrasonography. This was repeated at 3-6 months postpartum., Results: Of the 153 women, 84 (54.9%) returned at a mean of 4.8 months postpartum. Of these women, 60 (71.4%) had a vaginal delivery and the remainder a caesarean section (20 emergency and 4 elective). Overall, there were statistically significant increases in bladder neck descent (P = 0.003), pelvic organ descent and levator hiatal distensibility (all P < 0001) at the postpartum assessment. Levator avulsion was diagnosed in nine (15%) of those delivered vaginally. Postpartum vaginal laxity was the commonest bothersome vaginal symptom, reported by 51 women (60.7%)., Conclusions: There is significant alteration in pelvic organ support and levator hiatal distensibility postpartum, with more marked effects in women after vaginal delivery. Of Black primiparous women, 15% sustained levator trauma after their first vaginal delivery.

Introduction and Hypothesis: The etiology of pelvic organ prolapse (POP) likely includes over-distension or tears (avulsion) of the levator ani muscle. However, there is a lack of studies evaluating the association between symptoms of POP and these factors. This study was designed to determine the association between POP symptoms and clinical prolapse stage on the one hand, and pelvic floor functional anatomy on the other hand., Methods: This prospective observational study included 258 patients seen at a tertiary urogynecological unit with symptoms of POP as defined by pertinent ICIQ questions. After informed consent and a detailed history including ICIQ responses, 3D transperineal ultrasonography was performed using a GE Voluson i ultrasound system. Offline analysis was performed on de-identified datasets., Results: The mean age of the patients was 60.6 years (25-91 years) and their mean BMI was 29.8 kg/m 2 (18-53 kg/m 2 ). Levator defects were found in 78 (32.4%) of the patients and the defect was bilateral in almost half of these patients (n = 36). There were significant associations between awareness and visualization of a vaginal lump on the one hand and hiatal area measurements as well as diagnosis of avulsion on the other. Interference with everyday life was significantly associated with hiatal area and prolapse stage, but not with avulsion., Conclusions: There is a significant association between awareness, visualization and/or feeling of a vaginal lump and abnormal pelvic floor functional anatomy, that is, hiatal ballooning and levator avulsion.

Purpose of Review: The purpose of this review is to review the data on the relationship of obesity and pelvic organ prolapse (POP). This review is timely and relevant as the prevalence of obesity is increasing worldwide, and it is an important risk factor to consider in counseling women on management of prolapse symptoms and outcomes for surgical treatment., Recent Findings: The main findings in the literature include: Obesity is increasing worldwide and impacts health, social life, work and healthcare costs. Elevated BMI is an important lifestyle factor affecting pelvic prolapse. The most probable mechanism of POP development among obese women is the increase in intra-abdominal pressure that causes weakening of pelvic floor muscles and fascia. Obesity is associated with significant pelvic floor symptoms and impairment of quality of life (QOL). Weight loss is likely not associated with anatomic improvement, but may be associated with prolapse symptom improvement. Weight loss should be considered a primary option in obese women for its beneficial effects on multiple organ systems and reducing pelvic floor disorder (PFD) symptoms. Although the operation time in obese women is significantly longer than in healthy weight women, the complication rate of surgery has not been shown to be increased compared to nonobese patients, regardless of route of surgery. There are data to support the vaginal approach in obese women. Some studies have shown that women with high body weight are associated with an increase in the risk for both anatomical and functional recurrence, and other studies have shown no difference., Summary: Obesity is a prevalent modifiable condition that impacts PFDs including pelvic prolapse. Patients should be counseled using clinical judgment, knowledge of the literature and with the goal of improving QOL.

Purpose: Obesity is an established risk factor for pelvic floor disorders (PFD) but the effects of bariatric surgery on PFD are uncertain. This meta-analysis was conducted to evaluate the effects of bariatric surgery on PFD in obese women., Methods: A systematic search of PubMed, Cochrane Library, CNKI and CBM databases up to October 2016 was performed, and studies reporting pre-operative and post-operative outcomes in obese women undergoing bariatric surgery were included. The Pelvic Floor Distress Inventory (PFDI-20), the Pelvic Floor Incontinence Questionnaire (PFIQ-7), the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, Female Sexual Function Index and the International Consultation on Incontinence Questionnaire-Urinary Incontinence short form score were used for evaluating pelvic floor dysfunction after bariatric surgery., Results: Eleven cohort studies were finally included. Pooled results revealed that bariatric surgery was associated with a significant improvement in PFD for obese women on the whole [PFDI-20: SMD = 0.89, 95% CI (0.44, 1.34), P < 0.001; PFIQ-7: SMD = 1.23, 95% CI (0.17, 2.29), P = 0.023]. In the subscale analysis, there was significant improvement in urinary incontinence and pelvic organ prolapse. However, no significant improvement was found in fecal incontinence and sexual function., Conclusions: Bariatric surgery is associated with significant improvement in urinary incontinence, and has a benefit on pelvic organ prolapse for obese women. However, there is no significant improvement in fecal incontinence and sexual function. Further multi-center, large-scale and longer-term randomized controlled trials are needed to confirm these results.

Pelvic organ prolapse is common among women who have delivered vaginally or had a hysterectomy. In a total hysterectomy, the apical vaginal support is transected. Although evidence supports re-establishment of apical support, our research showed that this rarely occurs in hysterectomies. To address our lack of definitions of "significant" apical support loss and recommendations to guide surgeons as to when they should perform an apical support procedure, we analyzed patient data and found that a simple assessment of the genital hiatus can effectively screen for significant apical support loss. Our work will hopefully highlight the importance of apical support loss and current deficits in research and clinical guidelines.

Introduction and Hypothesis: The paravaginal defect has been a topic of active discussion concerning what it is, how to diagnose it, its role in anterior vaginal wall prolapse, and if and how to repair it. The aim of this article was to review the existing literature on paravaginal defect and discuss its role in the anterior vaginal wall support system, with an emphasis on anatomy and imaging., Methods: Articles related to paravaginal defects were identified through a PubMed search ending 1 July 2015., Results: Support of the anterior vaginal wall is a complex system involving levator ani muscle, arcus tendineus fascia pelvis (ATFP), pubocervical fascia, and uterosacral/cardinal ligaments. Studies conclude that physical examination is inconsistent in detecting paravaginal defects. Ultrasound (US) and magnetic resonance imaging (MRI) have been used to describe patterns in the appearance of the vagina and bladder when a paravaginal defect is suspected. Different terms have been used (e.g., sagging of bladder base, loss of tenting), which all represent changes in pelvic floor support but that could be due to both paravaginal and levator ani defects., Conclusion: Paravaginal support plays a role in supporting the anterior vaginal wall, but we still do not know the degree to which it contributes to the development of prolapse. Both MRI and US are useful in the diagnosis of paravaginal defects, but further studies are needed to evaluate their use.

Introduction: Pelvic floor disorders (PFDs), including pelvic organ prolapse (POP), stress and urgency urinary incontinence, and faecal incontinence, are common and arise from loss of pelvic support. Although severe disease often does not occur until women become older, pregnancy and childbirth are major risk factors for PFDs, especially POP. We understand little about modifiable factors that impact pelvic floor function recovery after vaginal birth. This National Institutes of Health (NIH)-funded Program Project, 'Bridging physical and cultural determinants of postpartum pelvic floor support and symptoms following vaginal delivery', uses mixed-methods research to study the influences of intra-abdominal pressure, physical activity, body habitus and muscle fitness on pelvic floor support and symptoms as well as the cultural context in which women experience those changes., Methods and Analysis: Using quantitative methods, we will evaluate whether pelvic floor support and symptoms 1 year after the first vaginal delivery are affected by biologically plausible factors that may impact muscle, nerve and connective tissue healing during recovery (first 8 weeks postpartum) and strengthening (remainder of the first postpartum year). Using qualitative methods, we will examine cultural aspects of perceptions, explanations of changes in pelvic floor support, and actions taken by Mexican-American and Euro-American primipara, emphasising early changes after childbirth. We will summarise project results in a resource toolkit that will enhance opportunities for dialogue between women, their families and providers, and across lay and medical discourses. We anticipate enrolling up to 1530 nulliparous women into the prospective cohort study during the third trimester, following those who deliver vaginally 1 year postpartum. Participants will be drawn from this cohort to meet the project's aims., Ethics and Dissemination: The University of Utah and Intermountain Healthcare Institutional Review Boards approved this study. Data are stored in a secure password-protected database. Papers summarising the primary results and ancillary analyses will be published in peer-reviewed journals., Competing Interests: Conflicts of Interest: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Introduction: The study aimed to analyze the relation between the degree of puborectalis muscle trauma and subjective symptoms and objective findings of pelvic organ prolapse (POP), comparing two continuous scoring systems with a discrete scoring system for translabial ultrasound imaging., Material and Methods: In this retrospective observational study the records of patients attending a tertiary urogynecological unit between January 2012 and December 2014 were analyzed. POP assessment included a standardized interview, clinical examination using Pelvic Organ Prolapse Quantification and four-dimensional translabial ultrasound. Puborectalis muscle trauma was assessed with tomographic ultrasound imaging using two continuous scoring systems and a previously established discrete system. Receiver operating characteristics and adjusted odds ratios were used for comparison of scoring systems in predicting symptoms and signs of POP., Results: Of 1258 women analyzed, 52.6% complained of prolapse symptoms. On ultrasound imaging, 65.7% of women had sonographically significant POP. Complete avulsion was diagnosed in 25.3% of women, being unilateral in 13.9% and bilateral in 11.4%. A maximum score in the 6-point and the 12-point tomographic ultrasound imaging scale increased the odds for a diagnosis of any significant POP on ultrasound by 4.4 and 4.8 times, respectively, compared with 4.6 times for the discrete diagnosis of bilateral avulsion. For all avulsion scoring systems the relation was strongest for cystocele and uterine prolapse., Conclusions: A continuous avulsion scoring system based on tomographic findings does not provide superior performance for the prediction of subjective symptoms and objective findings of prolapse compared with a discrete diagnostic system of unilateral or bilateral avulsion., (© 2016 Nordic Federation of Societies of Obstetrics and Gynecology.)

Background: Recognition and assessment of apical vaginal support defects remains a significant challenge in the evaluation and management of prolapse. There are several reasons that this is likely: (1) Although the Pelvic Organ Prolapse-Quantification examination is the standard prolapse staging system used in the Female Pelvic Medicine and Reconstructive Surgery field for reporting outcomes, this assessment is not used commonly in clinical care outside the subspecialty; (2) no clinically useful and accepted definition of apical support loss exists, and (3) no consensus or guidelines address the degree of apical support loss at which an apical support procedure should be performed routinely., Objective: The purpose of this study was to identify a simple screening measure for significant loss of apical vaginal support., Study Design: This was an analysis of women with Pelvic Organ Prolapse-Quantification stage 0-IV prolapse. Women with total vaginal length of ≥7 cm were included to define a population with "normal" vaginal length. Univariable and linear regression analyses were used to identify Pelvic Organ Prolapse-Quantification points that were associated with 3 definitions of apical support loss: the International Consultation on Incontinence, the Pelvic Floor Disorders Network revised eCARE, and a Pelvic Organ Prolapse-Quantification point C cut-point developed by Dietz et al. Linear and logistic regression models were created to assess predictors of overall apical support loss according to these definitions. Receiver operator characteristic curves were generated to determine test characteristics of the predictor variables and the areas under the curves were calculated., Results: Of 469 women, 453 women met the inclusion criterion. The median Pelvic Organ Prolapse-Quantification stage was III, and the median leading edge of prolapse was +2 cm (range, -3 to 12 cm). By stage of prolapse (0-IV), mean genital hiatus size (genital hiatus; mid urethra to posterior fourchette) increased: 2.0 ± 0.5, 3.0 ± 0.5, 4.0 ± 1.0, 5.0 ± 1.0, and 6.5 ± 1.5 cm, respectively (P < .01). Pelvic Organ Prolapse-Quantification points B anterior, B posterior, and genital hiatus had moderate-to-strong associations with overall apical support loss and all definitions of apical support loss. Linear regression models that predict overall apical support loss and logistic regression models predict apical support loss as defined by International Continence Society, eCARE, and the point C; cut-point definitions were fit with points B anterior, B posterior, and genital hiatus; these 3 points explained more than one-half of the model variance. Receiver operator characteristic analysis for all definitions of apical support loss found that genital hiatus >3.75 cm was highly predictive of apical support loss (area under the curve, >0.8 in all models)., Conclusions: Increasing genital hiatus size is associated highly with and predictive of apical vaginal support loss. Specifically, the Pelvic Organ Prolapse-Quantification measurement genital hiatus of ≥3.75 cm is highly predictive of apical support loss by all study definitions. This simple measurement can be used to screen for apical support loss and the need for further evaluation of apical vaginal support before planning a hysterectomy or prolapse surgery., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: To describe changes in pelvic organ support from mid pregnancy until 1 year postpartum among nulliparous pregnant women, and to examine whether delivery route affects changes in pelvic organ support., Design: Prospective cohort study., Setting: Akershus University Hospital in Norway., Population: A cohort of 300 nulliparous pregnant women included at mid-pregnancy., Methods: Pelvic organ support assessed at 21 and 37 weeks of gestation, and again at 6 weeks, 6 months, and 12 months postpartum, by the use of the Pelvic Organ Prolapse Quantification (POP-Q) system. Linear mixed model was used to assess longitudinal change in pelvic organ support., Main Outcome Measures: Prevalence of anatomic POP. Change in POP-Q variables over time and between delivery groups., Results: The prevalence of anatomic POP ranged from 0 to 10%. Vaginal POP-Q points made a cranial shift from mid to late pregnancy, a caudal shift following delivery, and again a cranial shift after 6 weeks postpartum. Postpartum change was present following both vaginal and caesarean deliveries, but was more pronounced following vaginal delivery. The perineal body and genital hiatus became longer from mid to late pregnancy, and shortened after 6 weeks postpartum. At 12 months postpartum all POP-Q points, except cervix, had recovered to baseline in the vaginal delivery group., Conclusions: The prevalence of anatomic POP was low in this cohort. There was change in pelvic organ support both during pregnancy and following vaginal as well as caesarean delivery. The short-term ability to recover was good after the first pregnancy and delivery., Tweetable Abstract: Pelvic organ support changes during pregnancy. A contribution to the risk of POP?, (© 2015 Royal College of Obstetricians and Gynaecologists.)

Objective: The impact of simple and radical hysterectomy on all aspects of pelvic floor dysfunctions was evaluated in current study., Study Design: This retrospective cohort study included 142 patients; 58 women (40.8%) who have undergone simple, 41 (28.8%) radical hysterectomy, and 43 (30.2%) women without any surgical intervention to serve as the control group. The validated versions of the Urogenital Distress Inventory (UDI-6), Incontinence Impact Questionnaire (IIQ-7), Pelvic Floor and Incontinence Sexual Impact Questionnaire (PISQ-12), Wexner Incontinence Scale score and pelvic organ prolapse quantification (POP-Q) system were used in detailed evaluation of pelvic floor dysfunction. One-way ANOVA and Pearson's chi square tests were performed in statistical analysis., Results: It was found that there were significant differences in irritative and obstructive scores of UDI-6 between Type III hysterectomy group and Type I hysterectomy group. In addition, patients of Type I hysterectomy had significant higher irritative and obstructive scores than the control group. Type III hysterectomy had the most significant deteriorating effect on sexual life, based on scores of PISQ-12 compared to both Type I hysterectomy group and control group., Conclusion: Hysterectomy results in detrimental effects on the quality of life (QoL) regarding all aspects of pelvic floor functions especially in women of radical hysterectomy. Urinary dysfunctional symptoms like urgency, obstruction and especially sexual problems are more bothersome and difficult to overcome. The impact of hysterectomy on QoL should be investigated as a whole and may be more profound than previously thought., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

As the field of reconstructive pelvic surgery continues to evolve, with descriptions of new procedures to repair pelvic organ prolapse, it remains imperative to maintain a functional understanding of pelvic floor anatomy and support. The goal of this review was to provide a focused, conceptual approach to differentiating anatomic defects contributing to prolapse in the various compartments of the vagina. Rather than provide exhaustive descriptions of pelvic floor anatomy, basic pelvic floor anatomy is reviewed, new and historical concepts of pelvic floor support are discussed, and relevance to the surgical management of specific anatomic defects is addressed., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Elevated body mass index (BMI) is associated with the incidence, prevalence, and progression of pelvic organ prolapse (POP). This study investigated the effect of peripartum BMI on pelvic floor support 1 year postpartum (PP1y). One hundred eight nulliparous women had their BMI recorded and underwent POP assessments using the Pelvic Organ Prolapse Quantification System at baseline, third trimester (36th to 38th week of pregnancy [G36-38w]), and PP1y. Pelvic organ prolapse was defined as ≥stage II. Women gained on average 1.9 kg between baseline and PP1y. After adjustment, increasing BMI PP1y was associated with increasing anterior wall descent (P < .0001) and higher odds of having POP PP1y (odds ratio: 1.41, 95% confidence interval: 1.01-1.97, P = .045). Trial of labor compared to unlabored cesarean delivery, POP G36-38w, and decreased fetal weight were independently associated with anterior vaginal wall laxity PP1y. Our finding suggests that postpartum BMI influences pelvic floor laxity 1 year after delivery. Postpartum weight reduction may serve as a strategy for POP prevention in some women., (© The Author(s) 2015.)

Introduction and Hypothesis: It is known that pelvic floor muscle trauma (PFMT) after vaginal delivery is associated with pelvic organ prolapse (POP) symptoms (sPOP) and signs (POP-Q ≥2) in patient populations. Our aims were to establish the prevalence and investigate a possible association between PFMT and sPOP and POP-Q ≥2 in healthy women 20 years after their first delivery., Methods: During 2013 and 2014 we conducted a cross-sectional study among 847 women who delivered their first child between 1990 and 1997. Women responded to a postal questionnaire and were offered a clinical examination including prolapse grading and pelvic floor ultrasonography. The main outcome measures were sPOP, POP-Q ≥2 and PFMT, defined by levator avulsion or a levator hiatal area on Valsalva manoeuvre of >40 cm(2) on ultrasonography., Results: Of the 847 eligible women, 608 (72 %) were examined. Data on POP symptoms, POP-Q stage, levator avulsion and levator hiatal area were available in 598, 608, 606 and 554 women, respectively, and of these 75 (13%) had sPOP, 275 (45%) had POP-Q ≥2, 113 (19 %) had levator avulsion and 164 (30%) had a levator hiatal area >40 cm(2). Levator avulsion was associated with POP-Q ≥2 with an odds ratio (OR) of 9.91 and a 95% confidence interval (CI) of 5.73 - 17.13, and with sPOP (OR 2.28, 95% CI 1.34 - 3.91). Levator hiatal area >40 cm(2) was associated with POP-Q ≥2 (OR 6.98, 95% CI 4.54, - 10.74) and sPOP (OR 3.28, 95 % CI 1.96 - 5.50)., Conclusion: Many healthy women selected from the general population have symptoms and signs of POP 20 years after their first delivery, and PFMT is associated with POP-Q ≥2 and sPOP.

Purpose: Both congenital and traumatic factors are likely to play a role in the etiology of female pelvic organ prolapse. We hypothesized that congenital prolapse may be less bothersome than traumatic prolapse related to vaginal childbirth., Methods: This is a retrospective study using 482 archived data sets of patients seen for urodynamic testing. Patients had an interview, clinical and sonographic examination using 4D translabial ultrasound. Prolapse bother was determined by visual analog scale (VAS)., Results: A total of 463 patients were seen, of which 254 (55 %) suffered from symptoms of prolapse. The median bother attributable to these symptoms on VAS was 2 (0-10). Clinically significant prolapse was found in 81 % (cystocele 63 %, uterine prolapse 13 %, enterocele 5 %, rectocele 52 %). Evidence of major childbirth-related trauma, i.e., avulsion, was diagnosed in 118 (26 %), and it was bilateral in 9 %. On univariate analysis, clinical stage, maximal prolapse on ultrasound, levator avulsion, vaginal parity and hiatal area were significantly associated with prolapse bother. In a multivariate linear regression analysis, only prolapse extent remained a significant predictor (P < 0.0001), implying that evidence of traumatic prolapse etiology had no significant influence on prolapse bother., Conclusion: The presence of levator avulsion did not influence the degree of bother resulting from pelvic organ prolapse symptoms. Hence, increased prolapse bother does not seem to be associated with evidence of traumatic prolapse etiology.

Objectives: To investigate the postnatal prevalence of sonographically diagnosed pelvic floor trauma, and the correlations with various antenatal/intrapartum predictors in primiparous women., Methods: This was a prospective cohort study performed in a tertiary hospital with 9000 deliveries per annum. Of those invited, 202 (23.2%) primiparous participants were assessed clinically at least 1 year after delivery by Pelvic Organ Prolapse Quantification (POP-Q), two/three-dimensional transperineal sonography and quantification of serum collagen type III levels., Results: There was a high prevalence of clinically significant pelvic organ prolapse (POP) on POP-Q staging: uterine prolapse, 63%; cystocele, 42%; and rectocele, 23%. Ballooning of the levator ani muscle (LAM) hiatus was detected in 33% and LAM avulsion in 29% of participants, with partial LAM avulsion occurring in 15% and complete avulsion in 14%. Postnatal POP symptoms (odds ratios (ORs) given here for presence of multiple prolapse symptoms) were positively associated with similar prepregnancy symptoms (OR, 7.2 (95% CI, 1.19-44.33)), LAM avulsion (OR, 4.8 (95% CI, 1.99-11.34)) and forceps delivery (borderline significance; OR, 1.8 (95% CI, 0.96-3.25)) and negatively associated with elective (OR, 0.2 (95% CI, 0.09-0.63)) and emergency (OR, 0.3 (95% CI, 0.12-0.83)) Cesarean section. LAM abnormality was associated with forceps delivery (OR, 4.9 (95% CI, 1.44-16.97)) and prolapse (OR, 6.8-11.7 (95% CI, 2.34-78.51)), whereas collagen levels did not play a role (OR, 1.001 (95% CI, 0.99-1.02))., Conclusions: Clinically significant POP was common in relatively young premenopausal primiparous women. Partial or full levator avulsion was seen in 29% of participants and was associated with POP and related symptoms. Congenital factors seem to play little role in the etiology of LAM trauma, and the main risk factor seems to be forceps delivery. Avoidance of difficult vaginal deliveries may prevent severe pelvic floor trauma., (Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd.)

Introduction and Hypothesis: Levator avulsion is an etiological factor for female pelvic organ prolapse (POP) and generally occurs during a first vaginal birth. However, most women with POP present decades later. This study aimed to estimate latency between pelvic floor trauma and presentation for POP surgery., Methods: This was a retrospective observational study in a tertiary urogynecological unit to which 354 patients presented for evaluation prior to prolapse surgery between June 2011 and December 2012. All underwent an interview, clinical assessment [International Continence Society Pelvic Organ Prolapse Quantification score (ICS POPQ) and 4D translabial ultrasound (US). Postprocessing analysis of US volumes was blinded against clinical data. The main outcome measure was temporal latency between first vaginal birth and prolapse presentation in women with levator avulsion., Results: Three hundred and fifty-four patients presented with symptoms of prolapse, of whom 115 (32 %) were found to have an avulsion of the levator ani muscle. Of these, 30 patients were excluded due to previous prolapse surgery, leaving 85, all of whom showed significant prolapse on US and/or clinical staging. Mean latency between first vaginal delivery and presentation was 33.5 (3-66.3) years. There were no associations between latency and potential predictors, except for maternal age at first birth, which was associated with shorter latency (r = -0.45 , P < 0.001). There was a trend toward shorter latency after forceps delivery (P = 0.09)., Conclusions: Average latency between first birth and presentation for prolapse surgery in women with avulsion was 33.5 (3-66) years. Maternal age at first vaginal birth and possibly forceps delivery were associated with shorter time to presentation.

Objective: Vaginal childbirth has a substantial effect on pelvic organ supports, which may be mediated by levator ani (LA) avulsion or hiatal overdistension. Although the impact of a first vaginal delivery on the hiatus has been investigated, little is known about the effect of subsequent births. This study was designed to evaluate the association between vaginal parity and hiatal dimension., Design: Retrospective observational study., Setting: A tertiary urogynaecological unit in Australia., Population: A total of 780 archived data sets of women seen for symptoms of lower urinary tract and pelvic floor dysfunction., Methods: Standardised in-house interview and assessment using the International Continence Society (ICS) pelvic organ prolapse quantification (POP-Q), and four-dimensional translabial ultrasound. Offline analysis for hiatal dimensions was undertaken blinded to history and clinical examination., Main Outcome Measures: Hiatal area on maximum Valsalva., Results: Of 780 women, 64 were excluded because of missing ultrasound volumes, leaving 716 for analysis: 96% (n = 686) were parous, with a median parity of three (interquartile range, IQR 2-3), and 91.2% (n = 653) were vaginally parous. Levator avulsion was found in 21% (n = 148). The mean hiatal area on Valsalva was 29 cm(2) (SD 9.4 cm(2) ). On one-way anova, vaginal parity was significantly associated with hiatal area (P < 0.001). Most of the effect seems to occur with the first delivery. Subsequent deliveries do not seem to have any significant effect on hiatal dimensions. This remained true after controlling for potential confounding factors using multivariate regression analysis (P = 0.0123)., Conclusions: Vaginal parity was strongly associated with hiatal area on Valsalva. Most of this effect seems to be associated with the first vaginal delivery., (© 2014 Royal College of Obstetricians and Gynaecologists.)

This study investigated the incidences of urinary incontinence and pelvic organ prolapse as well as pelvic floor muscle strength after cesarean section and vaginal delivery. From June 2010 to July 2011, 149 puerpera in Shenzhen Hospital, Peking University, were divided into the cesarean section group (N = 66) and the vaginal delivery group (N = 83). Postpartum urinary incontinence analysis, pelvic examination, and pelvic muscle contraction analysis using the PHENIX neuromuscular therapy instrument were performed to compare urinary incontinence, pelvic organ prolapse, and pelvic floor muscle condition between the 2 groups. The incidences of urinary incontinence in the cesarean and vaginal delivery groups were 9.09% (6/66) and 16.87% (14/83), respectively (P > 0.05); the incidences of pelvic organ prolapse were 53.03% (35/66) and 86.75% (72/83), respectively (P < 0.05). There was no significant difference in pelvic muscle pressure or electrophysiological examination results between the 2 groups (P > 0.05). Hence, cesarean section has a protective effect on early postpartum pelvic organ prolapse, but the delivery modes do not differ significantly with respect to the incidence of postpartum urinary incontinence or pelvic muscle floor muscle strength.

Introduction and Hypothesis: The aim of this study was to evaluate pelvic floor dysfunction and anatomical signs of pelvic organ prolapse (POP) in patients with levator ani muscle (LAM) trauma compared with patients with an intact LAM 1 year postpartum., Methods: In a prospective case-control study, primiparous women after vaginal delivery, with LAM trauma diagnosed on 3D ultrasound, were included in the case group. Controls consisted of patients who fulfilled the same inclusion criteria but had an intact levator. All women were investigated 1 year postpartum in respect of bladder, bowel, prolapse, and sexual function using the Australian Pelvic Floor Questionnaire. POP was assessed according to the Pelvic Organ Prolapse Quantification (POP-Q) system and pelvic floor muscle strength using the Oxford Grading Scale., Results: Forty patients were included: 20 with and 20 without levator trauma. Urinary symptoms were significantly more frequent in women with LAM trauma compared with controls (p = 0.01). The two groups were comparable in respect of bowel, sexual, and prolapse symptoms (p = 0.24, p = 0.60, p = 0.99 respectively). Unlike POP stages II and III, POP stage I was significantly more common in LAM trauma patients (n = 19, 95 %) than in controls (n = 10, 50 %) (p =0.003). A positive association was noted between POP stage I and LAM trauma (RR = 7.2). The involvement of multiple compartments was significantly more frequent in cases than in controls (p = 0.003)., Conclusions: Except for urinary symptoms, LAM trauma was asymptomatic in nearly all patients 1 year postpartum. However, POP stage I involving multiple compartments occurred more frequently in LAM trauma patients than in controls.

Introduction and Hypothesis: The goal of this study was to use a well-described system of quantifying levator ani defect (LAD) severity using magnetic resonance imaging (MRI) to examine the relationship between defect severity and the presence or absence of prolapse., Methods: This is a secondary analysis of two case-control studies comparing 284 cases (with prolapse) to 219 controls (normal support) defined by using Pelvic Organ Prolapse Quantification (POP-Q) exams. LAD were assessed on MRI, with scores from 0 (no defects) to 6 (complete, bilateral defects). The number of cases and controls at each score were compared. Logistic regression and receiver operating characteristic (ROC) analyses were used to quantify relationships between LAD and prolapse., Results: The proportion of cases exceeds the overall prolapse rate in this study at LAD scores ≥3, with higher rates of prolapse at higher LAD scores (p < 0.0000001). Prolapse risk stratifies into low risk at LAD scores 0-2, moderate at 3-5, and high at 6. ROC analysis for classification of prolapse based on LAD scores has an area under the curve of 69.9% (p < 0.001), suggesting LAD alone can discriminate between normal support and prolapse for nearly 70% of patients. Logistic regression identified higher parity and higher LAD scores as independent predictors of prolapse., Conclusions: There are three clusters of prolapse risk: low (0-2), moderate (3-5), and high (6). Although LAD have a dose-response-like effect for prolapse, other factors are clearly involved.

Introduction and Hypothesis: The aim was to test the hypothesis that the pelvic outlet diameter (POD) is associated with pelvic organ prolapse (POP) in squirrel monkeys., Methods: Magnetic resonance images (MRI) were obtained from 55 females with and without POP. Commercial software was used by two observers to measure the POD. POD, age, parity, and weight for the two groups were compared using Student's t test. Associations of age, parity, and body weight with POD were evaluated with linear regression analysis. Multiple regression analysis examined the relationships of age, parity, and POD with POP. Receiver operating curve methods were used to set thresholds., Results: Observers concurred on measurements (Cronbach's alpha = 0.96 with lower 95% confidence limit of 0.94). POD was not related to parity (p = 0.10) or weight (p = 0.053), but was inversely related to age (p = 0.011). Animals with POP did not differ from those without POP with regard to age (p = 0.10), weight (p = 0.17), or POD (p = 0.99). The groups differed with regard to parity (p = 0.007) and multiple regression methods demonstrated that only parity had a significant relationship with POP (p = 0.002). Parity greater than 2 had 64% specificity and 89% sensitivity for POP., Conclusions: POD size does not contribute to POP in squirrel monkeys. This study confirms that among variables of age, body weight, POD, and parity, only parity appears as a risk factor for POP in squirrel monkeys.

Objective: This study aimed to assess the association between episiotomy and measures of pelvic organ prolapse quantification system (POP-Q) in a cohort of women with vaginal parturition., Study Design: A prospective study was conducted with 549 eligible patients with vaginal delivery history. Women who were pregnant, gave birth within the preceding 6 months period, had a known history of pre-pregnant prolapse, had a history of hysterectomy or any operation performed for pelvic organ prolapsus and stress urinary incontinence, refused to participate and to whom POP-Q examination could not be performed (due to anatomic or orthopedic problems) were excluded. Patients were categorized as women with episiotomy and without episiotomy. The degree of genital prolapse was assessed by using POP-Q system. The effect of episiotomy on overall POP-Q stage and individual POP-Q points was calculated with logistic regression., Results: 439 patients had a history of episiotomy whereas 110 patients had no episiotomy. 38.2% of women without an episiotomy, and 32.0% of women with episiotomy had genital prolapse determined by POP-Q system. There was no statistically significant association between episiotomy and POP-Q stage (AOR, -0.24; 95% CI, -0.65-0.18, P=0.26). Episiotomy was found among the independent predictors for certain POP-Q points such as Bp, perineal body (pb) and total vaginal length (tvl). Episiotomy was negatively correlated with prolapse of Bp and with pb and tvl., Conclusion: Episiotomy had an effect on certain POP-Q indices, but had no influence on overall POP-Q stage., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Introduction: Imaging of the levator hiatus, the largest potential hernial portal in the human body, requires axial plane imaging by ultrasound or magnetic resonance imaging. The aim of this study is to determine whether 2D translabial ultrasound may identify excessive hiatal distensibility by measuring the anteroposterior (AP) diameter of the hiatus. This may become clinically relevant for risk stratification of women prior to prolapse surgery., Methods: This is a retrospective analysis of 577 women seen at a tertiary urogynaecological unit between May 2008 and September 2010. All women underwent a standardised interview, clinical prolapse assessment (ICS POP-Q) and translabial ultrasound. The hiatal AP diameter was measured at rest, on Valsalva and during pelvic floor muscle contraction. All analyses were performed offline, blinded against clinical data., Results: There was a strong statistical relationship between reported prolapse symptoms/pelvic organ descent and hiatal AP diameter on Valsalva (P < 0.001 on chi-squared test for trend). A cut-off of 6 cm of the AP hiatal diameter on Valsalva yielded a specificity of 0.64 and a sensitivity of 0.7 for detecting significant prolapse on ultrasound., Conclusion: Hiatal ballooning can be diagnosed with 2D translabial ultrasound. We propose that an AP hiatal diameter on Valsalva of up to 5.99 cm be regarded as normal, with 6-<6.5 cm defined as mild, 6.5-<7 cm as 'moderate', 7-<7.5 cm as 'marked' and 7.5 or more as 'severe' ballooning., (© 2013 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Pelvic organ prolapse (POP) is a prevalent and disabling condition. The pathophysiology of prolapse is multifactorial, and no single mechanism adequately explains all aspects of its development. The pathophysiology of POP is complex and incompletely understood. Smooth muscle (SM), an integral part of the vaginal wall and endopelvic structures that support the pelvic viscera, has also been implicated in the pathophysiology of POP. In this article, we review the role of smooth muscle cells (SMC) in the pathophysiology of POP, also addressing the anatomy of SM in pelvic floor, morphometric analysis, biomechanical properties, and potential mechanisms.

Objectives: The purpose of this study was to describe the current practice patterns of general gynecologists regarding management of various urogynecologic conditions., Methods: A 15-item Web-based survey was sent to obstetrician and gynecologists in 2011. Subjects who chose to participate answered questions about their comfort level with management of various urogynecologic conditions, their perceptions of the need for a pelvic reconstructive surgeon in their community, and when they feel it is appropriate to refer to a specialist., Results: Two hundred ninety-four obstetrics/gynecology generalists responded to the survey with overall 33% response rate. There was a wide range of comfort level depending on the complexity of the condition. Most of the subjects felt comfortable in the management of stress and urge incontinence, cystocele, rectocele, and uterine prolapse. On the other hand, most of the subjects were uncomfortable with management of intrinsic sphincter deficiency, fecal incontinence, recurrent incontinence after failed surgery, and complications of vaginal mesh surgery. In addition, there was wide variation in types of surgical options offered by different practitioners. When we compared the results by age, younger gynecologists have a smaller repertoire of procedures they offer for treatment of urogynecologic conditions. Burch colposuspension, uterosacral ligament suspension, and colpocleisis were performed more often by older surgeons than younger surgeons. On the other hand, cystoscopy was performed more commonly by the younger group., Conclusions: Among general gynecologists, there is a wide range in both comfort level for management of different urogynecologic conditions and types of urogynecologic services performed.

The investigation of female pelvic floor function and anatomy is moving from the fringes to the mainstream of urogynaecology and female urology, and it is becoming increasingly relevant for obstetrics. We are coming to realise that pelvic floor trauma in labour is common, usually overlooked, and a major factor in the causation of pelvic organ prolapse. Modern imaging methods such as magnetic resonance and 3D/4D ultrasound have enabled us to diagnose such trauma reliably and accurately, most commonly in the form of an avulsion of the puborectalis muscle; that is, a disconnection of the muscle from its insertion on the os pubis. Such damage to the levator muscle is macroscopically evident and can also be palpated, a skill that is available to every clinician, requiring neither investment nor specialised equipment. In this review, I will describe pelvic floor assessment by palpation and ultrasound and illustrate the commonest abnormalities and their clinical consequences. This paper will not focus on magnetic resonance imaging due to technical restrictions, cost and access issues in most jurisdictions, and because several papers have recently shown that ultrasound is at least as effective in diagnosing such trauma. Anal sphincter trauma is generally well covered in the literature and hence not subject of this review., (© 2013 The Author ANZJOG © 2013 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)